837 Health Care Claim:
Professional
HIPAA/V4010X098A1/837: 837 Health Care Claim: Professional
Version: 1.0 Final
Author:
Company:
Publication:
Modified:
Current:
Kelli Gonczeruk & Cindy
Brown
Blue Shield of California
12/9/2010
12/9/2010
12/9/2010
12/1/2010
Health Care Claim: Professional - 837
Table of Contents
837
. . .
Health Care Claim: Professional . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
1
ISA
. .
Interchange Control Header . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
22
GS
. .
Functional Group Header . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
25
ST
. .
Transaction Set Header . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
27
BHT
. .
Beginning of Hierarchical Transaction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
28
REF
. .
Transmission Type Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
30
1000A
. .
Loop Submitter Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
31
NM1
. .
Submitter Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
32
PER
. .
Submitter EDI Contact Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
34
1000B
. .
Loop Receiver Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
36
NM1
. .
Receiver Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
37
2000A
. .
Loop Billing/Pay-to Provider Hierarchical Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
39
HL
. .
Billing/Pay-to Provider Hierarchical Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
40
PRV
. .
Billing/Pay-to Provider Specialty Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
42
CUR
. .
Foreign Currency Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
44
. .
2010AA Loop Billing Provider Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
46
NM1
. .
Billing Provider Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
47
N3
. .
Billing Provider Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
50
N4
. .
Billing Provider City/State/ZIP Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
51
REF
. .
Billing Provider Secondary Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
53
REF
. .
Credit/Debit Card Billing Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
55
PER
. .
Billing Provider Contact Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
56
. .
2010AB Loop Pay-to Provider Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
58
NM1
. .
Pay-to Provider Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
59
N3
. .
Pay-to Provider Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
61
N4
. .
Pay-to Provider City/State/ZIP Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
62
REF
. .
Pay-to-Provider Secondary Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
64
2000B
. .
Loop Subscriber Hierarchical Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
66
HL
. .
Subscriber Hierarchical Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
67
SBR
. .
Subscriber Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
69
PAT
. .
Patient Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
72
. .
2010BA Loop Subscriber Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
74
NM1
. .
Subscriber Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
75
N3
. .
Subscriber Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
78
N4
. .
Subscriber City/State/ZIP Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
79
DMG
. .
Subscriber Demographic Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
81
REF
. .
Subscriber Secondary Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
82
REF
. .
Property and Casualty Claim Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
83
. .
2010BB Loop Payer Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
84
837P_CG.ecs
i
For internal use only
12/1/2010
Health Care Claim: Professional - 837
NM1
. .
Payer Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
85
N3
. .
Payer Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
87
N4
. .
Payer City/State/ZIP Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
88
REF
. .
Payer Secondary Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
90
. .
2010BC Loop Responsible Party Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
91
NM1
. .
Responsible Party Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
92
N3
. .
Responsible Party Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
94
N4
. .
Responsible Party City/State/ZIP Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
95
. .
2010BD Loop Credit/Debit Card Holder Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
97
NM1
. .
Credit/Debit Card Holder Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
98
REF
Credit/Debit Card Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
100
2300
Loop Claim Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
101
CLM
Claim Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
103
DTP
Date - Initial Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
110
DTP
Date - Date Last Seen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
111
DTP
Date - Onset of Current Illness/Symptom . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
112
DTP
Date - Acute Manifestation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
113
DTP
Date - Similar Illness/Symptom Onset . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
114
DTP
Date - Accident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
115
DTP
Date - Last Menstrual Period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
116
DTP
Date - Last X-ray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
117
DTP
Date - Hearing and Vision Prescription Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
118
DTP
Date - Disability Begin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
119
DTP
Date - Disability End . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
120
DTP
Date - Last Worked . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
121
DTP
Date - Authorized Return to Work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
122
DTP
Date - Admission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
123
DTP
Date - Discharge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
124
DTP
Date - Assumed and Relinquished Care Dates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
125
PWK
Claim Supplemental Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
126
CN1
Contract Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
128
AMT
Credit/Debit Card Maximum Amount . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
130
AMT
Patient Amount Paid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
131
AMT
Total Purchased Service Amount . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
132
REF
Service Authorization Exception Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
133
REF
Mandatory Medicare (Section 4081) Crossover Indicator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
134
REF
Mammography Certification Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
135
REF
Prior Authorization or Referral Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
136
REF
Original Reference Number (ICN/DCN) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
138
REF
Clinical Laboratory Improvement Amendment (CLIA) Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
140
REF
Repriced Claim Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
141
REF
Adjusted Repriced Claim Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
142
REF
Investigational Device Exemption Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
837P_CG.ecs
ii
For internal use only
12/1/2010
Health Care Claim: Professional - 837
REF
143
Claim Identification Number for Clearing Houses and Other Transmission Intermediaries . . . <PH>
144
REF
Ambulatory Patient Group (APG) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
145
REF
Medical Record Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
146
REF
Demonstration Project Identifier . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
147
K3
File Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
148
NTE
Claim Note . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
149
CR1
Ambulance Transport Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
150
CR2
Spinal Manipulation Service Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
153
CRC
Ambulance Certification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
155
CRC
Patient Condition Information: Vision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
161
CRC
Homebound Indicator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
164
CRC
EPSDT Referral . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
165
HI
Health Care Diagnosis Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
168
HCP
Claim Pricing/Repricing Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
173
2305
Loop Home Health Care Plan Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
176
CR7
Home Health Care Plan Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
177
HSD
Health Care Services Delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
178
2310A
Loop Referring Provider Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
181
NM1
Referring Provider Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
182
PRV
Referring Provider Specialty Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
185
REF
Referring Provider Secondary Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
186
2310B
Loop Rendering Provider Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
188
NM1
Rendering Provider Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
189
PRV
Rendering Provider Specialty Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
192
REF
Rendering Provider Secondary Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
194
2310C
Loop Purchased Service Provider Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
195
NM1
Purchased Service Provider Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
196
REF
Purchased Service Provider Secondary Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
198
2310D
Loop Service Facility Location . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
199
NM1
Service Facility Location . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
200
N3
Service Facility Location Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
202
N4
Service Facility Location City/State/ZIP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
203
REF
Service Facility Location Secondary Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
205
2310E
Loop Supervising Provider Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
206
NM1
Supervising Provider Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
207
REF
Supervising Provider Secondary Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
209
2320
Loop Other Subscriber Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
210
SBR
Other Subscriber Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
212
CAS
Claim Level Adjustments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
216
AMT
Coordination of Benefits (COB) Payer Paid Amount . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
222
AMT
Coordination of Benefits (COB) Approved Amount . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
223
AMT
Coordination of Benefits (COB) Allowed Amount . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
224
AMT
Coordination of Benefits (COB) Patient Responsibility Amount . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
837P_CG.ecs
iii
For internal use only
12/1/2010
Health Care Claim: Professional - 837
AMT
225
Coordination of Benefits (COB) Covered Amount . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
226
AMT
Coordination of Benefits (COB) Discount Amount . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
227
AMT
Coordination of Benefits (COB) Per Day Limit Amount . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
228
AMT
Coordination of Benefits (COB) Patient Paid Amount . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
229
AMT
Coordination of Benefits (COB) Tax Amount . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
230
AMT
Coordination of Benefits (COB) Total Claim Before Taxes Amount . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
231
DMG
Subscriber Demographic Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
232
OI
Other Insurance Coverage Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
233
MOA
Medicare Outpatient Adjudication Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
234
2330A
Loop Other Subscriber Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
237
NM1
Other Subscriber Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
238
N3
Other Subscriber Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
240
N4
Other Subscriber City/State/ZIP Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
241
REF
Other Subscriber Secondary Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
243
2330B
Loop Other Payer Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
244
NM1
Other Payer Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
245
PER
Other Payer Contact Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
247
DTP
Claim Adjudication Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
249
REF
Other Payer Secondary Identifier . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
250
REF
Other Payer Prior Authorization or Referral Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
252
REF
Other Payer Claim Adjustment Indicator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
253
2330C
Loop Other Payer Patient Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
254
NM1
Other Payer Patient Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
255
REF
Other Payer Patient Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
257
2330D
Loop Other Payer Referring Provider . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
258
NM1
Other Payer Referring Provider . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
259
REF
Other Payer Referring Provider Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
260
2330E
Loop Other Payer Rendering Provider . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
261
NM1
Other Payer Rendering Provider . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
262
REF
Other Payer Rendering Provider Secondary Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
263
2330F
Loop Other Payer Purchased Service Provider . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
264
NM1
Other Payer Purchased Service Provider . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
265
REF
Other Payer Purchased Service Provider Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
266
2330G
Loop Other Payer Service Facility Location . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
267
NM1
Other Payer Service Facility Location . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
268
REF
Other Payer Service Facility Location Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
269
2330H
Loop Other Payer Supervising Provider . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
270
NM1
Other Payer Supervising Provider . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
271
REF
Other Payer Supervising Provider Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
272
2400
Loop Service Line . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
273
LX
Service Line . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
275
SV1
Professional Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
276
SV5
Durable Medical Equipment Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
837P_CG.ecs
iv
For internal use only
12/1/2010
Health Care Claim: Professional - 837
PWK
283
DMERC CMN Indicator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
285
CR1
Ambulance Transport Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
286
CR2
Spinal Manipulation Service Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
288
CR3
Durable Medical Equipment Certification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
290
CR5
Home Oxygen Therapy Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
291
CRC
Ambulance Certification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
294
CRC
Hospice Employee Indicator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
300
CRC
DMERC Condition Indicator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
302
DTP
Date - Service Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
306
DTP
Date - Certification Revision Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
308
DTP
Date - Begin Therapy Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
309
DTP
Date - Last Certification Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
310
DTP
Date - Date Last Seen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
311
DTP
Date - Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
312
DTP
Date - Oxygen Saturation/Arterial Blood Gas Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
313
DTP
Date - Shipped . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
314
DTP
Date - Onset of Current Symptom/Illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
315
DTP
Date - Last X-ray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
316
DTP
Date - Acute Manifestation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
317
DTP
Date - Initial Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
318
DTP
Date - Similar Illness/Symptom Onset . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
319
MEA
Test Result . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
320
CN1
Contract Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
322
REF
Repriced Line Item Reference Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
324
REF
Adjusted Repriced Line Item Reference Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
325
REF
Prior Authorization or Referral Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
326
REF
Line Item Control Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
327
REF
Mammography Certification Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
328
REF
Clinical Laboratory Improvement Amendment (CLIA) Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
329
REF
Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification . . . . . . . . . <PH>
330
REF
Immunization Batch Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
331
REF
Ambulatory Patient Group (APG) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
332
REF
Oxygen Flow Rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
333
REF
Universal Product Number (UPN) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
334
AMT
Sales Tax Amount . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
336
AMT
Approved Amount . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
337
AMT
Postage Claimed Amount . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
338
K3
File Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
339
NTE
Line Note . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
340
PS1
Purchased Service Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
341
HSD
Health Care Services Delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
342
HCP
Line Pricing/Repricing Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
345
2410
Loop Drug Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
837P_CG.ecs
v
For internal use only
12/1/2010
Health Care Claim: Professional - 837
LIN
349
Drug Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
350
CTP
Drug Pricing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
352
REF
Prescription Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
354
2420A
Loop Rendering Provider Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
355
NM1
Rendering Provider Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
356
PRV
Rendering Provider Specialty Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
358
REF
Rendering Provider Secondary Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
359
2420B
Loop Purchased Service Provider Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
361
NM1
Purchased Service Provider Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
363
REF
Purchased Service Provider Secondary Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
365
2420C
Loop Service Facility Location . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
366
NM1
Service Facility Location . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
367
N3
Service Facility Location Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
369
N4
Service Facility Location City/State/ZIP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
370
REF
Service Facility Location Secondary Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
372
2420D
Loop Supervising Provider Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
373
NM1
Supervising Provider Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
374
REF
Supervising Provider Secondary Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
376
2420E
Loop Ordering Provider Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
377
NM1
Ordering Provider Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
378
N3
Ordering Provider Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
380
N4
Ordering Provider City/State/ZIP Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
381
REF
Ordering Provider Secondary Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
383
PER
Ordering Provider Contact Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
384
2420F
Loop Referring Provider Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
386
NM1
Referring Provider Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
387
PRV
Referring Provider Specialty Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
389
REF
Referring Provider Secondary Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
390
2420G
Loop Other Payer Prior Authorization or Referral Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
391
NM1
Other Payer Prior Authorization or Referral Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
392
REF
Other Payer Prior Authorization or Referral Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
394
2430
Loop Line Adjudication Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
395
SVD
Line Adjudication Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
396
CAS
Line Adjustment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
400
DTP
Line Adjudication Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
406
2440
Loop Form Identification Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
407
LQ
Form Identification Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
408
FRM
Supporting Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
409
2000C
Loop Patient Hierarchical Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
411
HL
Patient Hierarchical Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
412
PAT
Patient Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
414
2010CA Loop Patient Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
417
NM1
837P_CG.ecs
Patient Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
vi
For internal use only
12/1/2010
Health Care Claim: Professional - 837
N3
418
Patient Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
420
N4
Patient City/State/ZIP Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
421
DMG
Patient Demographic Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
423
REF
Patient Secondary Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
424
REF
Property and Casualty Claim Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
425
2300
Loop Claim Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
426
CLM
Claim Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
428
DTP
Date - Initial Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
434
DTP
Date - Date Last Seen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
435
DTP
Date - Onset of Current Illness/Symptom . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
436
DTP
Date - Acute Manifestation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
437
DTP
Date - Similar Illness/Symptom Onset . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
438
DTP
Date - Accident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
439
DTP
Date - Last Menstrual Period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
440
DTP
Date - Last X-ray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
441
DTP
Date - Hearing and Vision Prescription Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
442
DTP
Date - Disability Begin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
443
DTP
Date - Disability End . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
444
DTP
Date - Last Worked . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
445
DTP
Date - Authorized Return to Work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
446
DTP
Date - Admission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
447
DTP
Date - Discharge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
448
DTP
Date - Assumed and Relinquished Care Dates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
449
PWK
Claim Supplemental Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
450
CN1
Contract Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
452
AMT
Credit/Debit Card Maximum Amount . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
454
AMT
Patient Amount Paid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
455
AMT
Total Purchased Service Amount . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
456
REF
Service Authorization Exception Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
457
REF
Mandatory Medicare (Section 4081) Crossover Indicator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
458
REF
Mammography Certification Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
459
REF
Prior Authorization or Referral Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
460
REF
Original Reference Number (ICN/DCN) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
462
REF
Clinical Laboratory Improvement Amendment (CLIA) Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
464
REF
Repriced Claim Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
465
REF
Adjusted Repriced Claim Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
466
REF
Investigational Device Exemption Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
467
REF
Claim Identification Number for Clearing Houses and Other Transmission Intermediaries . . . <PH>
468
REF
Ambulatory Patient Group (APG) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
469
REF
Medical Record Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
470
REF
Demonstration Project Identifier . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
471
K3
File Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
472
NTE
Claim Note . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
837P_CG.ecs
vii
For internal use only
12/1/2010
Health Care Claim: Professional - 837
CR1
473
Ambulance Transport Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
474
CR2
Spinal Manipulation Service Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
476
CRC
Ambulance Certification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
478
CRC
Patient Condition Information: Vision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
484
CRC
Homebound Indicator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
487
CRC
EPSDT Referral . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
488
HI
Health Care Diagnosis Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
491
HCP
Claim Pricing/Repricing Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
496
2305
Loop Home Health Care Plan Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
499
CR7
Home Health Care Plan Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
500
HSD
Health Care Services Delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
501
2310A
Loop Referring Provider Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
504
NM1
Referring Provider Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
505
PRV
Referring Provider Specialty Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
508
REF
Referring Provider Secondary Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
509
2310B
Loop Rendering Provider Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
510
NM1
Rendering Provider Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
511
PRV
Rendering Provider Specialty Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
513
REF
Rendering Provider Secondary Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
514
2310C
Loop Purchased Service Provider Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
515
NM1
Purchased Service Provider Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
516
REF
Purchased Service Provider Secondary Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
518
2310D
Loop Service Facility Location . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
519
NM1
Service Facility Location . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
520
N3
Service Facility Location Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
522
N4
Service Facility Location City/State/ZIP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
523
REF
Service Facility Location Secondary Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
525
2310E
Loop Supervising Provider Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
526
NM1
Supervising Provider Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
527
REF
Supervising Provider Secondary Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
529
2320
Loop Other Subscriber Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
530
SBR
Other Subscriber Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
532
CAS
Claim Level Adjustments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
536
AMT
Coordination of Benefits (COB) Payer Paid Amount . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
542
AMT
Coordination of Benefits (COB) Approved Amount . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
543
AMT
Coordination of Benefits (COB) Allowed Amount . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
544
AMT
Coordination of Benefits (COB) Patient Responsibility Amount . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
545
AMT
Coordination of Benefits (COB) Covered Amount . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
546
AMT
Coordination of Benefits (COB) Discount Amount . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
547
AMT
Coordination of Benefits (COB) Per Day Limit Amount . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
548
AMT
Coordination of Benefits (COB) Patient Paid Amount . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
549
AMT
Coordination of Benefits (COB) Tax Amount . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
550
AMT
Coordination of Benefits (COB) Total Claim Before Taxes Amount . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
837P_CG.ecs
viii
For internal use only
12/1/2010
Health Care Claim: Professional - 837
DMG
551
Subscriber Demographic Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
552
OI
Other Insurance Coverage Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
553
MOA
Medicare Outpatient Adjudication Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
554
2330A
Loop Other Subscriber Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
557
NM1
Other Subscriber Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
558
N3
Other Subscriber Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
560
N4
Other Subscriber City/State/ZIP Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
561
REF
Other Subscriber Secondary Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
563
2330B
Loop Other Payer Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
564
NM1
Other Payer Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
565
PER
Other Payer Contact Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
567
DTP
Claim Adjudication Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
569
REF
Other Payer Secondary Identifier . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
570
REF
Other Payer Prior Authorization or Referral Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
572
REF
Other Payer Claim Adjustment Indicator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
573
2330C
Loop Other Payer Patient Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
574
NM1
Other Payer Patient Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
575
REF
Other Payer Patient Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
577
2330D
Loop Other Payer Referring Provider . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
578
NM1
Other Payer Referring Provider . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
579
REF
Other Payer Referring Provider Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
580
2330E
Loop Other Payer Rendering Provider . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
581
NM1
Other Payer Rendering Provider . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
582
REF
Other Payer Rendering Provider Secondary Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
583
2330F
Loop Other Payer Purchased Service Provider . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
584
NM1
Other Payer Purchased Service Provider . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
585
REF
Other Payer Purchased Service Provider Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
586
2330G
Loop Other Payer Service Facility Location . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
587
NM1
Other Payer Service Facility Location . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
588
REF
Other Payer Service Facility Location Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
589
2330H
Loop Other Payer Supervising Provider . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
590
NM1
Other Payer Supervising Provider . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
591
REF
Other Payer Supervising Provider Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
592
2400
Loop Service Line . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
593
LX
Service Line . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
595
SV1
Professional Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
596
SV5
Durable Medical Equipment Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
602
PWK
DMERC CMN Indicator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
604
CR1
Ambulance Transport Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
605
CR2
Spinal Manipulation Service Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
607
CR3
Durable Medical Equipment Certification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
609
CR5
Home Oxygen Therapy Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
610
CRC
Ambulance Certification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
837P_CG.ecs
ix
For internal use only
12/1/2010
Health Care Claim: Professional - 837
CRC
613
Hospice Employee Indicator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
619
CRC
DMERC Condition Indicator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
621
DTP
Date - Service Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
625
DTP
Date - Certification Revision Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
627
DTP
Date - Begin Therapy Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
628
DTP
Date - Last Certification Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
629
DTP
Date - Date Last Seen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
630
DTP
Date - Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
631
DTP
Date - Oxygen Saturation/Arterial Blood Gas Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
632
DTP
Date - Shipped . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
633
DTP
Date - Onset of Current Symptom/Illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
634
DTP
Date - Last X-ray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
635
DTP
Date - Acute Manifestation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
636
DTP
Date - Initial Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
637
DTP
Date - Similar Illness/Symptom Onset . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
638
MEA
Test Result . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
639
CN1
Contract Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
641
REF
Repriced Line Item Reference Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
643
REF
Adjusted Repriced Line Item Reference Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
644
REF
Prior Authorization or Referral Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
645
REF
Line Item Control Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
646
REF
Mammography Certification Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
647
REF
Clinical Laboratory Improvement Amendment (CLIA) Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
648
REF
Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification . . . . . . . . . <PH>
649
REF
Immunization Batch Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
650
REF
Ambulatory Patient Group (APG) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
651
REF
Oxygen Flow Rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
652
REF
Universal Product Number (UPN) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
653
AMT
Sales Tax Amount . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
655
AMT
Approved Amount . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
656
AMT
Postage Claimed Amount . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
657
K3
File Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
658
NTE
Line Note . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
659
PS1
Purchased Service Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
660
HSD
Health Care Services Delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
661
HCP
Line Pricing/Repricing Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
664
2410
Loop Drug Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
668
LIN
Drug Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
669
CTP
Drug Pricing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
672
REF
Prescription Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
674
2420A
Loop Rendering Provider Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
675
NM1
Rendering Provider Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
676
PRV
Rendering Provider Specialty Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
837P_CG.ecs
x
For internal use only
12/1/2010
Health Care Claim: Professional - 837
REF
678
Rendering Provider Secondary Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
679
2420B
Loop Purchased Service Provider Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
680
NM1
Purchased Service Provider Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
681
REF
Purchased Service Provider Secondary Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
683
2420C
Loop Service Facility Location . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
684
NM1
Service Facility Location . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
685
N3
Service Facility Location Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
687
N4
Service Facility Location City/State/ZIP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
688
REF
Service Facility Location Secondary Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
690
2420D
Loop Supervising Provider Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
691
NM1
Supervising Provider Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
692
REF
Supervising Provider Secondary Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
694
2420E
Loop Ordering Provider Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
695
NM1
Ordering Provider Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
696
N3
Ordering Provider Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
698
N4
Ordering Provider City/State/ZIP Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
699
REF
Ordering Provider Secondary Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
701
PER
Ordering Provider Contact Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
702
2420F
Loop Referring Provider Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
704
NM1
Referring Provider Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
705
PRV
Referring Provider Specialty Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
707
REF
Referring Provider Secondary Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
708
2420G
Loop Other Payer Prior Authorization or Referral Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
709
NM1
Other Payer Prior Authorization or Referral Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
710
REF
Other Payer Prior Authorization or Referral Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
712
2430
Loop Line Adjudication Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
713
SVD
Line Adjudication Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
714
CAS
Line Adjustment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
718
DTP
Line Adjudication Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
724
2440
Loop Form Identification Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
725
LQ
Form Identification Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
726
FRM
Supporting Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
727
SE
Transaction Set Trailer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
729
GE
Functional Group Trailer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
730
IEA
Interchange Control Trailer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
731
837P_CG.ecs
xi
For internal use only
12/1/2010
Health Care Claim: Professional - 837
837
Health Care Claim: Professional
Functional Group= HC
Purpose: This Draft Standard for Trial Use contains the format and establishes the data contents of the Health Care
Claim Transaction Set (837) for use within the context of an Electronic Data Interchange (EDI) environment. This
transaction set can be used to submit health care claim billing information, encounter information, or both, from
providers of health care services to payers, either directly or via intermediary billers and claims clearinghouses. It
can also be used to transmit health care claims and billing payment information between payers with different
payment responsibilities where coordination of benefits is required or between payers and regulatory agencies to
monitor the rendering, billing, and/or payment of health care services within a specific health care/insurance industry
segment.For purposes of this standard, providers of health care products or services may include entities such as
physicians, hospitals and other medical facilities or suppliers, dentists, and pharmacies, and entities providing
medical information to meet regulatory requirements. The payer refers to a third party entity that pays claims or
administers the insurance product or benefit or both. For example, a payer may be an insurance company, health
maintenance organization (HMO), preferred provider organization (PPO), government agency (Medicare, Medicaid,
Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), etc.) or an entity such as a third party
administrator (TPA) or third party organization (TPO) that may be contracted by one of those groups. A regulatory
agency is an entity responsible, by law or rule, for administering and monitoring a statutory benefits program or a
specific health care/insurance industry segment.
Not Defined:
Pos
Id
Segment Name
ISA
GS
Interchange Control
Header
Functional Group Header
Pos
Id
Segment Name
005
010
ST
BHT
015
REF
Transaction Set Header
Beginning of Hierarchical
Transaction
Transmission Type
Identification
Req
Max Use
Repeat
Notes
Usage
M
1
Required
M
1
Required
Req
Max Use
M
M
1
1
Required
Required
O
1
Required
Heading:
LOOP ID - 1000A
020
045
NM1
PER
1
Submitter Name
Submitter EDI Contact
Information
O
O
1
2
LOOP ID - 1000B
020
Repeat
Receiver Name
O
1
Id
Segment Name
Req
Max Use
Usage
N1/020L
N1/020
1
NM1
Notes
Required
Required
N1/020L
N1/020
Required
Notes
Usage
Detail:
Pos
LOOP ID - 2000A
001
HL
003
PRV
010
CUR
>1
Billing/Pay-to Provider
Hierarchical Level
Billing/Pay-to Provider
Specialty Information
Foreign Currency
Information
M
1
Required
O
1
Situational
O
1
Situational
O
1
LOOP ID - 2010AA
015
837P_CG.ecs
NM1
Repeat
Billing Provider Name
1
1
N2/015L
N2/015
Required
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos
Id
Segment Name
025
030
N3
N4
035
REF
035
REF
040
PER
Billing Provider Address
Billing Provider
City/State/ZIP Code
Billing Provider Secondary
Identification
Credit/Debit Card Billing
Information
Billing Provider Contact
Information
Req
Max Use
O
O
1
1
Required
Required
O
8
Situational
O
8
Situational
O
2
Situational
LOOP ID - 2010AB
015
025
030
NM1
N3
N4
035
REF
1
HL
005
007
SBR
PAT
NM1
N3
N4
032
DMG
035
REF
035
REF
NM1
N3
N4
REF
O
5
Subscriber Hierarchical
Level
Subscriber Information
Patient Information
M
1
NM1
N3
N4
Required
O
O
1
1
Required
Situational
O
O
O
1
1
1
O
1
Situational
O
4
Situational
O
1
Situational
O
O
O
O
1
1
1
3
O
O
O
1
1
1
Subscriber Name
Subscriber Address
Subscriber City/State/ZIP
Code
Subscriber Demographic
Information
Subscriber Secondary
Identification
Property and Casualty
Claim Number
NM1
035
REF
837P_CG.ecs
Situational
Required
Required
Situational
1
Payer Name
Payer Address
Payer City/State/ZIP Code
Payer Secondary
Identification
Responsible Party Name
Responsible Party Address
Responsible Party
City/State/ZIP Code
Credit/Debit Card Holder
Name
Credit/Debit Card
Information
1
O
2
2
Required
Situational
Situational
Situational
N2/015L
N2/015
1
Required
Situational
Situational
N2/015L
N2/015
1
O
N2/015L
N2/015
1
LOOP ID - 2010BD
015
N2/015
>1
LOOP ID - 2010BC
015
025
030
N2/015L
1
1
1
LOOP ID - 2010BB
015
025
030
035
Usage
O
O
O
LOOP ID - 2010BA
015
025
030
Notes
Pay-to Provider Name
Pay-to Provider Address
Pay-to Provider
City/State/ZIP Code
Pay-to-Provider Secondary
Identification
LOOP ID - 2000B
001
Repeat
Situational
Required
Required
N2/015L
N2/015
Situational
Situational
For internal use only
12/1/2010
Pos
Health Care Claim: Professional - 837
Id
Segment Name
Req
Max Use
LOOP ID - 2300
130
135
135
135
CLM
DTP
DTP
DTP
135
135
DTP
DTP
135
135
DTP
DTP
135
135
DTP
DTP
135
135
135
135
DTP
DTP
DTP
DTP
135
135
135
DTP
DTP
DTP
155
PWK
160
175
CN1
AMT
175
175
AMT
AMT
180
REF
180
REF
180
REF
180
REF
180
REF
180
REF
180
180
REF
REF
180
REF
837P_CG.ecs
Repeat
Notes
Usage
100
Claim Information
Date - Initial Treatment
Date - Date Last Seen
Date - Onset of Current
Illness/Symptom
Date - Acute Manifestation
Date - Similar
Illness/Symptom Onset
Date - Accident
Date - Last Menstrual
Period
Date - Last X-ray
Date - Hearing and Vision
Prescription Date
Date - Disability Begin
Date - Disability End
Date - Last Worked
Date - Authorized Return
to Work
Date - Admission
Date - Discharge
Date - Assumed and
Relinquished Care Dates
Claim Supplemental
Information
Contract Information
Credit/Debit Card
Maximum Amount
Patient Amount Paid
Total Purchased Service
Amount
Service Authorization
Exception Code
Mandatory Medicare
(Section 4081) Crossover
Indicator
Mammography
Certification Number
Prior Authorization or
Referral Number
Original Reference
Number (ICN/DCN)
Clinical Laboratory
Improvement Amendment
(CLIA) Number
Repriced Claim Number
Adjusted Repriced Claim
Number
Investigational Device
Exemption Number
O
O
O
O
1
1
1
1
Required
Situational
Situational
Situational
O
O
5
10
Situational
Situational
O
O
10
1
Situational
Situational
O
O
1
1
Situational
Situational
O
O
O
O
5
5
1
1
Situational
Situational
Situational
Situational
O
O
O
1
1
2
Situational
Situational
Situational
O
10
Situational
O
O
1
1
Situational
Situational
O
O
1
1
Situational
Situational
O
1
Situational
O
1
Situational
O
1
Situational
O
2
Situational
O
1
Situational
O
3
Situational
O
O
1
1
Situational
Situational
O
1
Situational
3
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos
Id
Segment Name
Req
Max Use
180
REF
180
REF
180
180
REF
REF
185
190
195
K3
NTE
CR1
200
CR2
220
220
CRC
CRC
220
220
231
CRC
CRC
HI
241
HCP
Claim Identification
Number for Clearing
Houses and Other
Transmission
Intermediaries
Ambulatory Patient Group
(APG)
Medical Record Number
Demonstration Project
Identifier
File Information
Claim Note
Ambulance Transport
Information
Spinal Manipulation
Service Information
Ambulance Certification
Patient Condition
Information: Vision
Homebound Indicator
EPSDT Referral
Health Care Diagnosis
Code
Claim Pricing/Repricing
Information
O
1
Situational
O
4
Situational
O
O
1
1
Situational
Situational
O
O
O
10
1
1
Situational
Situational
Situational
O
1
Situational
O
O
3
3
Situational
Situational
O
O
O
1
1
1
Situational
Situational
Situational
O
1
Situational
Home Health Care Plan
Information
Health Care Services
Delivery
O
1
Situational
O
3
Situational
Referring Provider Name
Referring Provider
Specialty Information
Referring Provider
Secondary Identification
O
O
1
1
O
5
Rendering Provider Name
Rendering Provider
Specialty Information
Rendering Provider
Secondary Identification
O
O
1
1
O
5
Purchased Service
Provider Name
Purchased Service
Provider Secondary
Identification
O
1
O
5
Service Facility Location
O
1
LOOP ID - 2305
242
CR7
243
HSD
NM1
PRV
271
REF
NM1
PRV
271
REF
NM1
271
REF
837P_CG.ecs
NM1
N2/250L
N2/250
Situational
Situational
Situational
N2/250L
N2/250
Situational
Situational
1
4
Situational
Situational
Situational
1
LOOP ID - 2310D
250
Usage
N2/250L
N2/250
1
LOOP ID - 2310C
250
N2/195
2
LOOP ID - 2310B
250
255
Notes
6
LOOP ID - 2310A
250
255
Repeat
N2/250L
N2/250
Situational
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos
Id
Segment Name
265
N3
270
N4
271
REF
Service Facility Location
Address
Service Facility Location
City/State/ZIP
Service Facility Location
Secondary Identification
Req
Max Use
O
1
Required
O
1
Required
O
5
Situational
LOOP ID - 2310E
250
NM1
271
REF
1
SBR
295
300
CAS
AMT
300
AMT
300
AMT
300
AMT
300
AMT
300
AMT
300
AMT
300
AMT
300
AMT
300
AMT
305
DMG
310
OI
320
MOA
NM1
N3
N4
355
REF
837P_CG.ecs
Usage
N2/250L
O
1
O
5
Other Subscriber
Information
Claim Level Adjustments
Coordination of Benefits
(COB) Payer Paid Amount
Coordination of Benefits
(COB) Approved Amount
Coordination of Benefits
(COB) Allowed Amount
Coordination of Benefits
(COB) Patient
Responsibility Amount
Coordination of Benefits
(COB) Covered Amount
Coordination of Benefits
(COB) Discount Amount
Coordination of Benefits
(COB) Per Day Limit
Amount
Coordination of Benefits
(COB) Patient Paid
Amount
Coordination of Benefits
(COB) Tax Amount
Coordination of Benefits
(COB) Total Claim Before
Taxes Amount
Subscriber Demographic
Information
Other Insurance Coverage
Information
Medicare Outpatient
Adjudication Information
O
1
N2/250
O
O
5
1
Situational
Situational
O
1
Situational
O
1
Situational
O
1
Situational
O
1
Situational
O
1
Situational
O
1
Situational
O
1
Situational
O
1
Situational
O
1
Situational
O
1
Situational
O
1
Required
O
1
Situational
O
O
O
1
1
1
O
3
5
N2/290L
N2/290
1
Other Subscriber Name
Other Subscriber Address
Other Subscriber
City/State/ZIP Code
Other Subscriber
Secondary Identification
Situational
Situational
10
LOOP ID - 2330A
325
332
340
Notes
Supervising Provider
Name
Supervising Provider
Secondary Identification
LOOP ID - 2320
290
Repeat
Situational
N2/325L
N2/325
Required
Situational
Situational
Situational
For internal use only
12/1/2010
Pos
Health Care Claim: Professional - 837
Id
Segment Name
Req
Max Use
LOOP ID - 2330B
325
345
NM1
PER
350
355
DTP
REF
355
REF
355
REF
Other Payer Name
Other Payer Contact
Information
Claim Adjudication Date
Other Payer Secondary
Identifier
Other Payer Prior
Authorization or Referral
Number
Other Payer Claim
Adjustment Indicator
NM1
355
REF
NM1
355
REF
NM1
355
REF
1
2
Situational
Situational
O
2
Situational
O
2
Situational
NM1
355
REF
Other Payer Patient
Information
Other Payer Patient
Identification
O
1
O
3
Other Payer Referring
Provider
Other Payer Referring
Provider Identification
O
1
O
3
O
1
O
3
Other Payer Purchased
Service Provider
Other Payer Purchased
Service Provider
Identification
O
1
O
3
NM1
Other Payer Service
Facility Location
Other Payer Service
Facility Location
Identification
O
1
355
REF
O
3
325
NM1
355
REF
1
O
3
Service Line
Professional Service
O
O
1
1
LOOP ID - 2400
365
370
837P_CG.ecs
LX
SV1
Situational
Required
N2/325L
N2/325
Situational
Required
N2/325L
N2/325
Situational
Required
N2/325L
N2/325
Situational
Required
50
6
N2/325L
N2/325
1
O
Situational
Required
1
Other Payer Supervising
Provider
Other Payer Supervising
Provider Identification
N2/325L
N2/325
1
LOOP ID - 2330H
Situational
Situational
1
Other Payer Rendering
Provider
Other Payer Rendering
Provider Secondary
Identification
Required
Situational
N2/325L
N2/325
2
LOOP ID - 2330G
325
N2/325
1
LOOP ID - 2330F
325
N2/325L
O
O
LOOP ID - 2330E
325
1
Usage
1
2
LOOP ID - 2330D
325
Notes
O
O
LOOP ID - 2330C
325
Repeat
N2/365L
N2/365
Required
Required
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos
Id
Segment Name
400
SV5
420
425
PWK
CR1
430
CR2
435
CR3
445
CR5
450
450
CRC
CRC
450
CRC
455
455
DTP
DTP
455
455
DTP
DTP
455
455
455
DTP
DTP
DTP
455
455
DTP
DTP
455
455
455
455
DTP
DTP
DTP
DTP
462
465
470
MEA
CN1
REF
470
REF
470
REF
470
470
REF
REF
470
REF
470
REF
Durable Medical
Equipment Service
DMERC CMN Indicator
Ambulance Transport
Information
Spinal Manipulation
Service Information
Durable Medical
Equipment Certification
Home Oxygen Therapy
Information
Ambulance Certification
Hospice Employee
Indicator
DMERC Condition
Indicator
Date - Service Date
Date - Certification
Revision Date
Date - Begin Therapy Date
Date - Last Certification
Date
Date - Date Last Seen
Date - Test
Date - Oxygen
Saturation/Arterial Blood
Gas Test
Date - Shipped
Date - Onset of Current
Symptom/Illness
Date - Last X-ray
Date - Acute Manifestation
Date - Initial Treatment
Date - Similar
Illness/Symptom Onset
Test Result
Contract Information
Repriced Line Item
Reference Number
Adjusted Repriced Line
Item Reference Number
Prior Authorization or
Referral Number
Line Item Control Number
Mammography
Certification Number
Clinical Laboratory
Improvement Amendment
(CLIA) Identification
Referring Clinical
Laboratory Improvement
Amendment (CLIA) Facility
837P_CG.ecs
Req
Max Use
O
1
O
O
1
1
O
5
Situational
O
1
Situational
O
1
Situational
O
O
3
1
Situational
Situational
O
2
Situational
O
O
1
1
Required
Situational
O
O
1
1
Situational
Situational
O
O
O
1
2
3
Situational
Situational
Situational
O
O
1
1
Situational
Situational
O
O
O
O
1
1
1
1
Situational
Situational
Situational
Situational
O
O
O
20
1
1
Situational
Situational
Situational
O
1
Situational
O
2
Situational
O
O
1
1
Situational
Situational
O
1
Situational
O
1
Situational
7
Repeat
Notes
Usage
Situational
N2/425
Situational
Situational
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos
Id
470
REF
470
REF
470
470
REF
REF
475
475
475
480
485
488
AMT
AMT
AMT
K3
NTE
PS1
491
HSD
492
HCP
Segment Name
Identification
Immunization Batch
Number
Ambulatory Patient Group
(APG)
Oxygen Flow Rate
Universal Product Number
(UPN)
Sales Tax Amount
Approved Amount
Postage Claimed Amount
File Information
Line Note
Purchased Service
Information
Health Care Services
Delivery
Line Pricing/Repricing
Information
Req
Max Use
O
1
Situational
O
4
Situational
O
O
1
1
Situational
Situational
O
O
O
O
O
O
1
1
1
10
1
1
Situational
Situational
Situational
Situational
Situational
Situational
O
1
Situational
O
1
Situational
LOOP ID - 2410
494
495
496
LIN
CTP
REF
25
Drug Identification
Drug Pricing
Prescription Number
O
O
O
1
1
1
LOOP ID - 2420A
500
505
NM1
PRV
525
REF
Rendering Provider Name
Rendering Provider
Specialty Information
Rendering Provider
Secondary Identification
O
O
1
1
O
5
NM1
525
REF
NM1
N3
520
N4
525
REF
NM1
525
REF
837P_CG.ecs
Situational
Situational
Situational
N2/500L
Situational
Situational
Situational
N2/500L
Purchased Service
Provider Name
Purchased Service
Provider Secondary
Identification
O
1
O
5
Service Facility Location
Service Facility Location
Address
Service Facility Location
City/State/ZIP
Service Facility Location
Secondary Identification
O
O
1
1
N2/500
O
1
Required
O
5
Situational
O
1
O
5
8
N2/500L
N2/500
1
Supervising Provider
Name
Supervising Provider
Secondary Identification
Situational
Situational
1
LOOP ID - 2420D
500
Usage
N2/494L
N2/500
1
LOOP ID - 2420C
500
514
Notes
N2/494
1
LOOP ID - 2420B
500
Repeat
Situational
Required
N2/500L
N2/500
Situational
Situational
For internal use only
12/1/2010
Pos
Health Care Claim: Professional - 837
Id
Segment Name
Req
Max Use
LOOP ID - 2420E
500
514
520
NM1
N3
N4
525
REF
530
PER
Ordering Provider Name
Ordering Provider Address
Ordering Provider
City/State/ZIP Code
Ordering Provider
Secondary Identification
Ordering Provider Contact
Information
NM1
PRV
525
REF
NM1
525
REF
SVD
545
550
CAS
DTP
5
Situational
O
1
Situational
LQ
FRM
Referring Provider Name
Referring Provider
Specialty Information
Referring Provider
Secondary Identification
O
O
1
1
O
5
Other Payer Prior
Authorization or Referral
Number
Other Payer Prior
Authorization or Referral
Number
O
1
O
2
O
1
O
O
99
1
Form Identification Code
Supporting Documentation
O
O
1
99
HL
PAT
NM1
N3
N4
032
DMG
035
REF
035
REF
837P_CG.ecs
CLM
DTP
Situational
Required
N2/540L
N2/540
Situational
Situational
Required
N2/551L
N2/551
N2/552
Situational
Required
>1
Patient Hierarchical Level
Patient Information
O
O
1
1
Situational
Required
1
N2/015L
Patient Name
Patient Address
Patient City/State/ZIP
Code
Patient Demographic
Information
Patient Secondary
Identification
Property and Casualty
Claim Number
O
O
O
1
1
1
O
1
Required
O
5
Situational
O
1
Situational
Claim Information
Date - Initial Treatment
O
O
1
1
LOOP ID - 2300
130
135
N2/500L
N2/500
5
LOOP ID - 2010CA
015
025
030
Situational
Situational
Situational
25
Line Adjudication
Information
Line Adjustment
Line Adjudication Date
Situational
Situational
Situational
N2/500L
N2/500
4
LOOP ID - 2000C
001
007
N2/500
2
LOOP ID - 2440
551
552
N2/500L
O
LOOP ID - 2430
540
1
Usage
1
1
1
LOOP ID - 2420G
500
Notes
O
O
O
LOOP ID - 2420F
500
505
Repeat
N2/015
Required
Required
Required
100
9
Required
Situational
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos
Id
Segment Name
135
135
DTP
DTP
135
135
DTP
DTP
135
135
DTP
DTP
135
135
DTP
DTP
135
135
135
135
DTP
DTP
DTP
DTP
135
135
135
DTP
DTP
DTP
155
PWK
160
175
CN1
AMT
175
175
AMT
AMT
180
REF
180
REF
180
REF
180
REF
180
REF
180
REF
180
180
REF
REF
180
REF
180
REF
Date - Date Last Seen
Date - Onset of Current
Illness/Symptom
Date - Acute Manifestation
Date - Similar
Illness/Symptom Onset
Date - Accident
Date - Last Menstrual
Period
Date - Last X-ray
Date - Hearing and Vision
Prescription Date
Date - Disability Begin
Date - Disability End
Date - Last Worked
Date - Authorized Return
to Work
Date - Admission
Date - Discharge
Date - Assumed and
Relinquished Care Dates
Claim Supplemental
Information
Contract Information
Credit/Debit Card
Maximum Amount
Patient Amount Paid
Total Purchased Service
Amount
Service Authorization
Exception Code
Mandatory Medicare
(Section 4081) Crossover
Indicator
Mammography
Certification Number
Prior Authorization or
Referral Number
Original Reference
Number (ICN/DCN)
Clinical Laboratory
Improvement Amendment
(CLIA) Number
Repriced Claim Number
Adjusted Repriced Claim
Number
Investigational Device
Exemption Number
Claim Identification
Number for Clearing
Houses and Other
Transmission
837P_CG.ecs
Req
Max Use
O
O
1
1
Situational
Situational
O
O
5
10
Situational
Situational
O
O
10
1
Situational
Situational
O
O
1
1
Situational
Situational
O
O
O
O
5
5
1
1
Situational
Situational
Situational
Situational
O
O
O
1
1
2
Situational
Situational
Situational
O
10
Situational
O
O
1
1
Situational
Situational
O
O
1
1
Situational
Situational
O
1
Situational
O
1
Situational
O
1
Situational
O
2
Situational
O
1
Situational
O
3
Situational
O
O
1
1
Situational
Situational
O
1
Situational
O
1
Situational
10
Repeat
Notes
Usage
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos
Id
180
REF
180
180
REF
REF
185
190
195
K3
NTE
CR1
200
CR2
220
220
CRC
CRC
220
220
231
CRC
CRC
HI
241
HCP
Segment Name
Intermediaries
Ambulatory Patient Group
(APG)
Medical Record Number
Demonstration Project
Identifier
File Information
Claim Note
Ambulance Transport
Information
Spinal Manipulation
Service Information
Ambulance Certification
Patient Condition
Information: Vision
Homebound Indicator
EPSDT Referral
Health Care Diagnosis
Code
Claim Pricing/Repricing
Information
Req
Max Use
O
4
Situational
O
O
1
1
Situational
Situational
O
O
O
10
1
1
Situational
Situational
Situational
O
1
Situational
O
O
3
3
Situational
Situational
O
O
O
1
1
1
Situational
Situational
Situational
O
1
Situational
LOOP ID - 2305
242
CR7
243
HSD
NM1
PRV
271
REF
NM1
PRV
271
REF
O
1
Situational
O
3
Situational
Referring Provider Name
Referring Provider
Specialty Information
Referring Provider
Secondary Identification
O
O
1
1
O
5
2
Rendering Provider Name
Rendering Provider
Specialty Information
Rendering Provider
Secondary Identification
O
O
1
1
O
5
NM1
Purchased Service
Provider Name
Purchased Service
Provider Secondary
Identification
O
1
271
REF
O
5
250
265
NM1
N3
270
N4
837P_CG.ecs
O
O
1
1
O
1
11
N2/250L
N2/250
Situational
Situational
Situational
N2/250L
N2/250
Situational
Situational
1
Service Facility Location
Service Facility Location
Address
Service Facility Location
Situational
Situational
Situational
1
LOOP ID - 2310D
N2/250L
N2/250
1
LOOP ID - 2310C
250
N2/195
Usage
Home Health Care Plan
Information
Health Care Services
Delivery
LOOP ID - 2310B
250
255
Notes
6
LOOP ID - 2310A
250
255
Repeat
N2/250L
N2/250
Situational
Required
Required
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos
Id
271
REF
Segment Name
City/State/ZIP
Service Facility Location
Secondary Identification
Req
Max Use
O
5
LOOP ID - 2310E
250
NM1
271
REF
SBR
295
300
CAS
AMT
300
AMT
300
AMT
300
AMT
300
AMT
300
AMT
300
AMT
300
AMT
300
AMT
300
AMT
305
DMG
310
OI
320
MOA
NM1
N3
N4
355
REF
837P_CG.ecs
NM1
N2/250L
O
1
O
5
Other Subscriber
Information
Claim Level Adjustments
Coordination of Benefits
(COB) Payer Paid Amount
Coordination of Benefits
(COB) Approved Amount
Coordination of Benefits
(COB) Allowed Amount
Coordination of Benefits
(COB) Patient
Responsibility Amount
Coordination of Benefits
(COB) Covered Amount
Coordination of Benefits
(COB) Discount Amount
Coordination of Benefits
(COB) Per Day Limit
Amount
Coordination of Benefits
(COB) Patient Paid
Amount
Coordination of Benefits
(COB) Tax Amount
Coordination of Benefits
(COB) Total Claim Before
Taxes Amount
Subscriber Demographic
Information
Other Insurance Coverage
Information
Medicare Outpatient
Adjudication Information
O
1
N2/250
O
O
5
1
Situational
Situational
O
1
Situational
O
1
Situational
O
1
Situational
O
1
Situational
O
1
Situational
O
1
Situational
O
1
Situational
O
1
Situational
O
1
Situational
O
1
Situational
O
1
Required
O
1
Situational
O
O
O
1
1
1
O
3
Other Payer Name
O
1
Situational
N2/325L
N2/325
Required
Situational
Situational
Situational
1
12
N2/290L
N2/290
1
Other Subscriber Name
Other Subscriber Address
Other Subscriber
City/State/ZIP Code
Other Subscriber
Secondary Identification
Situational
Situational
10
LOOP ID - 2330B
325
Usage
Supervising Provider
Name
Supervising Provider
Secondary Identification
LOOP ID - 2330A
325
332
340
Notes
Situational
1
LOOP ID - 2320
290
Repeat
N2/325L
N2/325
Required
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos
Id
Segment Name
Req
Max Use
345
PER
350
355
DTP
REF
355
REF
355
REF
Other Payer Contact
Information
Claim Adjudication Date
Other Payer Secondary
Identifier
Other Payer Prior
Authorization or Referral
Number
Other Payer Claim
Adjustment Indicator
O
2
Situational
O
O
1
2
Situational
Situational
O
2
Situational
O
2
Situational
Other Payer Patient
Information
Other Payer Patient
Identification
O
1
O
3
LOOP ID - 2330C
325
NM1
355
REF
1
LOOP ID - 2330D
325
NM1
355
REF
Other Payer Referring
Provider
Other Payer Referring
Provider Identification
O
1
O
3
NM1
355
REF
O
1
O
3
LOOP ID - 2330F
325
NM1
355
REF
O
1
O
3
LOOP ID - 2330G
325
NM1
355
REF
O
1
O
3
Other Payer Supervising
Provider
Other Payer Supervising
Provider Identification
O
1
O
3
LOOP ID - 2330H
325
NM1
355
REF
365
370
400
837P_CG.ecs
LX
SV1
SV5
O
O
O
1
1
1
13
Situational
N2/325L
Situational
Required
N2/325L
N2/325
Situational
Required
N2/325L
N2/325
Situational
Required
N2/325L
N2/325
Situational
Required
50
Service Line
Professional Service
Durable Medical
Equipment Service
N2/325L
N2/325
1
LOOP ID - 2400
Situational
Required
1
Other Payer Service
Facility Location
Other Payer Service
Facility Location
Identification
N2/325L
N2/325
1
Other Payer Purchased
Service Provider
Other Payer Purchased
Service Provider
Identification
Usage
Situational
1
Other Payer Rendering
Provider
Other Payer Rendering
Provider Secondary
Identification
Notes
N2/325
2
LOOP ID - 2330E
325
Repeat
N2/365L
N2/365
Required
Required
Situational
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos
420
425
Id
PWK
CR1
430
CR2
435
CR3
445
CR5
450
450
CRC
CRC
450
CRC
455
455
DTP
DTP
455
455
DTP
DTP
455
455
455
DTP
DTP
DTP
455
455
DTP
DTP
455
455
455
455
DTP
DTP
DTP
DTP
462
465
470
MEA
CN1
REF
470
REF
470
REF
470
470
REF
REF
470
REF
470
REF
470
REF
837P_CG.ecs
Segment Name
DMERC CMN Indicator
Ambulance Transport
Information
Spinal Manipulation
Service Information
Durable Medical
Equipment Certification
Home Oxygen Therapy
Information
Ambulance Certification
Hospice Employee
Indicator
DMERC Condition
Indicator
Date - Service Date
Date - Certification
Revision Date
Date - Begin Therapy Date
Date - Last Certification
Date
Date - Date Last Seen
Date - Test
Date - Oxygen
Saturation/Arterial Blood
Gas Test
Date - Shipped
Date - Onset of Current
Symptom/Illness
Date - Last X-ray
Date - Acute Manifestation
Date - Initial Treatment
Date - Similar
Illness/Symptom Onset
Test Result
Contract Information
Repriced Line Item
Reference Number
Adjusted Repriced Line
Item Reference Number
Prior Authorization or
Referral Number
Line Item Control Number
Mammography
Certification Number
Clinical Laboratory
Improvement Amendment
(CLIA) Identification
Referring Clinical
Laboratory Improvement
Amendment (CLIA) Facility
Identification
Immunization Batch
Req
O
O
Max Use
1
1
O
5
Situational
O
1
Situational
O
1
Situational
O
O
3
1
Situational
Situational
O
2
Situational
O
O
1
1
Required
Situational
O
O
1
1
Situational
Situational
O
O
O
1
2
3
Situational
Situational
Situational
O
O
1
1
Situational
Situational
O
O
O
O
1
1
1
1
Situational
Situational
Situational
Situational
O
O
O
20
1
1
Situational
Situational
Situational
O
1
Situational
O
2
Situational
O
O
1
1
Situational
Situational
O
1
Situational
O
1
Situational
O
1
Situational
14
Repeat
Notes
N2/425
Usage
Situational
Situational
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos
Id
470
REF
470
470
REF
REF
475
475
475
480
485
488
AMT
AMT
AMT
K3
NTE
PS1
491
HSD
492
HCP
Segment Name
Number
Ambulatory Patient Group
(APG)
Oxygen Flow Rate
Universal Product Number
(UPN)
Sales Tax Amount
Approved Amount
Postage Claimed Amount
File Information
Line Note
Purchased Service
Information
Health Care Services
Delivery
Line Pricing/Repricing
Information
Req
Max Use
O
4
Situational
O
O
1
1
Situational
Situational
O
O
O
O
O
O
1
1
1
10
1
1
Situational
Situational
Situational
Situational
Situational
Situational
O
1
Situational
O
1
Situational
O
O
O
1
1
1
LOOP ID - 2410
494
495
496
LIN
CTP
REF
25
Drug Identification
Drug Pricing
Prescription Number
LOOP ID - 2420A
500
505
NM1
PRV
525
REF
Rendering Provider Name
Rendering Provider
Specialty Information
Rendering Provider
Secondary Identification
O
O
1
1
O
5
NM1
525
REF
NM1
N3
520
N4
525
REF
NM1
525
REF
837P_CG.ecs
NM1
N2/500L
Situational
Situational
Situational
N2/500L
O
1
O
5
Service Facility Location
Service Facility Location
Address
Service Facility Location
City/State/ZIP
Service Facility Location
Secondary Identification
O
O
1
1
N2/500
O
1
Required
O
5
Situational
Supervising Provider
Name
Supervising Provider
Secondary Identification
O
1
O
5
1
15
Situational
Required
N2/500L
N2/500
Situational
Situational
1
O
N2/500L
N2/500
1
Ordering Provider Name
Situational
Situational
1
LOOP ID - 2420E
500
Situational
Situational
Situational
Purchased Service
Provider Name
Purchased Service
Provider Secondary
Identification
LOOP ID - 2420D
500
Usage
N2/494L
N2/500
1
LOOP ID - 2420C
500
514
Notes
N2/494
1
LOOP ID - 2420B
500
Repeat
N2/500L
N2/500
Situational
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos
Id
Segment Name
514
520
N3
N4
525
REF
530
PER
Ordering Provider Address
Ordering Provider
City/State/ZIP Code
Ordering Provider
Secondary Identification
Ordering Provider Contact
Information
Req
Max Use
O
O
1
1
Situational
Situational
O
5
Situational
O
1
Situational
LOOP ID - 2420F
500
505
NM1
PRV
525
REF
2
Referring Provider Name
Referring Provider
Specialty Information
Referring Provider
Secondary Identification
O
O
1
1
O
5
LOOP ID - 2420G
500
NM1
525
REF
Other Payer Prior
Authorization or Referral
Number
Other Payer Prior
Authorization or Referral
Number
O
1
O
2
SVD
545
550
CAS
DTP
O
1
O
O
99
1
Form Identification Code
Supporting Documentation
Transaction Set Trailer
O
O
M
1
99
1
Req
Max Use
M
M
1
1
LOOP ID - 2440
551
552
555
LQ
FRM
SE
Usage
N2/500L
Situational
Situational
Situational
N2/500L
N2/500
Situational
Required
25
Line Adjudication
Information
Line Adjustment
Line Adjudication Date
Notes
N2/500
4
LOOP ID - 2430
540
Repeat
N2/540L
N2/540
Situational
Situational
Required
5
N2/551L
N2/551
N2/552
Situational
Required
Required
Notes
Usage
Not Defined:
Pos
Id
Segment Name
GE
IEA
Functional Group Trailer
Interchange Control Trailer
Repeat
Required
Required
Notes:
1/020L
1/020
1/020L
1/020
2/015L
Loop 1000 contains submitter and receiver information. If any intermediary receivers change or add data
in any way, then they add an occurrence to the loop as a form of identification. The added loop
occurrence must be the last occurrence of the loop.
Loop 1000 contains submitter and receiver information. If any intermediary receivers change or add data
in any way, then they add an occurrence to the loop as a form of identification. The added loop
occurrence must be the last occurrence of the loop.
Loop 1000 contains submitter and receiver information. If any intermediary receivers change or add data
in any way, then they add an occurrence to the loop as a form of identification. The added loop
occurrence must be the last occurrence of the loop.
Loop 1000 contains submitter and receiver information. If any intermediary receivers change or add data
in any way, then they add an occurrence to the loop as a form of identification. The added loop
occurrence must be the last occurrence of the loop.
Loop 2010 contains information about entities that apply to all claims in loop 2300. For example, these
entities may include billing provider, pay-to provider, insurer, primary administrator, contract holder, or
837P_CG.ecs
16
For internal use only
12/1/2010
2/015
2/015L
2/015
2/015L
2/015
2/015L
2/015
2/015L
2/015
2/015L
2/015
2/195
2/250L
2/250
2/250L
2/250
2/250L
2/250
2/250L
2/250
2/250L
2/250
2/290L
2/290
2/325L
2/325
Health Care Claim: Professional - 837
claimant.
Loop 2010 contains information about entities that apply to all claims in loop 2300. For example, these
entities may include billing provider, pay-to provider, insurer, primary administrator, contract holder, or
claimant.
Loop 2010 contains information about entities that apply to all claims in loop 2300. For example, these
entities may include billing provider, pay-to provider, insurer, primary administrator, contract holder, or
claimant.
Loop 2010 contains information about entities that apply to all claims in loop 2300. For example, these
entities may include billing provider, pay-to provider, insurer, primary administrator, contract holder, or
claimant.
Loop 2010 contains information about entities that apply to all claims in loop 2300. For example, these
entities may include billing provider, pay-to provider, insurer, primary administrator, contract holder, or
claimant.
Loop 2010 contains information about entities that apply to all claims in loop 2300. For example, these
entities may include billing provider, pay-to provider, insurer, primary administrator, contract holder, or
claimant.
Loop 2010 contains information about entities that apply to all claims in loop 2300. For example, these
entities may include billing provider, pay-to provider, insurer, primary administrator, contract holder, or
claimant.
Loop 2010 contains information about entities that apply to all claims in loop 2300. For example, these
entities may include billing provider, pay-to provider, insurer, primary administrator, contract holder, or
claimant.
Loop 2010 contains information about entities that apply to all claims in loop 2300. For example, these
entities may include billing provider, pay-to provider, insurer, primary administrator, contract holder, or
claimant.
Loop 2010 contains information about entities that apply to all claims in loop 2300. For example, these
entities may include billing provider, pay-to provider, insurer, primary administrator, contract holder, or
claimant.
Loop 2010 contains information about entities that apply to all claims in loop 2300. For example, these
entities may include billing provider, pay-to provider, insurer, primary administrator, contract holder, or
claimant.
Loop 2010 contains information about entities that apply to all claims in loop 2300. For example, these
entities may include billing provider, pay-to provider, insurer, primary administrator, contract holder, or
claimant.
The CR1 through CR5 and CRC certification segments appear on both the claim level and the service line
level because certifications can be submitted for all services on a claim or for individual services.
Certification information at the claim level applies to all service lines of the claim, unless overridden by
certification information at the service line level.
Loop 2310 contains information about the rendering, referring, or attending provider.
Loop 2310 contains information about the rendering, referring, or attending provider.
Loop 2310 contains information about the rendering, referring, or attending provider.
Loop 2310 contains information about the rendering, referring, or attending provider.
Loop 2310 contains information about the rendering, referring, or attending provider.
Loop 2310 contains information about the rendering, referring, or attending provider.
Loop 2310 contains information about the rendering, referring, or attending provider.
Loop 2310 contains information about the rendering, referring, or attending provider.
Loop 2310 contains information about the rendering, referring, or attending provider.
Loop 2310 contains information about the rendering, referring, or attending provider.
Loop 2320 contains insurance information about: paying and other Insurance Carriers for that Subscriber,
Subscriber of the Other Insurance Carriers, School or Employer Information for that Subscriber.
Loop 2320 contains insurance information about: paying and other Insurance Carriers for that Subscriber,
Subscriber of the Other Insurance Carriers, School or Employer Information for that Subscriber.
Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop
2320.
Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop
837P_CG.ecs
17
For internal use only
12/1/2010
2/325L
2/325
2/325L
2/325
2/325L
2/325
2/325L
2/325
2/325L
2/325
2/325L
2/325
2/325L
2/325
2/365L
2/365
2/425
2/494L
2/494
2/500L
2/500
2/500L
2/500
2/500L
2/500
Health Care Claim: Professional - 837
2320.
Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop
2320.
Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop
2320.
Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop
2320.
Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop
2320.
Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop
2320.
Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop
2320.
Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop
2320.
Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop
2320.
Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop
2320.
Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop
2320.
Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop
2320.
Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop
2320.
Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop
2320.
Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop
2320.
Loop 2400 contains Service Line information.
Loop 2400 contains Service Line information.
The CR1 through CR5 and CRC certification segments appear on both the claim level and the service line
level because certifications can be submitted for all services on a claim or for individual services.
Certification information at the claim level applies to all service lines of the claim, unless overridden by
certification information at the service line level.
Loop 2410 contains compound drug components, quantities and prices.
Loop 2410 contains compound drug components, quantities and prices.
Loop 2420 contains information about the rendering, referring, or attending provider on a service line
level. These segments override the information in the claim - level segments if the entity identifier codes in
each NM1 segment are the same.
Loop 2420 contains information about the rendering, referring, or attending provider on a service line
level. These segments override the information in the claim - level segments if the entity identifier codes in
each NM1 segment are the same.
Loop 2420 contains information about the rendering, referring, or attending provider on a service line
level. These segments override the information in the claim - level segments if the entity identifier codes in
each NM1 segment are the same.
Loop 2420 contains information about the rendering, referring, or attending provider on a service line
level. These segments override the information in the claim - level segments if the entity identifier codes in
each NM1 segment are the same.
Loop 2420 contains information about the rendering, referring, or attending provider on a service line
level. These segments override the information in the claim - level segments if the entity identifier codes in
each NM1 segment are the same.
Loop 2420 contains information about the rendering, referring, or attending provider on a service line
level. These segments override the information in the claim - level segments if the entity identifier codes in
each NM1 segment are the same.
837P_CG.ecs
18
For internal use only
12/1/2010
2/500L
2/500
2/500L
2/500
2/500L
2/500
2/500L
2/500
2/540L
2/540
2/551L
2/551
2/552
2/015L
2/015
2/195
2/250L
2/250
2/250L
2/250
2/250L
2/250
2/250L
2/250
2/250L
2/250
Health Care Claim: Professional - 837
Loop 2420 contains information about the rendering, referring, or attending provider on a service line
level. These segments override the information in the claim - level segments if the entity identifier codes in
each NM1 segment are the same.
Loop 2420 contains information about the rendering, referring, or attending provider on a service line
level. These segments override the information in the claim - level segments if the entity identifier codes in
each NM1 segment are the same.
Loop 2420 contains information about the rendering, referring, or attending provider on a service line
level. These segments override the information in the claim - level segments if the entity identifier codes in
each NM1 segment are the same.
Loop 2420 contains information about the rendering, referring, or attending provider on a service line
level. These segments override the information in the claim - level segments if the entity identifier codes in
each NM1 segment are the same.
Loop 2420 contains information about the rendering, referring, or attending provider on a service line
level. These segments override the information in the claim - level segments if the entity identifier codes in
each NM1 segment are the same.
Loop 2420 contains information about the rendering, referring, or attending provider on a service line
level. These segments override the information in the claim - level segments if the entity identifier codes in
each NM1 segment are the same.
Loop 2420 contains information about the rendering, referring, or attending provider on a service line
level. These segments override the information in the claim - level segments if the entity identifier codes in
each NM1 segment are the same.
Loop 2420 contains information about the rendering, referring, or attending provider on a service line
level. These segments override the information in the claim - level segments if the entity identifier codes in
each NM1 segment are the same.
SVD01 identifies the payer which adjudicated the corresponding service line and must match DE 67 in the
NM109 position 325 for the payer.
SVD01 identifies the payer which adjudicated the corresponding service line and must match DE 67 in the
NM109 position 325 for the payer.
Loop 2440 provides certificate of medical necessity information for the procedure identified in SV101 in
position 2/3700.
Loop 2440 provides certificate of medical necessity information for the procedure identified in SV101 in
position 2/3700.
RM segment provides question numbers and responses for the questions on the medical necessity
information form identified in LQ position 551.
Loop 2010 contains information about entities that apply to all claims in loop 2300. For example, these
entities may include billing provider, pay-to provider, insurer, primary administrator, contract holder, or
claimant.
Loop 2010 contains information about entities that apply to all claims in loop 2300. For example, these
entities may include billing provider, pay-to provider, insurer, primary administrator, contract holder, or
claimant.
The CR1 through CR5 and CRC certification segments appear on both the claim level and the service line
level because certifications can be submitted for all services on a claim or for individual services.
Certification information at the claim level applies to all service lines of the claim, unless overridden by
certification information at the service line level.
Loop 2310 contains information about the rendering, referring, or attending provider.
Loop 2310 contains information about the rendering, referring, or attending provider.
Loop 2310 contains information about the rendering, referring, or attending provider.
Loop 2310 contains information about the rendering, referring, or attending provider.
Loop 2310 contains information about the rendering, referring, or attending provider.
Loop 2310 contains information about the rendering, referring, or attending provider.
Loop 2310 contains information about the rendering, referring, or attending provider.
Loop 2310 contains information about the rendering, referring, or attending provider.
Loop 2310 contains information about the rendering, referring, or attending provider.
Loop 2310 contains information about the rendering, referring, or attending provider.
837P_CG.ecs
19
For internal use only
12/1/2010
2/290L
2/290
2/325L
2/325
2/325L
2/325
2/325L
2/325
2/325L
2/325
2/325L
2/325
2/325L
2/325
2/325L
2/325
2/325L
2/325
2/365L
2/365
2/425
2/494L
2/494
2/500L
2/500
2/500L
2/500
Health Care Claim: Professional - 837
Loop 2320 contains insurance information about: paying and other Insurance Carriers for that Subscriber,
Subscriber of the Other Insurance Carriers, School or Employer Information for that Subscriber.
Loop 2320 contains insurance information about: paying and other Insurance Carriers for that Subscriber,
Subscriber of the Other Insurance Carriers, School or Employer Information for that Subscriber.
Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop
2320.
Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop
2320.
Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop
2320.
Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop
2320.
Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop
2320.
Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop
2320.
Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop
2320.
Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop
2320.
Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop
2320.
Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop
2320.
Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop
2320.
Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop
2320.
Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop
2320.
Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop
2320.
Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop
2320.
Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop
2320.
Loop 2400 contains Service Line information.
Loop 2400 contains Service Line information.
The CR1 through CR5 and CRC certification segments appear on both the claim level and the service line
level because certifications can be submitted for all services on a claim or for individual services.
Certification information at the claim level applies to all service lines of the claim, unless overridden by
certification information at the service line level.
Loop 2410 contains compound drug components, quantities and prices.
Loop 2410 contains compound drug components, quantities and prices.
Loop 2420 contains information about the rendering, referring, or attending provider on a service line
level. These segments override the information in the claim - level segments if the entity identifier codes in
each NM1 segment are the same.
Loop 2420 contains information about the rendering, referring, or attending provider on a service line
level. These segments override the information in the claim - level segments if the entity identifier codes in
each NM1 segment are the same.
Loop 2420 contains information about the rendering, referring, or attending provider on a service line
level. These segments override the information in the claim - level segments if the entity identifier codes in
each NM1 segment are the same.
Loop 2420 contains information about the rendering, referring, or attending provider on a service line
level. These segments override the information in the claim - level segments if the entity identifier codes in
837P_CG.ecs
20
For internal use only
12/1/2010
2/500L
2/500
2/500L
2/500
2/500L
2/500
2/500L
2/500
2/500L
2/500
2/540L
2/540
2/551L
2/551
2/552
Health Care Claim: Professional - 837
each NM1 segment are the same.
Loop 2420 contains information about the rendering, referring, or attending provider on a service line
level. These segments override the information in the claim - level segments if the entity identifier codes in
each NM1 segment are the same.
Loop 2420 contains information about the rendering, referring, or attending provider on a service line
level. These segments override the information in the claim - level segments if the entity identifier codes in
each NM1 segment are the same.
Loop 2420 contains information about the rendering, referring, or attending provider on a service line
level. These segments override the information in the claim - level segments if the entity identifier codes in
each NM1 segment are the same.
Loop 2420 contains information about the rendering, referring, or attending provider on a service line
level. These segments override the information in the claim - level segments if the entity identifier codes in
each NM1 segment are the same.
Loop 2420 contains information about the rendering, referring, or attending provider on a service line
level. These segments override the information in the claim - level segments if the entity identifier codes in
each NM1 segment are the same.
Loop 2420 contains information about the rendering, referring, or attending provider on a service line
level. These segments override the information in the claim - level segments if the entity identifier codes in
each NM1 segment are the same.
Loop 2420 contains information about the rendering, referring, or attending provider on a service line
level. These segments override the information in the claim - level segments if the entity identifier codes in
each NM1 segment are the same.
Loop 2420 contains information about the rendering, referring, or attending provider on a service line
level. These segments override the information in the claim - level segments if the entity identifier codes in
each NM1 segment are the same.
Loop 2420 contains information about the rendering, referring, or attending provider on a service line
level. These segments override the information in the claim - level segments if the entity identifier codes in
each NM1 segment are the same.
Loop 2420 contains information about the rendering, referring, or attending provider on a service line
level. These segments override the information in the claim - level segments if the entity identifier codes in
each NM1 segment are the same.
SVD01 identifies the payer which adjudicated the corresponding service line and must match DE 67 in the
NM109 position 325 for the payer.
SVD01 identifies the payer which adjudicated the corresponding service line and must match DE 67 in the
NM109 position 325 for the payer.
Loop 2440 provides certificate of medical necessity information for the procedure identified in SV101 in
position 2/3700.
Loop 2440 provides certificate of medical necessity information for the procedure identified in SV101 in
position 2/3700.
RM segment provides question numbers and responses for the questions on the medical necessity
information form identified in LQ position 551.
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.
837P_CG.ecs
21
For internal use only
12/1/2010
Health Care Claim: Professional - 837
ISA Interchange Control Header
Pos:
Max: 1
Not Defined - Mandatory
Loop: N/A
Elements: 16
User Option (Usage): Required
Purpose: To start and identify an interchange of zero or more functional groups and interchange-related control
segments
Element Summary:
Ref
Id
Element Name
ISA01
I01
Authorization Information Qualifier
Req
Type
Min/Max
Usage
M
ID
2/2
Required
Description: Code to identify the type of information in the Authorization Information
CodeList Summary (Total Codes: 7, Included: 2)
Code Name
ISA02
I02
00
No Authorization Information Present (No Meaningful Information in I02)
ADVISED UNLESS SECURITY REQUIREMENTS MANDATE USE OF
ADDITIONAL IDENTIFICATION.
03
Additional Data Identification
Authorization Information
M
AN
10/10
Required
Description: Information used for additional identification or authorization of the
interchange sender or the data in the interchange; the type of information is set by the
Authorization Information Qualifier (I01)
ISA03
I03
Security Information Qualifier
M
ID
2/2
Required
Description: Code to identify the type of information in the Security Information
CodeList Summary (Total Codes: 2, Included: 2)
Code Name
ISA04
I04
00
No Security Information Present (No Meaningful Information in I04)
ADVISED UNLESS SECURITY REQUIREMENTS MANDATE USE OF
PASSWORD DATA.
01
Password
Security Information
M
AN
10/10
Required
Description: This is used for identifying the security information about the interchange
sender or the data in the interchange; the type of information is set by the Security
Information Qualifier (I03)
ISA05
I05
Interchange ID Qualifier
M
ID
2/2
Required
Description: Qualifier to designate the system/method of code structure used to designate
the sender or receiver ID element being qualified
This ID qualifies the Sender in ISA06.
CodeList Summary (Total Codes: 38, Included: 9)
Code Name
01
14
20
837P_CG.ecs
Duns (Dun & Bradstreet)
Duns Plus Suffix
Health Industry Number (HIN)
CODE SOURCE:
22
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Code Name
121: Health Industry Identification Number
27
28
29
30
33
ZZ
ISA06
I06
Carrier Identification Number as assigned by Health Care Financing Administration
(HCFA)
Fiscal Intermediary Identification Number as assigned by Health Care Financing
Administration (HCFA)
Medicare Provider and Supplier Identification Number as assigned by Health Care
Financing Administration (HCFA)
U.S. Federal Tax Identification Number
National Association of Insurance Commissioners Company Code (NAIC)
Mutually Defined
Interchange Sender ID
M
AN
15/15
Required
Description: Identification code published by the sender for other parties to use as the
receiver ID to route data to them; the sender always codes this value in the sender ID
element
ISA07
I05
Interchange ID Qualifier
M
ID
2/2
Required
Description: Qualifier to designate the system/method of code structure used to designate
the sender or receiver ID element being qualified
This ID qualifies the Receiver in ISA08.
CodeList Summary (Total Codes: 38, Included: 9)
Code Name
01
14
20
Duns (Dun & Bradstreet)
Duns Plus Suffix
Health Industry Number (HIN)
CODE SOURCE:
27
Carrier Identification Number as assigned by Health Care Financing Administration
(HCFA)
Fiscal Intermediary Identification Number as assigned by Health Care Financing
Administration (HCFA)
Medicare Provider and Supplier Identification Number as assigned by Health Care
Financing Administration (HCFA)
U.S. Federal Tax Identification Number
National Association of Insurance Commissioners Company Code (NAIC)
Mutually Defined
121: Health Industry Identification Number
28
29
30
33
ZZ
ISA08
I07
Interchange Receiver ID
M
AN
15/15
Required
Description: Identification code published by the receiver of the data; When sending, it is
used by the sender as their sending ID, thus other parties sending to them will use this as a
receiving ID to route data to them
ISA09
I08
Interchange Date
M
DT
6/6
Required
M
TM
4/4
Required
Description: Date of the interchange
The date format is YYMMDD.
ISA10
I09
Interchange Time
Description: Time of the interchange
The time format is HHMM.
837P_CG.ecs
23
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Ref
Id
Element Name
ISA11
I10
Interchange Control Standards
Identifier
Req
Type
Min/Max
Usage
M
ID
1/1
Required
Description: Code to identify the agency responsible for the control standard used by the
message that is enclosed by the interchange header and trailer
All valid standard codes are used. (Total Codes: 1)
ISA12
I11
Interchange Control Version Number
M
ID
5/5
Required
Description: Code specifying the version number of the interchange control segments
CodeList Summary (Total Codes: 14, Included: 1)
Code Name
00401 Draft Standards for Trial Use Approved for Publication by ASC X12 Procedures
Review Board through October 1997
ISA13
I12
Interchange Control Number
M
N0
9/9
Required
Description: A control number assigned by the interchange sender
The Interchange Control Number, ISA13, must be identical to the associated Interchange
Trailer IEA02.
ISA14
I13
Acknowledgment Requested
M
ID
1/1
Required
Description: Code sent by the sender to request an interchange acknowledgment (TA1)
See Section A.1.5.1 for interchange acknowledgment information.
All valid standard codes are used. (Total Codes: 2)
ISA15
I14
Usage Indicator
M
ID
1/1
Required
Description: Code to indicate whether data enclosed by this interchange envelope is test,
production or information
CodeList Summary (Total Codes: 3, Included: 2)
Code Name
P
T
ISA16
I15
Production Data
Test Data
Component Element Separator
M
1/1
Required
Description: Type is not applicable; the component element separator is a delimiter and
not a data element; this field provides the delimiter used to separate component data
elements within a composite data structure; this value must be different than the data
element separator and the segment terminator
Notes:
The ISA is a fixed record length segment and all positions within each of the data elements must be filled. The
first element separator defines the element separator to be used through the entire interchange. The segment
terminator used after the ISA defines the segment terminator to be used throughout the entire interchange.
Spaces in the example are represented by '.' for clarity.
Example:
ISA*00*..........*01*SECRET....*ZZ*SUBMITTERS.ID..*ZZ*RECEIVERS.ID...*930602*1253*U*00401*000000905*1
*T*:~
837P_CG.ecs
24
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos:
GS Functional Group Header
Max: 1
Not Defined - Mandatory
Loop: N/A
Elements: 8
User Option (Usage): Required
Purpose: To indicate the beginning of a functional group and to provide control information
Element Summary:
Ref
Id
Element Name
GS01
479
Functional Identifier Code
Req
Type
Min/Max
Usage
M
ID
2/2
Required
Description: Code identifying a group of application related transaction sets
CodeList Summary (Total Codes: 240, Included: 1)
Code Name
HC
GS02
142
Health Care Claim (837)
Application Sender's Code
M
AN
2/15
Required
Description: Code identifying party sending transmission; codes agreed to by trading
partners
Use this code to identify the unit sending the information.
GS03
124
Application Receiver's Code
M
AN
2/15
Required
Description: Code identifying party receiving transmission; codes agreed to by trading
partners
Use this code to identify the unit receiving the information.
GS04
373
Date
M
DT
8/8
Required
TM
4/8
Required
Description: Date expressed as CCYYMMDD
Use this date for the functional group creation date.
GS05
337
Time
M
Description: Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or
HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer
seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D
= tenths (0-9) and DD = hundredths (00-99)
Use this time for the creation time. The recommended format is HHMM.
GS06
28
Group Control Number
M
N0
1/9
Required
Description: Assigned number originated and maintained by the sender
GS07
455
Responsible Agency Code
M
ID
1/2
Required
Description: Code identifying the issuer of the standard; this code is used in conjunction
with Data Element 480
CodeList Summary (Total Codes: 2, Included: 1)
Code Name
X
GS08
480
Accredited Standards Committee X12
Version / Release / Industry Identifier
Code
M
AN
1/12
Required
Description: Code indicating the version, release, subrelease, and industry identifier of the
837P_CG.ecs
25
For internal use only
12/1/2010
Ref
Health Care Claim: Professional - 837
Id
Element Name
Req
Type
Min/Max
Usage
EDI standard being used, including the GS and GE segments; if code in DE455 in GS
segment is X, then in DE 480 positions 1-3 are the version number; positions 4-6 are the
release and subrelease, level of the version; and positions 7-12 are the industry or trade
association identifiers (optionally assigned by user); if code in DE455 in GS segment is T,
then other formats are allowed
CodeList Summary (Total Codes: 48, Included: 1)
Code
Name
004010X09
8A1
Draft Standards Approved for Publication by ASC X12 Procedures Review
Board through October 1997, as published in this implementation guide.
Semantics:
1. GS04 is the group date.
2. GS05 is the group time.
3. The data interchange control number GS06 in this header must be identical to the same data element in the
associated functional group trailer, GE02.
Comments:
1. A functional group of related transaction sets, within the scope of X12 standards, consists of a collection of
similar transaction sets enclosed by a functional group header and a functional group trailer.
Example:
GS*HC*SENDER CODE*RECEIVER CODE*19940331*0802*1*X*004010X097~
837P_CG.ecs
26
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 005
ST Transaction Set Header
Max: 1
Heading - Mandatory
Loop: N/A
Elements: 2
User Option (Usage): Required
Purpose: To indicate the start of a transaction set and to assign a control number
Element Summary:
Ref
Id
Element Name
ST01
143
Transaction Set Identifier Code
Req
Type
Min/Max
Usage
M
ID
3/3
Required
4/9
Required
Description: Code uniquely identifying a Transaction Set
The only valid value within this transaction set for ST01 is 837.
CodeList Summary (Total Codes: 298, Included: 1)
Code Name
837
ST02
329
Health Care Claim
REQUIRED
Transaction Set Control Number
M
AN
Description: Identifying control number that must be unique within the transaction set
functional group assigned by the originator for a transaction set
Alias: Transaction Set Control Number
The Transaction Set Control Numbers in ST02 and SE02 must be identical. This unique
number also aids in error resolution research. Submitters could begin sending transactions
using the number 0001 in this element and increment from there. The number must be
unique within a specific functional group (GS-GE) and interchange (ISA-IEA), but can
repeat in other groups and interchanges.
Semantics:
1. The transaction set identifier (ST01) used by the translation routines of the interchange partners to select the
appropriate transaction set definition (e.g., 810 selects the Invoice Transaction Set).
Example:
ST*837*987654~
837P_CG.ecs
27
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 010
BHT Beginning of Hierarchical
Max: 1
Heading - Mandatory
Transaction
Loop: N/A
Elements: 6
User Option (Usage): Required
Purpose: To define the business hierarchical structure of the transaction set and identify the business application
purpose and reference data, i.e., number, date, and time
Element Summary:
Ref
Id
Element Name
BHT01
1005
Hierarchical Structure Code
Req
Type
Min/Max
Usage
M
ID
4/4
Required
Description: Code indicating the hierarchical application structure of a transaction set that
utilizes the HL segment to define the structure of the transaction set
CodeList Summary (Total Codes: 61, Included: 1)
Code Name
0019 Information Source, Subscriber, Dependent
BHT02
353
Transaction Set Purpose Code
M
ID
2/2
Required
Description: Code identifying purpose of transaction set
Alias: Transaction Set Purpose Code
NSF Reference: AA0-23.0
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.
ORIGINAL: Original transmissions are claims/encounters which have never been sent to
the receiver. Generally nearly all transmissions to a payer entity (as the ultimate destination
of the transaction) are original.
REISSUE: In the case where a transmission was disrupted the receiver can request that
the batch be sent again. Use “Reissue” when resending transmission batches that have
been previously sent.
CodeList Summary (Total Codes: 65, Included: 2)
Code Name
00
18
BHT03
127
Original
Reissue
Reference Identification
O
AN
1/30
Required
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Originator Application Transaction Identifier
NSF Reference: AA0-05.0
The inventory file number of the tape or transmission assigned by the submitter’s system.
This number operates as a batch control number. It may or may not be identical to the
number carried in ST02.
BHT04
373
Date
O
DT
8/8
Required
Description: Date expressed as CCYYMMDD
Industry: Transaction Set Creation Date
NSF Reference: AA0-15.0
Identifies the date that the submitter created the file.
837P_CG.ecs
28
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Ref
Id
Element Name
BHT05
337
Time
Req
Type
Min/Max
Usage
O
TM
4/8
Required
Description: Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or
HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer
seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D
= tenths (0-9) and DD = hundredths (00-99)
Industry: Transaction Set Creation Time
NSF Reference: AA0-16.0
Use this time to identify the time of day that the submitter created the file.
BHT06
640
Transaction Type Code
O
ID
2/2
Required
Description: Code specifying the type of transaction
Industry: Claim or Encounter Identifier
Alias: Claim or Encounter Indicator
Although this element is required, submitters are not necessarily required to accurately
batch claims and encounters at this level. Generally CH is used for claims and RP is used
for encounters. However, if an ST-SE envelope contains both claims and encounters use
CH. Some trading partner agreements may specify using only one code.
CodeList Summary (Total Codes: 446, Included: 2)
Code Name
CH
Chargeable
Use this code when the transaction contains only fee-for-service claims or claims
with at least one chargeable line item. If it is not clear whether a transaction
contains claims or encounters, or if the transaction contains a mix of claims and
encounters, the developers of this implementation guide recommend using code
CH.
RP
Reporting
Use RP when the entire ST-SE envelope contains encounters.
Use RP when the transaction is being sent to an entity (usually not a payer or a
normal provider-payer transmission intermediary) for purposes other than
adjudication of a claim. Such an entity could be a state health data agency which
is using the 837 for health data reporting purposes.
Semantics:
1. BHT03 is the number assigned by the originator to identify the transaction within the originator's business
application system.
2. BHT04 is the date the transaction was created within the business application system.
3. BHT05 is the time the transaction was created within the business application system.
Notes:
1. The second example denotes the case where the entire transaction set contains ENCOUNTERS.
Example:
BHT*0019*00*0123*19970618*0932*CH~
BHT*0019*00*44445*19970213*0345*RP~
837P_CG.ecs
29
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 015
REF Transmission Type
Max: 1
Heading - Optional
Identification
Loop: N/A
Elements: 2
User Option (Usage): Required
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
1/30
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 1)
Code Name
87
REF02
127
Functional Category
Reference Identification
C
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Transmission Type Code
When piloting the transaction set, this value is 004010X098DA1. When sending the
transaction set in a production mode, this value is 004010X098A1.
User Note 6:
Always use only 004010X098A1.
The "D" suffix is not required as test submissions are identified by the value of "T" received
in ISA15.
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Example:
REF*87*004010X098A1~
837P_CG.ecs
30
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 020
Loop Submitter Name
Repeat: 1
Optional
Loop:
1000A
Elements: N/A
User Option (Usage): Required
Purpose: To supply the full name of an individual or organizational entity
Loop Summary:
Pos
Id
Segment Name
020
045
NM1
PER
Submitter Name
Submitter EDI Contact Information
Req
Max Use
O
O
1
2
Repeat
Usage
Required
Required
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
Notes:
1. The example in this NM1 and the subsequent N2 demonstrate how a name that is more than 35 characters
long could be handled between the NM1 and N2 segments.
2. See Section 2.4, Loop ID-1000, Data Overview, for a detailed description about using Loop ID-1000. Ignore the
Set Notes below.
3. Because this is a required segment, this is a required loop. See Appendix A for further details on ASC X12
syntax rules.
Example:
NM1*41*2*CRAMMER, DOLE, PALMER, AND JOHANSON*****46*W7933THU~
837P_CG.ecs
31
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 020
NM1 Submitter Name
Max: 1
Heading - Optional
Loop:
1000A
Elements: 7
User Option (Usage): Required
Purpose: To supply the full name of an individual or organizational entity
Element Summary:
Ref
Id
Element Name
NM101
98
Entity Identifier Code
Req
Type
Min/Max
Usage
M
ID
2/3
Required
Description: Code identifying an organizational entity, a physical location, property or an
individual
CodeList Summary (Total Codes: 1312, Included: 1)
Code Name
41
NM102
1065
Submitter
Entity Type Qualifier
M
ID
1/1
Required
AN
1/35
Required
Description: Code qualifying the type of entity
CodeList Summary (Total Codes: 14, Included: 2)
Code Name
1
2
NM103
1035
Person
Non-Person Entity
Name Last or Organization Name
O
Description: Individual last name or organizational name
Industry: Submitter Last or Organization Name
Alias: Submitter Name
NSF Reference: AA0-06.0
NM104
1036
Name First
O
AN
1/25
Situational
O
AN
1/25
Situational
Description: Individual first name
Industry: Submitter First Name
Alias: Submitter Name
Required if NM102=1 (person).
NM105
1037
Name Middle
Description: Individual middle name or initial
Industry: Submitter Middle Name
Alias: Submitter Name
Required if NM102=1 and the middle name/initial of the person is known.
NM108
66
Identification Code Qualifier
C
ID
1/2
Required
Description: Code designating the system/method of code structure used for Identification
Code (67)
CodeList Summary (Total Codes: 215, Included: 1)
837P_CG.ecs
32
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Code Name
46
NM109
67
Electronic Transmitter Identification Number (ETIN)
Established by trading partner agreement.
Identification Code
C
AN
2/80
Required
Description: Code identifying a party or other code
Industry: Submitter Identifier
Alias: Submitter Primary Identification Number
NSF Reference: AA0-02.0, ZA0-02.0
Syntax Rules:
1. P0809 - If either NM108 or NM109 is present, then the other is required.
2. C1110 - If NM111 is present, then NM110 is required.
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
Notes:
1. The example in this NM1 and the subsequent N2 demonstrate how a name that is more than 35 characters
long could be handled between the NM1 and N2 segments.
2. See Section 2.4, Loop ID-1000, Data Overview, for a detailed description about using Loop ID-1000. Ignore the
Set Notes below.
3. Because this is a required segment, this is a required loop. See Appendix A for further details on ASC X12
syntax rules.
Example:
NM1*41*2*CRAMMER, DOLE, PALMER, AND JOHANSON*****46*W7933THU~
837P_CG.ecs
33
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 045
PER Submitter EDI Contact
Max: 2
Heading - Optional
Information
Loop:
1000A
Elements: 8
User Option (Usage): Required
Purpose: To identify a person or office to whom administrative communications should be directed
Element Summary:
Ref
Id
Element Name
PER01
366
Contact Function Code
Req
Type
Min/Max
Usage
M
ID
2/2
Required
Description: Code identifying the major duty or responsibility of the person or group
named
CodeList Summary (Total Codes: 230, Included: 1)
Code Name
IC
PER02
93
Information Contact
Name
O
AN
1/60
Required
Description: Free-form name
Industry: Submitter Contact Name
NSF Reference: AA0-13.0
Use this data element when the name of the individual to contact is not already defined or
is different than the name within the prior name segment (e.g. N1 or NM1).
PER03
365
Communication Number Qualifier
C
ID
2/2
Required
Description: Code identifying the type of communication number
CodeList Summary (Total Codes: 40, Included: 4)
Code Name
ED
EM
FX
TE
PER04
364
Electronic Data Interchange Access Number
Electronic Mail
Facsimile
Telephone
Communication Number
C
AN
1/80
Required
Description: Complete communications number including country or area code when
applicable
NSF Reference: AA0-14.0
PER05
365
Communication Number Qualifier
C
ID
2/2
Situational
Description: Code identifying the type of communication number
Used at the discretion of the submitter.
CodeList Summary (Total Codes: 40, Included: 5)
Code Name
ED
EM
EX
FX
837P_CG.ecs
Electronic Data Interchange Access Number
Electronic Mail
Telephone Extension
Facsimile
34
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Code Name
TE
PER06
364
Telephone
Communication Number
C
AN
1/80
Situational
Description: Complete communications number including country or area code when
applicable
Used at the discretion of the submitter.
PER07
365
Communication Number Qualifier
C
ID
2/2
Situational
Description: Code identifying the type of communication number
Used at the discretion of the submitter.
CodeList Summary (Total Codes: 40, Included: 5)
Code Name
ED
EM
EX
FX
TE
PER08
364
Electronic Data Interchange Access Number
Electronic Mail
Telephone Extension
Facsimile
Telephone
Communication Number
C
AN
1/80
Situational
Description: Complete communications number including country or area code when
applicable
Used at the discretion of the submitter.
Syntax Rules:
1. P0304 - If either PER03 or PER04 is present, then the other is required.
2. P0506 - If either PER05 or PER06 is present, then the other is required.
3. P0708 - If either PER07 or PER08 is present, then the other is required.
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 should 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 (e.g., (534) 224-2525 would be represented as
5342242525). The extension, when applicable, should be included in the communication number immediately
after the telephone number.
2. The contact information in this segment should point to 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 combination of communication numbers
including extensions.
Example:
PER*IC*JANE DOE*TE*9005555555~
837P_CG.ecs
35
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 020
Loop Receiver Name
Repeat: 1
Optional
Loop:
1000B
Elements: N/A
User Option (Usage): Required
Purpose: To supply the full name of an individual or organizational entity
Loop Summary:
Pos
Id
Segment Name
Req
Max Use
020
NM1
Receiver Name
O
1
Repeat
Usage
Required
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
Notes:
1. Because this is a required segment, this is a required loop. See Appendix A for further details on ASC X12
syntax rules.
Example:
NM1*40*2*UNION MUTUAL OF OREGON*****46*11122333~
837P_CG.ecs
36
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 020
NM1 Receiver Name
Max: 1
Heading - Optional
Loop:
1000B
Elements: 5
User Option (Usage): Required
Purpose: To supply the full name of an individual or organizational entity
Element Summary:
Ref
Id
Element Name
NM101
98
Entity Identifier Code
Req
Type
Min/Max
Usage
M
ID
2/3
Required
Description: Code identifying an organizational entity, a physical location, property or an
individual
CodeList Summary (Total Codes: 1312, Included: 1)
Code Name
40
NM102
1065
Receiver
Entity Type Qualifier
M
ID
1/1
Required
AN
1/35
Required
1/2
Required
Description: Code qualifying the type of entity
CodeList Summary (Total Codes: 14, Included: 1)
Code Name
2
NM103
1035
Non-Person Entity
Name Last or Organization Name
O
Description: Individual last name or organizational name
Industry: Receiver Name
NM108
66
Identification Code Qualifier
C
ID
Description: Code designating the system/method of code structure used for Identification
Code (67)
CodeList Summary (Total Codes: 215, Included: 1)
Code Name
46
NM109
67
Electronic Transmitter Identification Number (ETIN)
Identification Code
C
AN
2/80
Required
Description: Code identifying a party or other code
Industry: Receiver Primary Identifier
Alias: Receiver Primary Identification Number
NSF Reference: AA0-17.0, ZA0-04.0
Syntax Rules:
1. P0809 - If either NM108 or NM109 is present, then the other is required.
2. C1110 - If NM111 is present, then NM110 is required.
Semantics:
1. NM102 qualifies NM103.
837P_CG.ecs
37
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
Notes:
1. Because this is a required segment, this is a required loop. See Appendix A for further details on ASC X12
syntax rules.
Example:
NM1*40*2*UNION MUTUAL OF OREGON*****46*11122333~
837P_CG.ecs
38
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 001
Loop Billing/Pay-to Provider
Hierarchical Level
Repeat: >1
Mandatory
Loop:
2000A
Elements: N/A
User Option (Usage): Required
Purpose: To identify dependencies among and the content of hierarchically related groups of data segments
Loop Summary:
Pos
Id
Segment Name
001
003
HL
PRV
010
015
015
CUR
Billing/Pay-to Provider Hierarchical Level
Billing/Pay-to Provider Specialty
Information
Foreign Currency Information
Loop 2010AA
Loop 2010AB
Req
Max Use
M
O
1
1
O
O
O
1
Repeat
Usage
Required
Situational
1
1
Situational
Required
Situational
Comments:
1. The HL segment is used to identify levels of detail information using a hierarchical structure, such as relating
line-item data to shipment data, and packaging data to line-item data.
2. The HL segment defines a top-down/left-right ordered structure.
3. HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction
set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which
case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each
subsequent HL segment within the transaction.
4. HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.
5. HL03 indicates the context of the series of segments following the current HL segment up to the next
occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent
segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
6. HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL
segment.
Notes:
1. Use the Billing Provider HL to identify the original entity who submitted the electronic claim/encounter to the
destination payer identified in Loop ID-2010BB. The billing provider entity may be a health care provider, a billing
service, or some other representative of the provider.
2. The NSF fields shown in Loop ID-2010AA and Loop ID-2010AB are intended to carry billing provider
information, not billing service information. Refer to your NSF manual for proper use of these fields. If Loop
2010AA contains information on a billing service rather than a billing provider), do not map the information in that
loop to the NSF billing provider fields for Medicare claims.
3. The Billing/Pay-to Provider HL may contain information about the Pay-to Provider entity. If the Pay-to Provider
entity is the same as the Billing Provider entity, then only use Loop ID-2010AA.
4. Because this is a required segment, this is a required loop. See Appendix A for further details on ASC X12
syntax rules.
5. Receiving trading partners may have system limitations regarding the size of the transmission they can receive.
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. While the implementation guide sets no specific limit to
the number of Billing/Pay-to Provider Hierarchical Level loops, there is an implied maximum of 5000.
6. If the Billing or Pay-to Provider is also the Rendering Provider and Loop ID-2310A is not used, the Loop
ID-2000 PRV must be used to indicate which entity (Billing or Pay-to) is the Rendering Provider.
Example:
HL*1**20*1~
837P_CG.ecs
39
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 001
HL Billing/Pay-to Provider
Max: 1
Detail - Mandatory
Hierarchical Level
Loop:
2000A
Elements: 3
User Option (Usage): Required
Purpose: To identify dependencies among and the content of hierarchically related groups of data segments
Element Summary:
Ref
Id
Element Name
HL01
628
Hierarchical ID Number
Req
Type
Min/Max
Usage
M
AN
1/12
Required
Description: A unique number assigned by the sender to identify a particular data
segment in a hierarchical structure
HL01 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
M
ID
1/2
Required
Description: Code defining the characteristic of a level in a hierarchical structure
CodeList Summary (Total Codes: 170, Included: 1)
Code Name
20
HL04
736
Information Source
Hierarchical Child Code
O
ID
1/1
Required
Description: Code indicating if there are hierarchical child data segments subordinate to
the level being described
CodeList Summary (Total Codes: 2, Included: 1)
Code Name
1
Additional Subordinate HL Data Segment in This Hierarchical Structure.
Comments:
1. The HL segment is used to identify levels of detail information using a hierarchical structure, such as relating
line-item data to shipment data, and packaging data to line-item data.
2. The HL segment defines a top-down/left-right ordered structure.
3. HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction
set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which
case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each
subsequent HL segment within the transaction.
4. HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.
5. HL03 indicates the context of the series of segments following the current HL segment up to the next
occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent
segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
6. HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL
segment.
Notes:
1. Use the Billing Provider HL to identify the original entity who submitted the electronic claim/encounter to the
destination payer identified in Loop ID-2010BB. The billing provider entity may be a health care provider, a billing
service, or some other representative of the provider.
2. The NSF fields shown in Loop ID-2010AA and Loop ID-2010AB are intended to carry billing provider
information, not billing service information. Refer to your NSF manual for proper use of these fields. If Loop
2010AA contains information on a billing service rather than a billing provider), do not map the information in that
837P_CG.ecs
40
For internal use only
12/1/2010
Health Care Claim: Professional - 837
loop to the NSF billing provider fields for Medicare claims.
3. The Billing/Pay-to Provider HL may contain information about the Pay-to Provider entity. If the Pay-to Provider
entity is the same as the Billing Provider entity, then only use Loop ID-2010AA.
4. Because this is a required segment, this is a required loop. See Appendix A for further details on ASC X12
syntax rules.
5. Receiving trading partners may have system limitations regarding the size of the transmission they can receive.
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. While the implementation guide sets no specific limit to
the number of Billing/Pay-to Provider Hierarchical Level loops, there is an implied maximum of 5000.
6. If the Billing or Pay-to Provider is also the Rendering Provider and Loop ID-2310A is not used, the Loop
ID-2000 PRV must be used to indicate which entity (Billing or Pay-to) is the Rendering Provider.
Example:
HL*1**20*1~
837P_CG.ecs
41
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 003
PRV Billing/Pay-to Provider
Max: 1
Detail - Optional
Specialty Information
Loop:
2000A
Elements: 3
User Option (Usage): Situational
Purpose: To specify the identifying characteristics of a provider
Element Summary:
Ref
Id
Element Name
Req
Type
Min/Max
Usage
PRV01
1221
Provider Code
M
ID
1/3
Required
ID
2/3
Required
Description: Code identifying the type of provider
User Note 6:
BI = Billing
PT = Pay To
CodeList Summary (Total Codes: 26, Included: 2)
Code Name
BI
PT
PRV02
128
Billing
Pay-To
Reference Identification Qualifier
M
Description: Code qualifying the Reference Identification
ZZ is used to indicate the “Health Care Provider Taxonomy” code list (provider specialty
code) which is available on the Washington Publishing Company web site:
http://www.wpc-edi.com. This taxonomy is maintained by the Blue Cross Blue Shield
Association and ASC X12N TG2 WG15.
User Note 6:
DO NOT PROVIDE TAXONOMY AT BILLING SEE 2310 RENDERRING. IF BOTH
SUBMITTED WILL CAUSE HIPAA ERROR. (BSCA is following CMS rules). Refer to 2310B
Rendering Provider.
CodeList Summary (Total Codes: 1503, Included: 1)
Code Name
ZZ
PRV03
127
Mutually Defined
Health Care Provider Taxonomy Code list
Reference Identification
M
AN
1/30
Required
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Provider Taxonomy Code
Alias: Provider Specialty Code
NSF Reference: BA0-22.0
User Note 6:
Provider Taxonomy Code
ExternalCodeList
Name: HCPT
Description: Health Care Provider Taxonomy
837P_CG.ecs
42
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Notes:
1. Required when adjudication is known to be impacted by the provider taxonomy code, and the Rendering
Provider is the same entity as the Billing and/or Pay-to Provider. In these cases, the Rendering Provider is being
identified at this level for all subsequent claims/encounters in this HL and Loop ID-2310B is not used.
2. This PRV is not used when the Billing or Pay-to Provider is a group and the individual Rendering Provider is in
loop 2310B. The PRV segment is then coded with the Rendering Provider in loop 2310B.
3. PRV02 qualifies PRV03.
Example:
PRV*BI*ZZ*203BA050N~
837P_CG.ecs
43
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 010
CUR Foreign Currency
Max: 1
Detail - Optional
Information
Loop:
2000A
Elements: 2
User Option (Usage): Situational
Purpose: To specify the currency (dollars, pounds, francs, etc.) used in a transaction
Element Summary:
Ref
Id
Element Name
CUR01
98
Entity Identifier Code
Req
Type
Min/Max
Usage
M
ID
2/3
Required
Description: Code identifying an organizational entity, a physical location, property or an
individual
CodeList Summary (Total Codes: 1312, Included: 1)
Code Name
85
CUR02
100
Billing Provider
Currency Code
M
ID
3/3
Required
Description: Code (Standard ISO) for country in whose currency the charges are specified
CODE SOURCE: 5: Countries, Currencies and Funds
ExternalCodeList
Name: 5
Description: Countries, Currencies and Funds
Syntax Rules:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
C0807 - If CUR08 is present, then CUR07 is required.
C0907 - If CUR09 is present, then CUR07 is required.
L101112 - If CUR10 is present, then at least one of CUR11 or CUR12 is required.
C1110 - If CUR11 is present, then CUR10 is required.
C1210 - If CUR12 is present, then CUR10 is required.
L131415 - If CUR13 is present, then at least one of CUR14 or CUR15 is required.
C1413 - If CUR14 is present, then CUR13 is required.
C1513 - If CUR15 is present, then CUR13 is required.
L161718 - If CUR16 is present, then at least one of CUR17 or CUR18 is required.
C1716 - If CUR17 is present, then CUR16 is required.
C1816 - If CUR18 is present, then CUR16 is required.
L192021 - If CUR19 is present, then at least one of CUR20 or CUR21 is required.
C2019 - If CUR20 is present, then CUR19 is required.
C2119 - If CUR21 is present, then CUR19 is required.
Comments:
1. See Figures Appendix for examples detailing the use of the CUR segment.
Notes:
1. The CUR segment is required if financial amounts submitted in this ST-SE envelop are for services provided in
a currency that is NOT normally used by the receiver for processing claims. For example, claims submitted by
United States (U.S.) providers to U.S. receivers are assumed to be in U.S. dollars. Claims submitted by Canadian
providers to Canadian receivers are assumed to be in Canadian dollars. Claims submitted by Canadian providers
837P_CG.ecs
44
For internal use only
12/1/2010
Health Care Claim: Professional - 837
to U.S. receivers are assumed to be in Canadian dollars. In that case the CUR would be used to indicate that the
billed amounts are in Canadian dollars. In cases where COB is involved, adjudicated adjustments and amounts
must also be in the currency indicated here.
Example:
CUR*85*CAN~
837P_CG.ecs
45
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 015
Loop Billing Provider Name
Repeat: 1
Optional
Loop:
2010AA
Elements: N/A
User Option (Usage): Required
Purpose: To supply the full name of an individual or organizational entity
Loop Summary:
Pos
Id
Segment Name
015
025
030
035
035
040
NM1
N3
N4
REF
REF
PER
Billing Provider Name
Billing Provider Address
Billing Provider City/State/ZIP Code
Billing Provider Secondary Identification
Credit/Debit Card Billing Information
Billing Provider Contact Information
Req
Max Use
O
O
O
O
O
O
1
1
1
8
8
2
Repeat
Usage
Required
Required
Required
Situational
Situational
Situational
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
Notes:
1. Although the name of this loop/segment is “Billing Provider” the loop/segment really identifies the billing entity.
The billing entity does not have to be a health care provider to use this loop. However, some payers do not
accept claims from non-provider billing entities.
2. Because this is a required segment, this is a required loop. See Appendix A for further details on ASC X12
syntax rules.
Example:
NM1*85*2*CRAMMER, DOLE, PALMER, AND JOHNANSE*****24*111223333~
837P_CG.ecs
46
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 015
NM1 Billing Provider Name
Max: 1
Detail - Optional
Loop:
2010AA
Elements: 8
User Option (Usage): Required
Purpose: To supply the full name of an individual or organizational entity
Element Summary:
Ref
Id
Element Name
NM101
98
Entity Identifier Code
Req
Type
Min/Max
Usage
M
ID
2/3
Required
Description: Code identifying an organizational entity, a physical location, property or an
individual
CodeList Summary (Total Codes: 1312, Included: 1)
Code Name
85
NM102
1065
Billing Provider
Use this code to indicate billing provider, billing submitter, and encounter reporting
entity.
Entity Type Qualifier
M
ID
1/1
Required
AN
1/35
Required
Description: Code qualifying the type of entity
CodeList Summary (Total Codes: 14, Included: 2)
Code Name
1
2
NM103
1035
Person
Non-Person Entity
Name Last or Organization Name
O
Description: Individual last name or organizational name
Industry: Billing Provider Last or Organizational Name
Alias: Billing Provider Name
NSF Reference: BA0-18.0 or BA0-19.0
NM104
1036
Name First
O
AN
1/25
Situational
O
AN
1/25
Situational
Description: Individual first name
Industry: Billing Provider First Name
Alias: Billing Provider Name
NSF Reference: BA0-20.0
Required if NM102=1 (person).
NM105
1037
Name Middle
Description: Individual middle name or initial
Industry: Billing Provider Middle Name
Alias: Billing Provider Name
NSF Reference: BA0-21.0
Required if NM102=1 and the middle name/initial of the person is known.
NM107
837P_CG.ecs
1039
Name Suffix
O
47
AN
1/10
Situational
For internal use only
12/1/2010
Ref
Health Care Claim: Professional - 837
Id
Element Name
Req
Type
Min/Max
Usage
C
ID
1/2
Required
Description: Suffix to individual name
Industry: Billing Provider Name Suffix
Alias: Billing Provider Name
Required if known.
NM108
66
Identification Code Qualifier
Description: Code designating the system/method of code structure used for Identification
Code (67)
If “XX - NPI” is used, then either the Employer’s Identification Number or the Social
Security Number of the provider must be carried in the REF in this loop.
User Note 6:
Use this qualifier with the National Provider Identifier, if available, otherwise use 24, 34 with
the Tax ID number.
If entity is different from the billing provider this rule applies to Loop 2010AB.
Same rule applies for Referring Provider Loop 2310A and Rendering Provider Loop 2310B.
CodeList Summary (Total Codes: 215, Included: 3)
Code Name
24
34
XX
NM109
67
Employer's Identification Number
Social Security Number
Health Care Financing Administration National Provider Identifier
Identification Code
C
AN
2/80
Required
Description: Code identifying a party or other code
Industry: Billing Provider Identifier
Alias: Billing Provider Primary Identification Number
NSF Reference: BA0-09.0, CA0-28.0, BA0-02.0, BA1-02.0, YA0-02.0, BA0-06.0, BA0-10.
0, BA0-12.0, BA0-13.0, BA0-14.0, BA0-15.0, BA0-16.0, BA0-17.0, BA0-24.0, YA0-06.0
User Note 6:
Example:
NM1*85*2*MD OFC*****XX*1234567891~
N3*ADDRESS~
N4*CITY*STATE*ZIP~
REF*EI*951234560~
REF*1B*00A123450~
ExternalCodeList
Name: 537
Description: Health Care Financing Administration National Provider Identifier
Syntax Rules:
1. P0809 - If either NM108 or NM109 is present, then the other is required.
2. C1110 - If NM111 is present, then NM110 is required.
Semantics:
1. NM102 qualifies NM103.
Comments:
837P_CG.ecs
48
For internal use only
12/1/2010
Health Care Claim: Professional - 837
1. NM110 and NM111 further define the type of entity in NM101.
Notes:
1. Although the name of this loop/segment is “Billing Provider” the loop/segment really identifies the billing entity.
The billing entity does not have to be a health care provider to use this loop. However, some payers do not
accept claims from non-provider billing entities.
2. Because this is a required segment, this is a required loop. See Appendix A for further details on ASC X12
syntax rules.
Example:
NM1*85*2*CRAMMER, DOLE, PALMER, AND JOHNANSE*****24*111223333~
837P_CG.ecs
49
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 025
N3 Billing Provider Address
Max: 1
Detail - Optional
Loop:
2010AA
Elements: 2
User Option (Usage): Required
Purpose: To specify the location of the named party
Element Summary:
Ref
Id
Element Name
N301
166
Address Information
Req
Type
Min/Max
Usage
M
AN
1/55
Required
Description: Address information
Industry: Billing Provider Address Line
Alias: Billing Provider Address 1
NSF Reference: BA1-07.0, BA1-13.0
User Note 6:
When submitting with NPI provide the physical address where services were rendered.
N302
166
Address Information
O
AN
1/55
Situational
Description: Address information
Industry: Billing Provider Address Line
Alias: Billing Provider Address 2
NSF Reference: BA1-08.0, BA1-14.0
Required if a second address line exists.
Example:
N3*225 MAIN STREET*BARKLEY BUILDING~
837P_CG.ecs
50
For internal use only
12/1/2010
Health Care Claim: Professional - 837
N4 Billing Provider City/State/ZIP
Code
Pos: 030
Max: 1
Detail - Optional
Loop:
2010AA
Elements: 4
User Option (Usage): Required
Purpose: To specify the geographic place of the named party
Element Summary:
Ref
Id
Element Name
N401
19
City Name
Req
Type
Min/Max
Usage
O
AN
2/30
Required
Description: Free-form text for city name
Industry: Billing Provider City Name
Alias: Billing Provider’s City
NSF Reference: BA1-09.0, BA1-15.0
User Note 6:
When submitting with NPI provide the physical address where services were rendered.
N402
156
State or Province Code
O
ID
2/2
Required
Description: Code (Standard State/Province) as defined by appropriate government
agency
Industry: Billing Provider State or Province Code
Alias: Billing Provider’s State
CODE SOURCE: 22: States and Outlying Areas of the U.S.
NSF Reference: BA1-10.0, BA1-16.0
ExternalCodeList
Name: 22
Description: States and Outlying Areas of the U.S.
N403
116
Postal Code
O
ID
3/15
Required
Description: Code defining international postal zone code excluding punctuation and
blanks (zip code for United States)
Industry: Billing Provider Postal Zone or ZIP Code
Alias: Billing Provider’s Zip Code
CODE SOURCE: 51: ZIP Code
NSF Reference: BA1-11.0, BA1-17.0
ExternalCodeList
Name: 51
Description: ZIP Code
N404
26
Country Code
O
ID
2/3
Situational
Description: Code identifying the country
Alias: Billing Provider Country Code
CODE SOURCE: 5: Countries, Currencies and Funds
Required if the address is out of the U.S.
ExternalCodeList
837P_CG.ecs
51
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Name: 5
Description: Countries, Currencies and Funds
Syntax Rules:
1. C0605 - If N406 is present, then N405 is required.
Comments:
1. A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
2. N402 is required only if city name (N401) is in the U.S. or Canada.
Example:
N4*CENTERVILLE*PA*17111~
837P_CG.ecs
52
For internal use only
12/1/2010
Health Care Claim: Professional - 837
REF Billing Provider Secondary
Identification
Pos: 035
Max: 8
Detail - Optional
Loop:
2010AA
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
Description: Code qualifying the Reference Identification
User Note 6:
Codes: EI, SY, 0B, 1B
The REF segment is used to report the Tax ID when the NPI is in NM109. When the NPI is
unavailable use your Tax ID in NM109. An additional REF segment should be created to
report.
Use 0B for CA State license #
Use 1B for BSC Provider ID
CodeList Summary (Total Codes: 1503, Included: 18)
Code Name
REF02
127
0B
1A
1B
1C
1D
1G
1H
1J
B3
BQ
EI
FH
G2
G5
LU
SY
State License Number
Blue Cross Provider Number
Blue Shield Provider Number
Medicare Provider Number
Medicaid Provider Number
Provider UPIN Number
CHAMPUS Identification Number
Facility ID Number
Preferred Provider Organization Number
Health Maintenance Organization Code Number
Employer's Identification Number
Clinic Number
Provider Commercial Number
Provider Site Number
Location Number
Social Security Number
The social security number may not be used for Medicare.
U3
X5
Unique Supplier Identification Number (USIN)
State Industrial Accident Provider Number
Reference Identification
C
AN
1/30
Required
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Billing Provider Additional Identifier
Alias: Billing Provider Secondary Identification Number
837P_CG.ecs
53
For internal use only
12/1/2010
Ref
Health Care Claim: Professional - 837
Id
Element Name
Req
Type
Min/Max
Usage
NSF Reference: CA0-28.0, BA0-02.0, BA1-02.0, YA0-06.0, BA0-06.0, BA0-10.0, BA0-12.
0, BA0-13.0, BA0-14.0, BA0-15.0, BA0-16.0, BA0-17.0, BA0-24.0, BA0-08.0, YA0-02.0
User Note 6:
Use only California State License Number or BSC Provider ID number.
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. Required when a secondary identification number is necessary to identify the entity. The primary identification
number should be carried in NM108/9 in this loop.
2. If the reason the number is being used in this REF can be met by the NPI, carried in the NM108/09 of this loop,
then this REF is not used.
3. If “code XX - NPI” is used in the NM108/09 of this loop, then either the Employer’s Identification Number or the
Social Security Number of the provider must be carried in this REF. The number sent is the one which is used on
the 1099. If additional numbers are needed the REF can be run up to 8 times.
Example:
REF*1G*98765~
837P_CG.ecs
54
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 035
REF Credit/Debit Card Billing
Max: 8
Detail - Optional
Information
Loop:
2010AA
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
1/30
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 8)
Code Name
06
8U
EM
IJ
LU
RB
ST
TT
REF02
127
System Number
Bank Assigned Security Identifier
Electronic Payment Reference Number
Standard Industry Classification (SIC) Code
Location Number
Rate code number
Store Number
Terminal Code
Reference Identification
C
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Billing Provider Credit Card Identifier
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. See Appendix G for use of this segment.
2. The information carried under this segment must never be sent to the payer. This information is only for use
between a provider and a service organization offering patient collection services. In this case, it is the
responsibility of the collection service organization to remove this segment before forwarding the claim to the
payer.
Example:
REF*8U*1112223333~
837P_CG.ecs
55
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 040
PER Billing Provider Contact
Max: 2
Detail - Optional
Information
Loop:
2010AA
Elements: 8
User Option (Usage): Situational
Purpose: To identify a person or office to whom administrative communications should be directed
Element Summary:
Ref
Id
Element Name
PER01
366
Contact Function Code
Req
Type
Min/Max
Usage
M
ID
2/2
Required
Description: Code identifying the major duty or responsibility of the person or group
named
CodeList Summary (Total Codes: 230, Included: 1)
Code Name
IC
PER02
93
Information Contact
Name
O
AN
1/60
Required
Description: Free-form name
Industry: Billing Provider Contact Name
Use this data element when the name of the individual to contact is not already defined or
is different than the name within the prior name segment (e.g. N1 or NM1).
PER03
365
Communication Number Qualifier
C
ID
2/2
Required
Description: Code identifying the type of communication number
CodeList Summary (Total Codes: 40, Included: 3)
Code Name
EM
FX
TE
PER04
364
Electronic Mail
Facsimile
Telephone
Communication Number
C
AN
1/80
Required
Description: Complete communications number including country or area code when
applicable
NSF Reference: BA1-12.0, BA1-18.0
PER05
365
Communication Number Qualifier
C
ID
2/2
Situational
Description: Code identifying the type of communication number
Used at the discretion of the billing provider.
CodeList Summary (Total Codes: 40, Included: 4)
Code Name
EM
EX
FX
TE
PER06
837P_CG.ecs
364
Electronic Mail
Telephone Extension
Facsimile
Telephone
Communication Number
C
56
AN
1/80
Situational
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Ref
Id
Element Name
Req
Type
Min/Max
Usage
Description: Complete communications number including country or area code when
applicable
Used at the discretion of the billing provider.
PER07
365
Communication Number Qualifier
C
ID
2/2
Situational
Description: Code identifying the type of communication number
Used at the discretion of the billing provider.
CodeList Summary (Total Codes: 40, Included: 4)
Code Name
EM
EX
FX
TE
PER08
364
Electronic Mail
Telephone Extension
Facsimile
Telephone
Communication Number
C
AN
1/80
Situational
Description: Complete communications number including country or area code when
applicable
Used at the discretion of the billing provider.
Syntax Rules:
1. P0304 - If either PER03 or PER04 is present, then the other is required.
2. P0506 - If either PER05 or PER06 is present, then the other is required.
3. P0708 - If either PER07 or PER08 is present, then the other is required.
Notes:
1. Required if this information is different that that contained in the Loop 1000A - Submitter PER segment.
2. 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 should 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 (e.g., (534) 224-2525 would be represented as
5342242525). The extension, when applicable, should be included in the communication number immediately
after the telephone number.
3. There are 2 repetitions of the PER segment to allow for six possible combination of communication numbers
including extensions.
Example:
PER*IC*JIM*TE*8007775555~
837P_CG.ecs
57
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 015
Loop Pay-to Provider Name
Repeat: 1
Optional
Loop:
2010AB
Elements: N/A
User Option (Usage): Situational
Purpose: To supply the full name of an individual or organizational entity
Loop Summary:
Pos
Id
Segment Name
015
025
030
035
NM1
N3
N4
REF
Pay-to Provider Name
Pay-to Provider Address
Pay-to Provider City/State/ZIP Code
Pay-to-Provider Secondary Identification
Req
Max Use
O
O
O
O
1
1
1
5
Repeat
Usage
Situational
Required
Required
Situational
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
Notes:
1. Required if the Pay-to Provider is a different entity than the Billing Provider.
2. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,
then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.
Example:
NM1*87*1*CRAMMER*JOSEPH****XX*09876543~
837P_CG.ecs
58
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 015
NM1 Pay-to Provider Name
Max: 1
Detail - Optional
Loop:
2010AB
Elements: 8
User Option (Usage): Situational
Purpose: To supply the full name of an individual or organizational entity
Element Summary:
Ref
Id
Element Name
NM101
98
Entity Identifier Code
Req
Type
Min/Max
Usage
M
ID
2/3
Required
Description: Code identifying an organizational entity, a physical location, property or an
individual
CodeList Summary (Total Codes: 1312, Included: 1)
Code Name
87
NM102
1065
Pay-to Provider
Entity Type Qualifier
M
ID
1/1
Required
Description: Code qualifying the type of entity
CodeList Summary (Total Codes: 14, Included: 2)
Code Name
NM103
1035
1
Person
If Person is used and if the pay-to provider is the same person as the rendering
provider, it is not necessary to use the Rendering Provider NM1 loop at the claim
loop (Loop ID-2300).
2
Non-Person Entity
If Non-Person Entity is used then the rendering provider NM1 loop (Loop
ID-2310B) must be used when appropriate to identify the person who rendered the
services.
Name Last or Organization Name
O
AN
1/35
Required
Description: Individual last name or organizational name
Industry: Pay-to Provider Last or Organizational Name
NSF Reference: BA0-18.0 or BA0-19.0
NM104
1036
Name First
O
AN
1/25
Situational
O
AN
1/25
Situational
Description: Individual first name
Industry: Pay-to Provider First Name
NSF Reference: BA0-20.0
Required if NM102=1 (person).
NM105
1037
Name Middle
Description: Individual middle name or initial
Industry: Pay-to Provider Middle Name
NSF Reference: BA0-21.0
Required if NM102=1 and the middle name/initial of the person is known.
NM107
837P_CG.ecs
1039
Name Suffix
O
59
AN
1/10
Situational
For internal use only
12/1/2010
Ref
Health Care Claim: Professional - 837
Id
Element Name
Req
Type
Min/Max
Usage
C
ID
1/2
Required
Description: Suffix to individual name
Industry: Pay-to Provider Name Suffix
Required if known.
NM108
66
Identification Code Qualifier
Description: Code designating the system/method of code structure used for Identification
Code (67)
If “XX - NPI” is used, then either the Employer’s Identification Number or the Social
Security Number of the provider must be carried in the REF in this loop.
CodeList Summary (Total Codes: 215, Included: 3)
Code Name
NM109
67
24
34
Employer's Identification Number
Social Security Number
The social security number may not be used for Medicare.
XX
Health Care Financing Administration National Provider Identifier
Identification Code
C
AN
2/80
Required
Description: Code identifying a party or other code
Industry: Pay-to Provider Identifier
Alias: Pay-to Provider Primary Identification Number
NSF Reference: BA0-09.0, CA0-28.0, BA0-02.0, BA1-02.0, YA0-02.0, BA0-06.0, BA0-10.
0, BA0-12.0, BA0-13.0, BA0-14.0, BA0-15.0, BA0-16.0, BA0-17.0, BA0-24.0, YA0-06.0
ExternalCodeList
Name: 537
Description: Health Care Financing Administration National Provider Identifier
Syntax Rules:
1. P0809 - If either NM108 or NM109 is present, then the other is required.
2. C1110 - If NM111 is present, then NM110 is required.
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
Notes:
1. Required if the Pay-to Provider is a different entity than the Billing Provider.
2. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,
then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.
Example:
NM1*87*1*CRAMMER*JOSEPH****XX*09876543~
837P_CG.ecs
60
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 025
N3 Pay-to Provider Address
Max: 1
Detail - Optional
Loop:
2010AB
Elements: 2
User Option (Usage): Required
Purpose: To specify the location of the named party
Element Summary:
Ref
Id
Element Name
N301
166
Address Information
Req
Type
Min/Max
Usage
M
AN
1/55
Required
O
AN
1/55
Situational
Description: Address information
Industry: Pay-to Provider Address Line
Alias: Pay-to Provider Address 1
NSF Reference: BA1-13.0, BA1-07.0
N302
166
Address Information
Description: Address information
Industry: Pay-to Provider Address Line
Alias: Pay-to Provider Address 2
NSF Reference: BA1-14.0, BA1-08.0
Required if a second address line exists.
Example:
N3*225 MAIN STREET*BARKLEY BUILDING~
837P_CG.ecs
61
For internal use only
12/1/2010
Health Care Claim: Professional - 837
N4 Pay-to Provider City/State/ZIP
Code
Pos: 030
Max: 1
Detail - Optional
Loop:
2010AB
Elements: 4
User Option (Usage): Required
Purpose: To specify the geographic place of the named party
Element Summary:
Ref
Id
Element Name
N401
19
City Name
Req
Type
Min/Max
Usage
O
AN
2/30
Required
O
ID
2/2
Required
Description: Free-form text for city name
Industry: Pay-to Provider City Name
NSF Reference: BA1-15.0, BA1-09.0
N402
156
State or Province Code
Description: Code (Standard State/Province) as defined by appropriate government
agency
Industry: Pay-to Provider State Code
CODE SOURCE: 22: States and Outlying Areas of the U.S.
NSF Reference: BA1-16.0, BA1-10.0
ExternalCodeList
Name: 22
Description: States and Outlying Areas of the U.S.
N403
116
Postal Code
O
ID
3/15
Required
Description: Code defining international postal zone code excluding punctuation and
blanks (zip code for United States)
Industry: Pay-to Provider Postal Zone or ZIP Code
Alias: Pay-to Provider Zip Code
CODE SOURCE: 51: ZIP Code
NSF Reference: BA1-17.0, BA1-11.0
ExternalCodeList
Name: 51
Description: ZIP Code
N404
26
Country Code
O
ID
2/3
Situational
Description: Code identifying the country
Alias: Pay-to Provider Country Code
CODE SOURCE: 5: Countries, Currencies and Funds
Required if the address is out of the U.S.
ExternalCodeList
Name: 5
Description: Countries, Currencies and Funds
Syntax Rules:
1. C0605 - If N406 is present, then N405 is required.
837P_CG.ecs
62
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Comments:
1. A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
2. N402 is required only if city name (N401) is in the U.S. or Canada.
Example:
N4*CENTERVILLE*PA*17111~
837P_CG.ecs
63
For internal use only
12/1/2010
Health Care Claim: Professional - 837
REF Pay-to-Provider Secondary
Identification
Pos: 035
Max: 5
Detail - Optional
Loop:
2010AB
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
Description: Code qualifying the Reference Identification
User Note 6:
Use 0B for CA State license # and 1B for BSC Provider ID.
CodeList Summary (Total Codes: 1503, Included: 18)
Code Name
REF02
127
0B
1A
1B
1C
1D
1G
1H
1J
B3
BQ
EI
FH
G2
G5
LU
SY
State License Number
Blue Cross Provider Number
Blue Shield Provider Number
Medicare Provider Number
Medicaid Provider Number
Provider UPIN Number
CHAMPUS Identification Number
Facility ID Number
Preferred Provider Organization Number
Health Maintenance Organization Code Number
Employer's Identification Number
Clinic Number
Provider Commercial Number
Provider Site Number
Location Number
Social Security Number
The social security number may not be used for Medicare.
U3
X5
Unique Supplier Identification Number (USIN)
State Industrial Accident Provider Number
Reference Identification
C
AN
1/30
Required
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Pay-to Provider Identifier
Alias: Pay-to Provider Additional Identifier
NSF Reference: BA0-09.0, CA0-28.0, BA0-02.0, BA1-02.0, YA0-02.0, BA0-06.0, BA0-10.
0, BA0-12.0, BA0-13.0, BA0-14.0, BA0-15.0, BA0-16.0, BA0-17.0, BA0-24.0, YA0-06.0
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
837P_CG.ecs
64
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. Required when a secondary identification number is necessary to identify the entity. The primary identification
number should be carried in NM109 in this loop.
2. If “code XX - NPI” is used in the NM108/09 of this loop, then either the Employer’s Identification Number or the
Social Security Number of the provider must be carried in this REF. The number sent is the one which is used on
the 1099. If additional numbers are needed the REF can be run up to 5 times.
Example:
REF*1G*98765~
837P_CG.ecs
65
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Loop Subscriber Hierarchical Level
Pos: 001
Repeat: >1
Mandatory
Loop:
2000B
Elements: N/A
User Option (Usage): Required
Purpose: To identify dependencies among and the content of hierarchically related groups of data segments
Loop Summary:
Pos
Id
Segment Name
001
005
007
015
015
015
015
130
HL
SBR
PAT
Subscriber Hierarchical Level
Subscriber Information
Patient Information
Loop 2010BA
Loop 2010BB
Loop 2010BC
Loop 2010BD
Loop 2300
Req
Max Use
M
O
O
O
O
O
O
O
1
1
1
Repeat
Usage
1
1
1
1
100
Required
Required
Situational
Required
Required
Situational
Situational
Situational
Comments:
1. The HL segment is used to identify levels of detail information using a hierarchical structure, such as relating
line-item data to shipment data, and packaging data to line-item data.
2. The HL segment defines a top-down/left-right ordered structure.
3. HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction
set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which
case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each
subsequent HL segment within the transaction.
4. HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.
5. HL03 indicates the context of the series of segments following the current HL segment up to the next
occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent
segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
6. HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL
segment.
Notes:
1. If the insured and the patient are the same person, use this HL to identify the insured/patient, skip the
subsequent (PATIENT) HL, and proceed directly to Loop ID-2300.
2. The Subscriber HL contains information about the person who is listed as the subscriber/insured for the
destination payer entity (Loop ID-2010BA). The Subscriber HL contains information identifying the subscriber
(Loop ID-2010BA), his or her insurance (Loop ID-2010BB), and responsible party (Loop ID-2010BC). In addition,
information about the credit/debit card holder is placed in this HL (Loop ID-2010BD). The credit/debit card holder
may or may not be the subscriber. See Appendix G, Credit/Debit Card Use, for a description of using Loop
ID-2010BD.
3. Because this is a required segment, this is a required loop. See Appendix A for further details on ASC X12
syntax rules.
4. Receiving trading partners may have system limitations regarding the size of the transmission they can receive.
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. While the implementation guide sets no specific limit to
the number of Subscriber Hierarchical Level loops, there is an implied maximum of 5000.
Example:
HL*2*1*22*1~
837P_CG.ecs
66
For internal use only
12/1/2010
Health Care Claim: Professional - 837
HL Subscriber Hierarchical Level
Pos: 001
Max: 1
Detail - Mandatory
Loop:
2000B
Elements: 4
User Option (Usage): Required
Purpose: To identify dependencies among and the content of hierarchically related groups of data segments
Element Summary:
Ref
Id
Element Name
HL01
628
Hierarchical ID Number
Req
Type
Min/Max
Usage
M
AN
1/12
Required
Description: A unique number assigned by the sender to identify a particular data
segment in a hierarchical structure
HL02
734
Hierarchical Parent ID Number
O
AN
1/12
Required
Description: Identification number of the next higher hierarchical data segment that the
data segment being described is subordinate to
HL03
735
Hierarchical Level Code
M
ID
1/2
Required
Description: Code defining the characteristic of a level in a hierarchical structure
CodeList Summary (Total Codes: 170, Included: 1)
Code Name
22
HL04
736
Subscriber
Hierarchical Child Code
O
ID
1/1
Required
Description: Code indicating if there are hierarchical child data segments subordinate to
the level being described
The claim loop (Loop ID-2300) can be used both 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/encounters for both the subscriber and a dependent
of theirs are being sent under the same billing provider HL (e.g., a father and son are both
involved in the same automobile accident and are treated by the same provider). In that
case, the subscriber HL04 = 1 because there is a dependent to this subscriber, but the
2300 loop for the subscriber/patient (father) would begin after the subscriber HL. The
dependent HL (son) would then be run and the 2300 loop for the dependent/patient would
be run after that HL. HL04=1 would also be used when a claim/encounter for a only a
dependent is being sent.
All valid standard codes are used. (Total Codes: 2)
Comments:
1. The HL segment is used to identify levels of detail information using a hierarchical structure, such as relating
line-item data to shipment data, and packaging data to line-item data.
2. The HL segment defines a top-down/left-right ordered structure.
3. HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction
set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which
case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each
subsequent HL segment within the transaction.
4. HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.
5. HL03 indicates the context of the series of segments following the current HL segment up to the next
occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent
segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
837P_CG.ecs
67
For internal use only
12/1/2010
Health Care Claim: Professional - 837
6. HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL
segment.
Notes:
1. If the insured and the patient are the same person, use this HL to identify the insured/patient, skip the
subsequent (PATIENT) HL, and proceed directly to Loop ID-2300.
2. The Subscriber HL contains information about the person who is listed as the subscriber/insured for the
destination payer entity (Loop ID-2010BA). The Subscriber HL contains information identifying the subscriber
(Loop ID-2010BA), his or her insurance (Loop ID-2010BB), and responsible party (Loop ID-2010BC). In addition,
information about the credit/debit card holder is placed in this HL (Loop ID-2010BD). The credit/debit card holder
may or may not be the subscriber. See Appendix G, Credit/Debit Card Use, for a description of using Loop
ID-2010BD.
3. Because this is a required segment, this is a required loop. See Appendix A for further details on ASC X12
syntax rules.
4. Receiving trading partners may have system limitations regarding the size of the transmission they can receive.
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. While the implementation guide sets no specific limit to
the number of Subscriber Hierarchical Level loops, there is an implied maximum of 5000.
Example:
HL*2*1*22*1~
837P_CG.ecs
68
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 005
SBR Subscriber Information
Max: 1
Detail - Optional
Loop:
2000B
Elements: 6
User Option (Usage): Required
Purpose: To record information specific to the primary insured and the insurance carrier for that insured
Element Summary:
Ref
Id
Element Name
SBR01
1138
Payer Responsibility Sequence Number
Code
Req
Type
Min/Max
Usage
M
ID
1/1
Required
Description: Code identifying the insurance carrier's level of responsibility for a payment
of a claim
Alias: Payer Responsibility Sequence Number Code
NSF Reference: DA1-02.0, DA0-02.0, DA2-02.0
CodeList Summary (Total Codes: 6, Included: 3)
Code Name
P
S
T
SBR02
1069
Primary
Secondary
Tertiary
Use to indicate ‘payer of last resort’.
Individual Relationship Code
O
ID
2/2
Situational
Description: Code indicating the relationship between two individuals or entities
Alias: Relationship Code
NSF Reference: DA0-17.0
Required when the subscriber is the same person as the patient. If the subscriber is not the
same person as the patient, do not use this element.
CodeList Summary (Total Codes: 153, Included: 1)
Code Name
18
SBR03
127
Self
Reference Identification
O
AN
1/30
Situational
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Insured Group or Policy Number
Alias: Group or Policy Number
NSF Reference: DA0-10.0
Required if the subscriber’s payer identification includes Group or Plan Number. This data
element is intended to carry the subscriber’s Group Number, not the number that uniquely
identifies the subscriber (Subscriber ID, Loop 2010BA-NM109).
User Note 6:
Claims for members in National Account groups require submission of the group number
found on their ID Card.
SBR04
93
Name
O
AN
1/60
Situational
Description: Free-form name
837P_CG.ecs
69
For internal use only
12/1/2010
Ref
Health Care Claim: Professional - 837
Id
Element Name
Industry: Insured Group Name
Req
Type
Min/Max
Usage
Alias: Group or Plan Name
NSF Reference: DA0-11.0
Required if the subscriber’s payer identification includes a Group or Plan Name.
SBR05
1336
Insurance Type Code
O
ID
1/3
Situational
Description: Code identifying the type of insurance policy within a specific insurance
program
Alias: Insurance type code
NSF Reference: DA0-06.0
Required when the destination payer (Loop 2010BB) is Medicare and Medicare is not the
primary payer (SBR01 equals “S” or “T”).
CodeList Summary (Total Codes: 45, Included: 9)
Code Name
12
13
14
15
16
41
42
43
47
SBR09
1032
Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group
Health Plan
Medicare Secondary End-Stage Renal Disease Beneficiary in the 12 month
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
Description: Code identifying type of claim
Alias: Claim Filing Indicator Code
Required prior to mandated used of PlanID. Not used after PlanID is mandated.
CodeList Summary (Total Codes: 45, Included: 23)
Code Name
09
10
Self-pay
Central Certification
NSF Reference:
11
12
13
14
15
16
AM
BL
Other Non-Federal Programs
Preferred Provider Organization (PPO)
Point of Service (POS)
Exclusive Provider Organization (EPO)
Indemnity Insurance
Health Maintenance Organization (HMO) Medicare Risk
Automobile Medical
Blue Cross/Blue Shield
NSF Reference:
CA0-23.0 (K), DA0-05.0 (K)
837P_CG.ecs
70
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Code Name
CA0-23.0 (G), DA0-05.0 (G), CA0-23.0 (P), DA0-05.0 (P)
CH
Champus
NSF Reference:
CA0-23.0 (H), DA0-05.0 (H)
CI
Commercial Insurance Co.
NSF Reference:
CA0-23.0 (F), DA0-05.0 (F)
DS
HM
Disability
Health Maintenance Organization
NSF Reference:
LI
LM
MB
Liability
Liability Medical
Medicare Part B
NSF Reference:
CA0-23.0 (I), DA0-05.0 (I)
CA0-23.0 (C), DA0-05.0 (C)
MC
Medicaid
NSF Reference:
CA0-23.0 (D), DA0-05.0 (D)
OF
Other Federal Program
NSF Reference:
CA0-23.0 (E), DA0-05.0 (E)
TV
Title V
NSF Reference:
DA0-05.0 (T)
VA
Veteran Administration Plan
NSF Reference:
DA0-05.0 (V)
WC
Workers' Compensation Health Claim
NSF Reference:
CA0-23.0 (B), DA0-05.0 (B)
ZZ
Mutually Defined
Unknown
NSF Reference:
CA0-23.0 (Z), DA0-05.0 (Z)
Semantics:
1.
2.
3.
4.
SBR02 specifies the relationship to the person insured.
SBR03 is policy or group number.
SBR04 is plan name.
SBR07 is destination payer code. A "Y" value indicates the payer is the destination payer; an "N" value
indicates the payer is not the destination payer.
Example:
SBR*P**GRP01020102******MB~
837P_CG.ecs
71
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 007
PAT Patient Information
Max: 1
Detail - Optional
Loop:
2000B
Elements: 5
User Option (Usage): Situational
Purpose: To supply patient information
Element Summary:
Ref
Id
Element Name
PAT05
1250
Date Time Period Format Qualifier
Req
Type
Min/Max
Usage
C
ID
2/3
Situational
Description: Code indicating the date format, time format, or date and time format
Required if patient is known to be deceased and the date of death is available to the
provider billing system.
CodeList Summary (Total Codes: 39, Included: 1)
Code Name
D8
PAT06
1251
Date Expressed in Format CCYYMMDD
Date Time Period
C
AN
1/35
Situational
Description: Expression of a date, a time, or range of dates, times or dates and times
Industry: Insured Individual Death Date
Alias: Date of Death
NSF Reference: CA0-21.0
Required if patient is known to be deceased and the date of death is available to the
provider billing system.
PAT07
355
Unit or Basis for Measurement Code
C
ID
2/2
Situational
Description: Code specifying the units in which a value is being expressed, or manner in
which a measurement has been taken
Required when PAT08 is used.
CodeList Summary (Total Codes: 794, Included: 1)
Code Name
01
PAT08
81
Actual Pounds
Weight
C
R
1/10
Situational
Description: Numeric value of weight
Industry: Patient Weight
NSF Reference: FA0-44.0, GU0-17.0
Required on:
1) claims/encounters involving EPO (epoetin) for patients on dialysis.
2) Medicare Durable Medical Equipment Regional Carriers certificate of medical necessity
(DMERC CMN) 02.03 and 10.02.
PAT09
1073
Yes/No Condition or Response Code
O
ID
1/1
Situational
Description: Code indicating a Yes or No condition or response
Industry: Pregnancy Indicator
Required when mandated by law. The determination of pregnancy should be completed in
compliance with applicable law. The “Y” code indicates that the patient is pregnant. If
837P_CG.ecs
72
For internal use only
12/1/2010
Ref
Health Care Claim: Professional - 837
Id
Element Name
Req
Type
PAT09 is not used it means the patient is not pregnant.
Min/Max
Usage
CodeList Summary (Total Codes: 4, Included: 1)
Code Name
Y
Yes
Syntax Rules:
1. P0506 - If either PAT05 or PAT06 is present, then the other is required.
2. P0708 - If either PAT07 or PAT08 is present, then the other is required.
Semantics:
1. PAT06 is the date of death.
2. PAT08 is the patient's weight.
3. PAT09 indicates whether the patient is pregnant or not pregnant. Code "Y" indicates the patient is pregnant;
code "N" indicates the patient is not pregnant.
Notes:
1. Required if the subscriber is the same person as the patient (Loop ID-2000B SBR02=18), and information in
this PAT segment (date of death, and/or patient weight) is necessary to file the claim/encounter (see PAT05, 06,
07, and 08).
Example:
PAT*****D8*19970314*01*146~
837P_CG.ecs
73
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 015
Loop Subscriber Name
Repeat: 1
Optional
Loop:
2010BA
Elements: N/A
User Option (Usage): Required
Purpose: To supply the full name of an individual or organizational entity
Loop Summary:
Pos
Id
Segment Name
015
025
030
032
035
035
NM1
N3
N4
DMG
REF
REF
Subscriber Name
Subscriber Address
Subscriber City/State/ZIP Code
Subscriber Demographic Information
Subscriber Secondary Identification
Property and Casualty Claim Number
Req
Max Use
O
O
O
O
O
O
1
1
1
1
4
1
Repeat
Usage
Required
Situational
Situational
Situational
Situational
Situational
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
Notes:
1. In worker’s compensation or other property and casualty claims, the “subscriber” may be a non-person entity
(i.e., the employer). However, this varies by state.
2. Because this is a required segment, this is a required loop. See Appendix A for further details on ASC X12
syntax rules.
Example:
NM1*IL*1*DOE*JOHN*T**JR*MI*123456~
837P_CG.ecs
74
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 015
NM1 Subscriber Name
Max: 1
Detail - Optional
Loop:
2010BA
Elements: 8
User Option (Usage): Required
Purpose: To supply the full name of an individual or organizational entity
Element Summary:
Ref
Id
Element Name
NM101
98
Entity Identifier Code
Req
Type
Min/Max
Usage
M
ID
2/3
Required
Description: Code identifying an organizational entity, a physical location, property or an
individual
CodeList Summary (Total Codes: 1312, Included: 1)
Code Name
IL
NM102
1065
Insured or Subscriber
Entity Type Qualifier
M
ID
1/1
Required
AN
1/35
Required
Description: Code qualifying the type of entity
CodeList Summary (Total Codes: 14, Included: 2)
Code Name
1
2
NM103
1035
Person
Non-Person Entity
Name Last or Organization Name
O
Description: Individual last name or organizational name
Industry: Subscriber Last Name
NSF Reference: CA0-04.0, DA0-19.0
NM104
1036
Name First
O
AN
1/25
Situational
O
AN
1/25
Situational
Description: Individual first name
Industry: Subscriber First Name
NSF Reference: CA0-05.0, DA0-20.0
Required if NM102=1 (person).
NM105
1037
Name Middle
Description: Individual middle name or initial
Industry: Subscriber Middle Name
NSF Reference: CA0-06.0, DA0-21.0
Required if NM102=1 and the middle name/initial of the person is known.
NM107
1039
Name Suffix
O
AN
1/10
Situational
Description: Suffix to individual name
Industry: Subscriber Name Suffix
Alias: Subscriber Generation
NSF Reference: CA0-07.0, DA0-22.0
Required if known.
837P_CG.ecs
75
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Ref
Id
Element Name
Examples: I, II, III, IV, Jr, Sr
NM108
66
Identification Code Qualifier
Req
Type
Min/Max
Usage
C
ID
1/2
Situational
Description: Code designating the system/method of code structure used for Identification
Code (67)
Required if NM102 = 1 (person)
CodeList Summary (Total Codes: 215, Included: 2)
Code Name
NM109
67
MI
Member Identification Number
The code MI is intended to be the subscriber’s identification number as assigned
by the payer. Payers use different terminology to convey the
same number. Therefore the 837 Professional Workgroup recommends using MI Member Identification Number to convey the following terms: Insured’s ID,
Subscriber’s ID, Health Insurance Claim Number (HIC), etc.
MI is also intended to be used in claims submitted to the Indian Health
Service/Contract Health Services (IHS/CHS) Fiscal Intermediary for the purpose
of reporting the Tribe Residency Code (Tribe County State).
In the event that a Social Security Number is also available on an IHS/CHS claim,
put the SSN in
REF02.
ZZ
Mutually Defined
The value ‘ZZ’, when used in this data element shall be defined as “HIPAA
Individual Identifier” once this identifier has been adopted. Under the Health
Insurance Portability and Accountability Act of 1996, the Secretary of the
Department of Health and Human Services must adopt a standard individual
identifier for use in this transaction.
Identification Code
C
AN
2/80
Situational
Description: Code identifying a party or other code
Industry: Subscriber Primary Identifier
NSF Reference: DA0-18.0, CA1-05.0, CA1-06.0
Required if the Subscriber is the patient. If the subscriber is not the patient, use if known.
An identifier must be present in either the subscriber or the patient loop.
User Note 6:
Use ID Number exactly as it appears on the Subscriber's ID card.
Syntax Rules:
1. P0809 - If either NM108 or NM109 is present, then the other is required.
2. C1110 - If NM111 is present, then NM110 is required.
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
Notes:
1. In worker’s compensation or other property and casualty claims, the “subscriber” may be a non-person entity
(i.e., the employer). However, this varies by state.
2. Because this is a required segment, this is a required loop. See Appendix A for further details on ASC X12
syntax rules.
837P_CG.ecs
76
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Example:
NM1*IL*1*DOE*JOHN*T**JR*MI*123456~
837P_CG.ecs
77
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 025
N3 Subscriber Address
Max: 1
Detail - Optional
Loop:
2010BA
Elements: 2
User Option (Usage): Situational
Purpose: To specify the location of the named party
Element Summary:
Ref
Id
Element Name
N301
166
Address Information
Req
Type
Min/Max
Usage
M
AN
1/55
Required
O
AN
1/55
Situational
Description: Address information
Industry: Subscriber Address Line
Alias: Subscriber Address 1
NSF Reference: CA0-11.0, DA2-04.0
N302
166
Address Information
Description: Address information
Industry: Subscriber Address Line
Alias: Subscriber Address 2
NSF Reference: CA0-12.0, DA2-05.0
Required if a second address line exists.
Notes:
1. Required if the patient is the same person as the subscriber. (Required when Loop ID-2000B, SBR02=18
(self)).
Example:
N3*125 CITY AVENUE~
837P_CG.ecs
78
For internal use only
12/1/2010
Health Care Claim: Professional - 837
N4 Subscriber City/State/ZIP Code
Pos: 030
Max: 1
Detail - Optional
Loop:
2010BA
Elements: 4
User Option (Usage): Situational
Purpose: To specify the geographic place of the named party
Element Summary:
Ref
Id
Element Name
N401
19
City Name
Req
Type
Min/Max
Usage
O
AN
2/30
Required
O
ID
2/2
Required
Description: Free-form text for city name
Industry: Subscriber City Name
NSF Reference: DA2-06.0, CA0-13.0
N402
156
State or Province Code
Description: Code (Standard State/Province) as defined by appropriate government
agency
Industry: Subscriber State Code
CODE SOURCE: 22: States and Outlying Areas of the U.S.
NSF Reference: CA0-14.0, DA2-07.0
ExternalCodeList
Name: 22
Description: States and Outlying Areas of the U.S.
N403
116
Postal Code
O
ID
3/15
Required
Description: Code defining international postal zone code excluding punctuation and
blanks (zip code for United States)
Industry: Subscriber Postal Zone or ZIP Code
Alias: Subscriber Zip Code
CODE SOURCE: 51: ZIP Code
NSF Reference: CA0-15.0, DA2-08.0
ExternalCodeList
Name: 51
Description: ZIP Code
N404
26
Country Code
O
ID
2/3
Situational
Description: Code identifying the country
Alias: Subscriber Country Code
CODE SOURCE: 5: Countries, Currencies and Funds
Required if the address is out of the U.S.
ExternalCodeList
Name: 5
Description: Countries, Currencies and Funds
Syntax Rules:
1. C0605 - If N406 is present, then N405 is required.
837P_CG.ecs
79
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Comments:
1. A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
2. N402 is required only if city name (N401) is in the U.S. or Canada.
Notes:
1. Required if the patient is the same person as the subscriber. (Required when Loop ID-2000B, SBR02=18
(self)).
Example:
N4*CENTERVILLE*PA*17111~
837P_CG.ecs
80
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 032
DMG Subscriber Demographic
Max: 1
Detail - Optional
Information
Loop:
2010BA
Elements: 3
User Option (Usage): Situational
Purpose: To supply demographic information
Element Summary:
Ref
Id
Element Name
DMG01
1250
Date Time Period Format Qualifier
Req
Type
Min/Max
Usage
C
ID
2/3
Required
Description: Code indicating the date format, time format, or date and time format
CodeList Summary (Total Codes: 39, Included: 1)
Code Name
D8
DMG02
1251
Date Expressed in Format CCYYMMDD
Date Time Period
C
AN
1/35
Required
Description: Expression of a date, a time, or range of dates, times or dates and times
Industry: Subscriber Birth Date
Alias: Date of Birth - Patient
NSF Reference: CA0-08.0, DA0-24.0
DMG03
1068
Gender Code
O
ID
1/1
Required
Description: Code indicating the sex of the individual
Industry: Subscriber Gender Code
Alias: Gender - Patient
NSF Reference: CA0-09.0, DA0-23.0
CodeList Summary (Total Codes: 7, Included: 3)
Code Name
F
M
U
Female
Male
Unknown
Syntax Rules:
1. P0102 - If either DMG01 or DMG02 is present, then the other is required.
Semantics:
1. DMG02 is the date of birth.
2. DMG07 is the country of citizenship.
3. DMG09 is the age in years.
Notes:
1. Required if the patient is the same person as the subscriber. (Required when Loop ID-2000B, SBR02=18
(self)).
Example:
DMG*D8*19330706*M~
837P_CG.ecs
81
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 035
REF Subscriber Secondary
Max: 4
Detail - Optional
Identification
Loop:
2010BA
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 4)
Code Name
REF02
127
1W
Member Identification Number
If NM108 = M1 do not use this code.
23
Client Number
This code is intended to be used only in claims submitted to the Indian Health
Service/Contract Health Services (IHS/CHS) Fiscal Intermediary for the purpose
of reporting the Health Record Number.
IG
SY
Insurance Policy Number
Social Security Number
The social security number may not be used for Medicare.
Reference Identification
C
AN
1/30
Required
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Subscriber Supplemental Identifier
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. Required when a secondary identification number is necessary to identify the entity. The primary identification
number should be carried in NM109 in this loop.
Example:
REF*SY*528446666~
837P_CG.ecs
82
For internal use only
12/1/2010
Health Care Claim: Professional - 837
REF Property and Casualty Claim
Number
Pos: 035
Max: 1
Detail - Optional
Loop:
2010BA
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
1/30
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 1)
Code Name
Y4
REF02
127
Agency Claim Number
Reference Identification
C
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Property Casualty Claim Number
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. In the case where the patient is the same person as the subscriber, the property and casualty claim number is
placed in Loop ID-2010BA. In the case where the patient is a different person than the subscriber, this number is
placed in Loop ID-2010CA. This number should be transmitted in only one place.
2. This is a property and casualty payer-assigned claim number. It is required on property and casualty claims.
Providers receive this number from the property and casualty payer during eligibility determinations or some other
communication with that payer. See Section 4.2, Property and Casualty, for additional information about property
and casualty claims.
3. Not required for HIPAA (The statutory definition of a health plan does not specifically include workers’
compensation programs, property and casualty programs, or disability insurance programs, and, consequently,
we are not requiring them to comply with the standards.) but may be required for other uses.
Example:
REF*Y4*4445555~
837P_CG.ecs
83
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 015
Loop Payer Name
Repeat: 1
Optional
Loop:
2010BB
Elements: N/A
User Option (Usage): Required
Purpose: To supply the full name of an individual or organizational entity
Loop Summary:
Pos
Id
Segment Name
015
025
030
035
NM1
N3
N4
REF
Payer
Payer
Payer
Payer
Name
Address
City/State/ZIP Code
Secondary Identification
Req
Max Use
O
O
O
O
1
1
1
3
Repeat
Usage
Required
Situational
Situational
Situational
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
Notes:
1. This is the destination payer.
2. Because this is a required segment, this is a required loop. See Appendix A for further details on ASC X12
syntax rules.
Example:
NM1*PR*2*UNION MUTUAL OF OREGON*****PI*11122333~
837P_CG.ecs
84
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 015
NM1 Payer Name
Max: 1
Detail - Optional
Loop:
2010BB
Elements: 5
User Option (Usage): Required
Purpose: To supply the full name of an individual or organizational entity
Element Summary:
Ref
Id
Element Name
NM101
98
Entity Identifier Code
Req
Type
Min/Max
Usage
M
ID
2/3
Required
Description: Code identifying an organizational entity, a physical location, property or an
individual
CodeList Summary (Total Codes: 1312, Included: 1)
Code Name
PR
NM102
1065
Payer
Entity Type Qualifier
M
ID
1/1
Required
AN
1/35
Required
1/2
Required
Description: Code qualifying the type of entity
CodeList Summary (Total Codes: 14, Included: 1)
Code Name
2
NM103
1035
Non-Person Entity
Name Last or Organization Name
O
Description: Individual last name or organizational name
Industry: Payer Name
NSF Reference: DA0-09.0
NM108
66
Identification Code Qualifier
C
ID
Description: Code designating the system/method of code structure used for Identification
Code (67)
CodeList Summary (Total Codes: 215, Included: 2)
Code Name
PI
XV
Payor Identification
Health Care Financing Administration National Payer Identification Number
(PAYERID)
CODE SOURCE:
540: Health Care Financing Administration National PlanID
NM109
67
Identification Code
C
AN
2/80
Required
Description: Code identifying a party or other code
Industry: Payer Identifier
Alias: Payer Primary Identifier
NSF Reference: DA0-07.0
ExternalCodeList
Name: 540
837P_CG.ecs
85
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Description: Health Care Financing Administration National PlanID
Syntax Rules:
1. P0809 - If either NM108 or NM109 is present, then the other is required.
2. C1110 - If NM111 is present, then NM110 is required.
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
Notes:
1. This is the destination payer.
2. Because this is a required segment, this is a required loop. See Appendix A for further details on ASC X12
syntax rules.
Example:
NM1*PR*2*UNION MUTUAL OF OREGON*****PI*11122333~
837P_CG.ecs
86
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 025
N3 Payer Address
Max: 1
Detail - Optional
Loop:
2010BB
Elements: 2
User Option (Usage): Situational
Purpose: To specify the location of the named party
Element Summary:
Ref
Id
Element Name
N301
166
Address Information
Req
Type
Min/Max
Usage
M
AN
1/55
Required
O
AN
1/55
Situational
Description: Address information
Industry: Payer Address Line
Alias: Payer Address 1
NSF Reference: DA1-04.0
N302
166
Address Information
Description: Address information
Industry: Payer Address Line
Alias: Payer Address 2
NSF Reference: DA1-05.0
Required if a second address line exists.
Notes:
1. Payer Address is required when the submitter intends for the claim to be printed on paper at the next EDI
location (e.g., a clearinghouse).
Example:
N3*225 MAIN STREET*BARKLEY BUILDING~
837P_CG.ecs
87
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 030
N4 Payer City/State/ZIP Code
Max: 1
Detail - Optional
Loop:
2010BB
Elements: 4
User Option (Usage): Situational
Purpose: To specify the geographic place of the named party
Element Summary:
Ref
Id
Element Name
N401
19
City Name
Req
Type
Min/Max
Usage
O
AN
2/30
Required
O
ID
2/2
Required
Description: Free-form text for city name
Industry: Payer City Name
NSF Reference: DA1-06.0
N402
156
State or Province Code
Description: Code (Standard State/Province) as defined by appropriate government
agency
Industry: Payer State Code
CODE SOURCE: 22: States and Outlying Areas of the U.S.
NSF Reference: DA1-07.0
ExternalCodeList
Name: 22
Description: States and Outlying Areas of the U.S.
N403
116
Postal Code
O
ID
3/15
Required
Description: Code defining international postal zone code excluding punctuation and
blanks (zip code for United States)
Industry: Payer Postal Zone or ZIP Code
Alias: Payer Zip Code
CODE SOURCE: 51: ZIP Code
NSF Reference: DA1-08.0
ExternalCodeList
Name: 51
Description: ZIP Code
N404
26
Country Code
O
ID
2/3
Situational
Description: Code identifying the country
Alias: Payer Country Code
CODE SOURCE: 5: Countries, Currencies and Funds
Required if the address is out of the U.S.
ExternalCodeList
Name: 5
Description: Countries, Currencies and Funds
Syntax Rules:
1. C0605 - If N406 is present, then N405 is required.
837P_CG.ecs
88
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Comments:
1. A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
2. N402 is required only if city name (N401) is in the U.S. or Canada.
Notes:
1. Payer Address is required when the submitter intends for the claim to be printed on paper at the next EDI
location (e.g., a clearinghouse).
Example:
N4*CENTERVILLE*PA*17111~
837P_CG.ecs
89
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 035
REF Payer Secondary
Max: 3
Detail - Optional
Identification
Loop:
2010BB
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 4)
Code Name
2U
Payer Identification Number
Used to identify any payer.
FY
NF
Claim Office Number
National Association of Insurance Commissioners (NAIC) Code
CODE SOURCE:
TJ
Federal Taxpayer's Identification Number
245: National Association of Insurance Commissioners (NAIC) Code
REF02
127
Reference Identification
C
AN
1/30
Required
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Payer Additional Identifier
NSF Reference: DA0-08.0
ExternalCodeList
Name: 245
Description: National Association of Insurance Commissioners (NAIC) Code
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. Required if additional identification numbers other than the primary identification number in NM108/09 in this
loop are necessary to adjudicate the claim/encounter.
Example:
REF*FY*435261708~
837P_CG.ecs
90
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 015
Loop Responsible Party Name
Repeat: 1
Optional
Loop:
2010BC
Elements: N/A
User Option (Usage): Situational
Purpose: To supply the full name of an individual or organizational entity
Loop Summary:
Pos
Id
Segment Name
015
025
030
NM1
N3
N4
Responsible Party Name
Responsible Party Address
Responsible Party City/State/ZIP Code
Req
Max Use
O
O
O
1
1
1
Repeat
Usage
Situational
Required
Required
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
Notes:
1. In general terms, the responsible party is someone who is not the subscriber/patient but who has financial
responsibility for the bill.
2. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,
then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.
3. Required for Medicare claims where there is a representative but the provider of medical services has neither
the responsible party’s signature nor the patient’s signature on file.
When a Medicare beneficiary is unable to execute a request for payment because of a mental or physical
condition, the request may be executed on the beneficiary’s behalf by a legal guardian, representative payee,
relative, friend, an employee of the institution providing care, or an employee of a governmental agency providing
assistance. In this circumstance, unless the requester is a representative payee for the beneficiary, the claim
must show the signature and address of the requester with an attached statement explaining the relationship
between the requester and the beneficiary, and why the beneficiary can’t sign. This information must be on the
claim unless it is on file with the provider.
Example:
NM1*QD*1*JONES*LISA~
837P_CG.ecs
91
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 015
NM1 Responsible Party Name
Max: 1
Detail - Optional
Loop:
2010BC
Elements: 6
User Option (Usage): Situational
Purpose: To supply the full name of an individual or organizational entity
Element Summary:
Ref
Id
Element Name
NM101
98
Entity Identifier Code
Req
Type
Min/Max
Usage
M
ID
2/3
Required
Description: Code identifying an organizational entity, a physical location, property or an
individual
NSF Reference: CA0-25.0
CodeList Summary (Total Codes: 1312, Included: 1)
Code Name
QD
NM102
1065
Responsible Party
Entity Type Qualifier
M
ID
1/1
Required
AN
1/35
Required
Description: Code qualifying the type of entity
CodeList Summary (Total Codes: 14, Included: 2)
Code Name
1
2
NM103
1035
Person
Non-Person Entity
Name Last or Organization Name
O
Description: Individual last name or organizational name
Industry: Responsible Party Last or Organization Name
NSF Reference: CB0-04.0
NM104
1036
Name First
O
AN
1/25
Situational
O
AN
1/25
Situational
Description: Individual first name
Industry: Responsible Party First Name
NSF Reference: CB0-05.0
Required if NM102=1 (person).
NM105
1037
Name Middle
Description: Individual middle name or initial
Industry: Responsible Party Middle Name
NSF Reference: CB0-06.0
Required if NM102=1 and the middle name/initial of the person is known.
NM107
1039
Name Suffix
O
AN
1/10
Situational
Description: Suffix to individual name
Industry: Responsible Party Suffix Name
Alias: Responsible Party Generation
Required if known.
837P_CG.ecs
92
For internal use only
12/1/2010
Ref
Health Care Claim: Professional - 837
Id
Element Name
Req
Type
Min/Max
Usage
Syntax Rules:
1. P0809 - If either NM108 or NM109 is present, then the other is required.
2. C1110 - If NM111 is present, then NM110 is required.
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
Notes:
1. In general terms, the responsible party is someone who is not the subscriber/patient but who has financial
responsibility for the bill.
2. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,
then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.
3. Required for Medicare claims where there is a representative but the provider of medical services has neither
the responsible party’s signature nor the patient’s signature on file.
When a Medicare beneficiary is unable to execute a request for payment because of a mental or physical
condition, the request may be executed on the beneficiary’s behalf by a legal guardian, representative payee,
relative, friend, an employee of the institution providing care, or an employee of a governmental agency providing
assistance. In this circumstance, unless the requester is a representative payee for the beneficiary, the claim
must show the signature and address of the requester with an attached statement explaining the relationship
between the requester and the beneficiary, and why the beneficiary can’t sign. This information must be on the
claim unless it is on file with the provider.
Example:
NM1*QD*1*JONES*LISA~
837P_CG.ecs
93
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 025
N3 Responsible Party Address
Max: 1
Detail - Optional
Loop:
2010BC
Elements: 2
User Option (Usage): Required
Purpose: To specify the location of the named party
Element Summary:
Ref
Id
Element Name
N301
166
Address Information
Req
Type
Min/Max
Usage
M
AN
1/55
Required
O
AN
1/55
Situational
Description: Address information
Industry: Responsible Party Address Line
Alias: Responsible Party Address 1
NSF Reference: CB0-07.0
N302
166
Address Information
Description: Address information
Industry: Responsible Party Address Line
Alias: Responsible Party Address 2
NSF Reference: CB0-08.0
Required if a second address line exists.
Example:
N3*123 MAIN STREET~
837P_CG.ecs
94
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 030
N4 Responsible Party
Max: 1
Detail - Optional
City/State/ZIP Code
Loop:
2010BC
Elements: 4
User Option (Usage): Required
Purpose: To specify the geographic place of the named party
Element Summary:
Ref
Id
Element Name
N401
19
City Name
Req
Type
Min/Max
Usage
O
AN
2/30
Required
O
ID
2/2
Required
Description: Free-form text for city name
Industry: Responsible Party City Name
NSF Reference: CB0-09.0
N402
156
State or Province Code
Description: Code (Standard State/Province) as defined by appropriate government
agency
Industry: Responsible Party State Code
CODE SOURCE: 22: States and Outlying Areas of the U.S.
NSF Reference: CB0-10.0
ExternalCodeList
Name: 22
Description: States and Outlying Areas of the U.S.
N403
116
Postal Code
O
ID
3/15
Required
Description: Code defining international postal zone code excluding punctuation and
blanks (zip code for United States)
Industry: Responsible Party Postal Zone or ZIP Code
Alias: Responsible Party Zip Code
CODE SOURCE: 51: ZIP Code
NSF Reference: CB0-11.0
ExternalCodeList
Name: 51
Description: ZIP Code
N404
26
Country Code
O
ID
2/3
Situational
Description: Code identifying the country
Alias: Responsible Party Country Code
CODE SOURCE: 5: Countries, Currencies and Funds
Required if the address is out of the U.S.
ExternalCodeList
Name: 5
Description: Countries, Currencies and Funds
Syntax Rules:
1. C0605 - If N406 is present, then N405 is required.
837P_CG.ecs
95
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Comments:
1. A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
2. N402 is required only if city name (N401) is in the U.S. or Canada.
Example:
N4*ANY TOWN*TX*75123~
837P_CG.ecs
96
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 015
Loop Credit/Debit Card Holder
Name
Repeat: 1
Optional
Loop:
2010BD
Elements: N/A
User Option (Usage): Situational
Purpose: To supply the full name of an individual or organizational entity
Loop Summary:
Pos
Id
Segment Name
015
035
NM1
REF
Credit/Debit Card Holder Name
Credit/Debit Card Information
Req
Max Use
O
O
1
2
Repeat
Usage
Situational
Situational
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
Notes:
1. It is not intended that credit/debit card information be conveyed to a health care payer. Trading partners are
responsible for ensuring that no federal or state privacy regulations are violated if credit/debit card information is
carried in the transmission.
2. The information carried under this segment must never be sent to the payer. This information is only for use
between a provider and a service organization offering patient collection services. In this case, it is the
responsibility of the collection service organization to remove this segment before forwarding the claim to the
payer.
Example:
NM1*AO*1*SMITH*JANE*L***MI*0000000000000000000~
837P_CG.ecs
97
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 015
NM1 Credit/Debit Card Holder
Max: 1
Detail - Optional
Name
Loop:
2010BD
Elements: 8
User Option (Usage): Situational
Purpose: To supply the full name of an individual or organizational entity
Element Summary:
Ref
Id
Element Name
NM101
98
Entity Identifier Code
Req
Type
Min/Max
Usage
M
ID
2/3
Required
Description: Code identifying an organizational entity, a physical location, property or an
individual
CodeList Summary (Total Codes: 1312, Included: 1)
Code Name
AO
NM102
1065
Account Of
Entity Type Qualifier
M
ID
1/1
Required
AN
1/35
Required
Description: Code qualifying the type of entity
CodeList Summary (Total Codes: 14, Included: 2)
Code Name
1
2
NM103
1035
Person
Non-Person Entity
Name Last or Organization Name
O
Description: Individual last name or organizational name
Industry: Credit or Debit Card Holder Last or Organizational Name
Alias: Credit/Debit Card Holder Name
NM104
1036
Name First
O
AN
1/25
Situational
AN
1/25
Situational
Description: Individual first name
Industry: Credit or Debit Card Holder First Name
Alias: Credit/Debit Card Holder Name
Required if NM102=1 (person).
NM105
1037
Name Middle
O
Description: Individual middle name or initial
Industry: Credit or Debit Card Holder Middle Name
Alias: Credit/Debit Card Holder Name
Required if NM102=1 and the middle name/initial of the person is known.
NM107
1039
Name Suffix
O
AN
1/10
Situational
Description: Suffix to individual name
Industry: Credit or Debit Card Holder Name Suffix
Alias: Credit/Debit Card Holder Name
Required if known.
837P_CG.ecs
98
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Ref
Id
Element Name
NM108
66
Identification Code Qualifier
Req
Type
Min/Max
Usage
C
ID
1/2
Required
Description: Code designating the system/method of code structure used for Identification
Code (67)
CodeList Summary (Total Codes: 215, Included: 1)
Code Name
MI
NM109
67
Member Identification Number
Identification Code
C
AN
2/80
Required
Description: Code identifying a party or other code
Industry: Credit or Debit Card Number
Alias: Credit/Debit Card Number
Syntax Rules:
1. P0809 - If either NM108 or NM109 is present, then the other is required.
2. C1110 - If NM111 is present, then NM110 is required.
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
Notes:
1. It is not intended that credit/debit card information be conveyed to a health care payer. Trading partners are
responsible for ensuring that no federal or state privacy regulations are violated if credit/debit card information is
carried in the transmission.
2. The information carried under this segment must never be sent to the payer. This information is only for use
between a provider and a service organization offering patient collection services. In this case, it is the
responsibility of the collection service organization to remove this segment before forwarding the claim to the
payer.
Example:
NM1*AO*1*SMITH*JANE*L***MI*0000000000000000000~
837P_CG.ecs
99
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 035
REF Credit/Debit Card
Max: 2
Detail - Optional
Information
Loop:
2010BD
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
1/30
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 2)
Code Name
AB
BB
REF02
127
Acceptable Source Purchaser ID
Authorization Number
Reference Identification
C
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Credit or Debit Card Authorization Number
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. The information carried under this segment must never be sent to the payer. This information is only for use
between a provider and a service organization offering patient collection services. In this case, it is the
responsibility of the collection service organization to remove this segment before forwarding the claim to the
payer.
Example:
REF*BB*111222333334~
837P_CG.ecs
100
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 130
Loop Claim Information
Repeat: 100
Optional
Loop: 2300 Elements: N/A
User Option (Usage): Situational
Purpose: To specify basic data about the claim
Loop Summary:
Pos
Id
Segment Name
130
135
135
135
135
135
135
135
135
135
CLM
DTP
DTP
DTP
DTP
DTP
DTP
DTP
DTP
DTP
135
135
135
135
135
135
135
DTP
DTP
DTP
DTP
DTP
DTP
DTP
155
160
175
175
175
180
180
PWK
CN1
AMT
AMT
AMT
REF
REF
180
180
180
180
REF
REF
REF
REF
180
180
180
180
REF
REF
REF
REF
180
180
REF
REF
Claim Information
Date - Initial Treatment
Date - Date Last Seen
Date - Onset of Current Illness/Symptom
Date - Acute Manifestation
Date - Similar Illness/Symptom Onset
Date - Accident
Date - Last Menstrual Period
Date - Last X-ray
Date - Hearing and Vision Prescription
Date
Date - Disability Begin
Date - Disability End
Date - Last Worked
Date - Authorized Return to Work
Date - Admission
Date - Discharge
Date - Assumed and Relinquished Care
Dates
Claim Supplemental Information
Contract Information
Credit/Debit Card Maximum Amount
Patient Amount Paid
Total Purchased Service Amount
Service Authorization Exception Code
Mandatory Medicare (Section 4081)
Crossover Indicator
Mammography Certification Number
Prior Authorization or Referral Number
Original Reference Number (ICN/DCN)
Clinical Laboratory Improvement
Amendment (CLIA) Number
Repriced Claim Number
Adjusted Repriced Claim Number
Investigational Device Exemption Number
Claim Identification Number for Clearing
Houses and Other Transmission
Intermediaries
Ambulatory Patient Group (APG)
Medical Record Number
837P_CG.ecs
101
Req
Max Use
O
O
O
O
O
O
O
O
O
O
1
1
1
1
5
10
10
1
1
1
Repeat
Required
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Usage
O
O
O
O
O
O
O
5
5
1
1
1
1
2
Situational
Situational
Situational
Situational
Situational
Situational
Situational
O
O
O
O
O
O
O
10
1
1
1
1
1
1
Situational
Situational
Situational
Situational
Situational
Situational
Situational
O
O
O
O
1
2
1
3
Situational
Situational
Situational
Situational
O
O
O
O
1
1
1
1
Situational
Situational
Situational
Situational
O
O
4
1
Situational
Situational
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos
Id
Segment Name
180
185
190
195
200
220
220
220
220
231
241
242
250
250
250
250
250
290
365
REF
K3
NTE
CR1
CR2
CRC
CRC
CRC
CRC
HI
HCP
Demonstration Project Identifier
File Information
Claim Note
Ambulance Transport Information
Spinal Manipulation Service Information
Ambulance Certification
Patient Condition Information: Vision
Homebound Indicator
EPSDT Referral
Health Care Diagnosis Code
Claim Pricing/Repricing Information
Loop 2305
Loop 2310A
Loop 2310B
Loop 2310C
Loop 2310D
Loop 2310E
Loop 2320
Loop 2400
Req
Max Use
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
1
10
1
1
1
3
3
1
1
1
1
Repeat
Usage
6
2
1
1
1
1
10
50
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Required
Semantics:
1. CLM02 is the total amount of all submitted charges of service segments for this claim.
2. CLM06 is provider signature on file indicator. A "Y" value indicates the provider signature is on file; an "N"
value indicates the provider signature is not on file.
3. CLM08 is assignment of benefits indicator. A "Y" value indicates insured or authorized person authorizes
benefits to be assigned to the provider; an "N" value indicates benefits have not been assigned to the
provider.
4. CLM13 is CHAMPUS nonavailability indicator. A "Y" value indicates a statement of non-availability is on file;
an "N" value indicates statement of nonavailability is not on file or not necessary.
5. CLM15 is charges itemized by service indicator. A "Y" value indicates charges are itemized by service; an "N"
value indicates charges are summarized by service.
6. CLM18 is explanation of benefit (EOB) indicator. A "Y" value indicates that a paper EOB is requested; an "N"
value indicates that no paper EOB is requested.
Notes:
1. Because this is a required segment, this is a required loop. See Appendix A for further details on ASC X12
syntax rules.
2. 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 ISA-IEA. Willing trading partners can agree to set limits higher.
3. 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 2010BD in the subscriber hierarchical level when the patient is the
subscriber, or it is placed at the patient/dependent hierarchical level when the patient is the dependent of the
subscriber as shown here. When the patient is the subscriber, loops 2000C and 2010CA are not sent. See
2.3.2.1, HL Segment, for details.
Example:
CLM*A37YH556*500***11::1*Y*A*Y*Y*C~
837P_CG.ecs
102
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 130
CLM Claim Information
Max: 1
Detail - Optional
Loop: 2300
Elements: 12
User Option (Usage): Required
Purpose: To specify basic data about the claim
Element Summary:
Ref
Id
Element Name
CLM01
1028
Claim Submitter's Identifier
Req
Type
Min/Max
Usage
M
AN
1/38
Required
Description: Identifier used to track a claim from creation by the health care provider
through payment
Industry: Patient Account Number
NSF Reference: CA0-03.0, CB0-03.0, DA0-03.0, DA1-03.0, DA2-03.0, EA0-03.0, EA103.0, EA2-03.0, FA0-03.0, FB0-03.0, FB1-03.0, FB2-03.0, FD0-03.0, FE0-03.0, GA0-03.0,
GC0-03.0, GX0-03.0, GX2-03.0, XA0-03.0, CA1-03. 0, GU0-03.0, HA0-03.0
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 completely unique
numbers for this field for each individual claim.
The maximum number of characters to be supported for this field is ’20’. A provider may
submit fewer characters depending upon their needs. However, the HIPAA maximum
requirement to be supported by any responding system is ’20’. Characters beyond 20 are
not required to be stored nor returned by any 837-receiving system.
CLM02
782
Monetary Amount
O
R
1/18
Required
Description: Monetary amount
Industry: Total Claim Charge Amount
Alias: Total Submitted Charges
NSF Reference: XA0-12.0
For encounter transmissions, zero (0) may be a valid amount.
CLM05
C023
Health Care Service Location
Information
O
Comp
Required
Description: To provide information that identifies the place of service or the type of bill
related to the location at which a health care service was rendered
Alias: Place of Service Code
NSF Reference: FA0-07.0
CLM05 applies to all service lines unless it is over written at the line level.
User Note 6:
AMBULANCE
Use the following codes for Type of Transport:
41- Land
42 Air or Water
CLM05-01
837P_CG.ecs
1331
Facility Code Value
M
103
AN
1/2
Required
For internal use only
12/1/2010
Ref
Health Care Claim: Professional - 837
Id
Element Name
Req
Type
Min/Max
Usage
Description: Code identifying the type of facility where services were performed; the first
and second positions of the Uniform Bill Type code or the Place of Service code from the
Electronic Media Claims National Standard Format
Industry: Facility Type Code
Use this element for codes identifying a place of service from code source 237. As a
courtesy, the codes are listed below, however, the code list is thought to be complete at the
time of publication of this implementation guideline. Since this list is subject to change, only
codes contained in the document available from code source 237 are to be supported in
this transaction and take precedence over any and all codes listed here.
11 Office
12 Home
21 Inpatient Hospital
22 Outpatient Hospital
23 Emergency Room - Hospital
24 Ambulatory Surgical Center
25 Birthing Center
26 Military Treatment Facility
31 Skilled Nursing Facility
32 Nursing Facility
33 Custodial Care Facility
34 Hospice
41 Ambulance - Land
42 Ambulance - Air or Water
51 Inpatient Psychiatric Facility
52 Psychiatric Facility Partial Hospitalization
53 Community Mental Health Center
54 Intermediate Care Facility/Mentally Retarded
55 Residential Substance Abuse Treatment Facility
56 Psychiatric Residential Treatment Center
50 Federally Qualified Health Center
60 Mass Immunization Center
61 Comprehensive Inpatient Rehabilitation Facility
62 Comprehensive Outpatient Rehabilitation Facility
65 End Stage Renal Disease Treatment Facility
71 State or Local Public Health Clinic
72 Rural Health Clinic
81 Independent Laboratory
99 Other Unlisted Facility
ExternalCodeList
Name: 237
Description: Place of Service from Health Care Financing Administration Claim Form
CLM05-03
1325
Claim Frequency Type Code
O
ID
1/1
Required
Description: Code specifying the frequency of the claim; this is the third position of the
Uniform Billing Claim Form Bill Type
Industry: Claim Frequency Code
Alias: Claim Submission Reason Code
CODE SOURCE: 235: Claim Frequency Type Code
User Note 6:
Code source 235
Use 1 for all original submissions. All other values will be treated as adjustments.
ExternalCodeList
Name: 235
837P_CG.ecs
104
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Description: Claim Frequency Type Code
CLM06
1073
Yes/No Condition or Response Code
O
ID
1/1
Required
1/1
Required
Description: Code indicating a Yes or No condition or response
Industry: Provider or Supplier Signature Indicator
Alias: Provider Signature on File
NSF Reference: EA0-37.0
CodeList Summary (Total Codes: 4, Included: 2)
Code Name
N
Y
CLM07
1359
No
Yes
Provider Accept Assignment Code
O
ID
Description: Code indicating whether the provider accepts assignment
Industry: Medicare Assignment Code
CLM07 indicates whether the provider accepts Medicare assignment.
The NSF mapping to FA0-59.0 occurs only in payer-to-payer COB situations.
All valid standard codes are used. (Total Codes: 4)
CLM08
1073
Yes/No Condition or Response Code
O
ID
1/1
Required
1/1
Required
Description: Code indicating a Yes or No condition or response
Industry: Benefits Assignment Certification Indicator
Alias: Assignment of Benefits Indicator
NSF Reference: DA0-15.0
CodeList Summary (Total Codes: 4, Included: 2)
Code Name
N
Y
CLM09
1363
No
Yes
Release of Information Code
O
ID
Description: Code indicating whether the provider has on file a signed statement by the
patient authorizing the release of medical data to other organizations
Alias: Release of Information Code
NSF Reference: EA0-13.0
All valid standard codes are used. (Total Codes: 6)
CLM10
1351
Patient Signature Source Code
O
ID
1/1
Situational
Description: Code indicating how the patient or subscriber authorization signatures were
obtained and how they are being retained by the provider
Alias: Patient Signature Source Code
NSF Reference: DA0-16.0
CLM10 is required except in cases where code ‘‘N’’ is used in CLM09.
All valid standard codes are used. (Total Codes: 5)
CLM11
C024
Related Causes Information
O
Comp
Situational
Description: To identify one or more related causes and associated state or country
information
837P_CG.ecs
105
For internal use only
12/1/2010
Ref
Health Care Claim: Professional - 837
Id
Element Name
Req
Alias: Accident/Employment/Related Causes
Type
Min/Max
Usage
CLM11-1, CLM11-2, or CLM11-3 are required when the condition being reported is
accident or employment related. If CLM11-1, CLM11-2, or CLM11-3 equals AP, then map
Yes to EA0-09.0. 2440 If DTP - Date of Accident (DTP01=439) is used, then CLM11 is
required.
CLM11-01
1362
Related-Causes Code
M
ID
2/3
Required
Description: Code identifying an accompanying cause of an illness, injury or an accident
Industry: Related Causes Code
NSF Reference: EA0-05.0 - Auto Accident or Other Accident, EA0-04.0 -Employment,
EA0-09.0 - Responsibility Indicator
CodeList Summary (Total Codes: 6, Included: 4)
Code Name
AA
AP
EM
OA
CLM11-02
1362
Auto Accident
Another Party Responsible
Employment
Other Accident
Related-Causes Code
O
ID
2/3
Situational
Description: Code identifying an accompanying cause of an illness, injury or an accident
Industry: Related Causes Code
NSF Reference: EA0-05.0 - Auto Accident or Other Accident, EA0-04.0 -Employment,
EA0-09.0 - Responsibility Indicator
Used if more than one code applies.
CodeList Summary (Total Codes: 6, Included: 4)
Code Name
AA
AP
EM
OA
CLM11-03
1362
Auto Accident
Another Party Responsible
Employment
Other Accident
Related-Causes Code
O
ID
2/3
Situational
Description: Code identifying an accompanying cause of an illness, injury or an accident
Industry: Related Causes Code
NSF Reference: EA0-05.0 - Auto Accident or Other Accident, EA0-04.0 -Employment,
EA0-09.0 - Responsibility Indicator
Used if more than one code applies.
CodeList Summary (Total Codes: 6, Included: 4)
Code Name
AA
AP
EM
OA
CLM11-04
156
Auto Accident
Another Party Responsible
Employment
Other Accident
State or Province Code
O
ID
2/2
Situational
Description: Code (Standard State/Province) as defined by appropriate government
agency
837P_CG.ecs
106
For internal use only
12/1/2010
Ref
Health Care Claim: Professional - 837
Id
Element Name
Req
Industry: Auto Accident State or Province Code
Type
Min/Max
Usage
CODE SOURCE: 22: States and Outlying Areas of the U.S.
NSF Reference: EA0-10.0
Required if CLM11-1, -2, or -3 = AA to identify the state in which the automobile accident
occurred. Use state postal code (CA = California, UT = Utah, etc).
ExternalCodeList
Name: 22
Description: States and Outlying Areas of the U.S.
CLM11-05
26
Country Code
O
ID
2/3
Situational
Description: Code identifying the country
CODE SOURCE: 5: Countries, Currencies and Funds
Required if the automobile accident occurred out of the United States to identify the
country in which the accident occurred.
ExternalCodeList
Name: 5
Description: Countries, Currencies and Funds
CLM12
1366
Special Program Code
O
ID
2/3
Situational
Description: Code indicating the Special Program under which the services rendered to
the patient were performed
Industry: Special Program Indicator
Alias: Special Program Code
NSF Reference: EA0-43.0
Required if the services were rendered under one of the following
circumstances/programs/projects.
CodeList Summary (Total Codes: 10, Included: 7)
Code Name
01
02
03
CLM16
1360
Early & Periodic Screening, Diagnosis, and Treatment (EPSDT) or Child Health
Assessment Program (CHAP)
Physically Handicapped Children's Program
Special Federal Funding
This code is used for Medicaid claims only.
05
Disability
This code is used for Medicaid claims only.
07
Induced Abortion - Danger to Life
This code is used for Medicaid claims only.
08
Induced Abortion - Rape or Incest
This code is used for Medicaid claims only.
09
Second Opinion or Surgery
This code is used for Medicaid claims only.
Provider Agreement Code
O
ID
1/1
Situational
Description: Code indicating the type of agreement under which the provider is submitting
this claim
Industry: Participation Agreement
837P_CG.ecs
107
For internal use only
12/1/2010
Ref
Health Care Claim: Professional - 837
Id
Element Name
Req
Type
Min/Max
Usage
Required if a non-participating (non-par) provider is submitting a participating (par)
claim/encounter. Sending the “P” code indicates that a non-par provider is sending a par
claim as allowed under certain plans.
CodeList Summary (Total Codes: 7, Included: 1)
Code Name
P
CLM20
1514
Participation Agreement
Delay Reason Code
O
ID
1/2
Situational
Description: Code indicating the reason why a request was delayed
Alias: Delay Reason Code
This element may be used if a particular claim is being transmitted in response to a request
for information (e.g., a 277), and the response has been delayed.
Required when claim is submitted late (past contracted date of filing limitations) and any of
the codes below apply.
CodeList Summary (Total Codes: 14, Included: 11)
Code Name
1
2
3
4
5
6
7
8
9
10
11
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
Semantics:
1. CLM02 is the total amount of all submitted charges of service segments for this claim.
2. CLM06 is provider signature on file indicator. A "Y" value indicates the provider signature is on file; an "N"
value indicates the provider signature is not on file.
3. CLM08 is assignment of benefits indicator. A "Y" value indicates insured or authorized person authorizes
benefits to be assigned to the provider; an "N" value indicates benefits have not been assigned to the
provider.
4. CLM13 is CHAMPUS nonavailability indicator. A "Y" value indicates a statement of non-availability is on file;
an "N" value indicates statement of nonavailability is not on file or not necessary.
5. CLM15 is charges itemized by service indicator. A "Y" value indicates charges are itemized by service; an "N"
value indicates charges are summarized by service.
6. CLM18 is explanation of benefit (EOB) indicator. A "Y" value indicates that a paper EOB is requested; an "N"
value indicates that no paper EOB is requested.
Notes:
1. Because this is a required segment, this is a required loop. See Appendix A for further details on ASC X12
syntax rules.
2. 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 ISA-IEA. Willing trading partners can agree to set limits higher.
3. For purposes of this documentation, the claim detail information is presented only in the dependent level.
837P_CG.ecs
108
For internal use only
12/1/2010
Health Care Claim: Professional - 837
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 2010BD in the subscriber hierarchical level when the patient is the
subscriber, or it is placed at the patient/dependent hierarchical level when the patient is the dependent of the
subscriber as shown here. When the patient is the subscriber, loops 2000C and 2010CA are not sent. See
2.3.2.1, HL Segment, for details.
Example:
CLM*A37YH556*500***11::1*Y*A*Y*Y*C~
837P_CG.ecs
109
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 135
DTP Date - Initial Treatment
Max: 1
Detail - Optional
Loop: 2300
Elements: 3
User Option (Usage): Situational
Purpose: To specify any or all of a date, a time, or a time period
Element Summary:
Ref
Id
Element Name
DTP01
374
Date/Time Qualifier
Req
Type
Min/Max
Usage
M
ID
3/3
Required
Description: Code specifying type of date or time, or both date and time
Industry: Date Time Qualifier
CodeList Summary (Total Codes: 1112, Included: 1)
Code Name
454
DTP02
1250
Initial Treatment
Date Time Period Format Qualifier
M
ID
2/3
Required
Description: Code indicating the date format, time format, or date and time format
CodeList Summary (Total Codes: 39, Included: 1)
Code Name
D8
DTP03
1251
Date Expressed in Format CCYYMMDD
Date Time Period
M
AN
1/35
Required
Description: Expression of a date, a time, or range of dates, times or dates and times
Industry: Initial Treatment Date
NSF Reference: GC0-05.0
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
Notes:
1. Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in Loop
ID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300
for that service line only.
2. Required on all claims involving spinal manipulation for Medicare Part B.
Example:
DTP*454*D8*19970115~
837P_CG.ecs
110
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 135
DTP Date - Date Last Seen
Max: 1
Detail - Optional
Loop: 2300
Elements: 3
User Option (Usage): Situational
Purpose: To specify any or all of a date, a time, or a time period
Element Summary:
Ref
Id
Element Name
DTP01
374
Date/Time Qualifier
Req
Type
Min/Max
Usage
M
ID
3/3
Required
Description: Code specifying type of date or time, or both date and time
Industry: Date Time Qualifier
CodeList Summary (Total Codes: 1112, Included: 1)
Code Name
304
DTP02
1250
Latest Visit or Consultation
Date Time Period Format Qualifier
M
ID
2/3
Required
Description: Code indicating the date format, time format, or date and time format
CodeList Summary (Total Codes: 39, Included: 1)
Code Name
D8
DTP03
1251
Date Expressed in Format CCYYMMDD
Date Time Period
M
AN
1/35
Required
Description: Expression of a date, a time, or range of dates, times or dates and times
Industry: Last Seen Date
NSF Reference: EA0-48.0
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
Notes:
1. Required when claims involve services from an independent physical therapist, occupational therapist, or
physician services involving routine foot care and it is known to impact the payer’s adjudication process.
2. This is the date that the patient was seen by the attending/supervising physician for the qualifying medical
condition related to the services performed.
Example:
DTP*304*D8*19970115~
837P_CG.ecs
111
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 135
DTP Date - Onset of Current
Max: 1
Detail - Optional
Illness/Symptom
Loop: 2300
Elements: 3
User Option (Usage): Situational
Purpose: To specify any or all of a date, a time, or a time period
Element Summary:
Ref
Id
Element Name
DTP01
374
Date/Time Qualifier
Req
Type
Min/Max
Usage
M
ID
3/3
Required
Description: Code specifying type of date or time, or both date and time
Industry: Date Time Qualifier
CodeList Summary (Total Codes: 1112, Included: 1)
Code Name
431
DTP02
1250
Onset of Current Symptoms or Illness
Date Time Period Format Qualifier
M
ID
2/3
Required
Description: Code indicating the date format, time format, or date and time format
CodeList Summary (Total Codes: 39, Included: 1)
Code Name
D8
DTP03
1251
Date Expressed in Format CCYYMMDD
Date Time Period
M
AN
1/35
Required
Description: Expression of a date, a time, or range of dates, times or dates and times
Industry: Onset of Current Illness or Injury Date
NSF Reference: EA0-07.0
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
Notes:
1. Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in Loop
ID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300
for that service line only.
2. Required when information is available and if different than the date of service. If not used, claim/service date
is assumed to be the date of onset of illness/symptoms.
Example:
DTP*431*D8*19970115~
837P_CG.ecs
112
For internal use only
12/1/2010
Health Care Claim: Professional - 837
DTP Date - Acute Manifestation
Pos: 135
Max: 5
Detail - Optional
Loop: 2300
Elements: 3
User Option (Usage): Situational
Purpose: To specify any or all of a date, a time, or a time period
Element Summary:
Ref
Id
Element Name
DTP01
374
Date/Time Qualifier
Req
Type
Min/Max
Usage
M
ID
3/3
Required
Description: Code specifying type of date or time, or both date and time
Industry: Date Time Qualifier
CodeList Summary (Total Codes: 1112, Included: 1)
Code Name
453
DTP02
1250
Acute Manifestation of a Chronic Condition
Date Time Period Format Qualifier
M
ID
2/3
Required
Description: Code indicating the date format, time format, or date and time format
CodeList Summary (Total Codes: 39, Included: 1)
Code Name
D8
DTP03
1251
Date Expressed in Format CCYYMMDD
Date Time Period
M
AN
1/35
Required
Description: Expression of a date, a time, or range of dates, times or dates and times
Industry: Acute Manifestation Date
NSF Reference: GC0-12.0
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
Notes:
1. Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in Loop
ID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300
for that service line only.
2. Required when Loop 2300 CR208 = “A” or “M”, the claim involves spinal manipulation, and the payer is
Medicare.
Example:
DTP*453*D8*19970115~
837P_CG.ecs
113
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 135
DTP Date - Similar
Max: 10
Detail - Optional
Illness/Symptom Onset
Loop: 2300
Elements: 3
User Option (Usage): Situational
Purpose: To specify any or all of a date, a time, or a time period
Element Summary:
Ref
Id
Element Name
DTP01
374
Date/Time Qualifier
Req
Type
Min/Max
Usage
M
ID
3/3
Required
Description: Code specifying type of date or time, or both date and time
Industry: Date Time Qualifier
CodeList Summary (Total Codes: 1112, Included: 1)
Code Name
438
DTP02
1250
Onset of Similar Symptoms or Illness
Date Time Period Format Qualifier
M
ID
2/3
Required
Description: Code indicating the date format, time format, or date and time format
CodeList Summary (Total Codes: 39, Included: 1)
Code Name
D8
DTP03
1251
Date Expressed in Format CCYYMMDD
Date Time Period
M
AN
1/35
Required
Description: Expression of a date, a time, or range of dates, times or dates and times
Industry: Similar Illness or Symptom Date
NSF Reference: EA0-16.0
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
Notes:
1. Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in Loop
ID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300
for that service line only.
2. Required when claim involves services to a patient experiencing symptoms similar or identical to previously
reported symptoms.
Example:
DTP*438*D8*19970115~
837P_CG.ecs
114
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 135
DTP Date - Accident
Max: 10
Detail - Optional
Loop: 2300
Elements: 3
User Option (Usage): Situational
Purpose: To specify any or all of a date, a time, or a time period
Element Summary:
Ref
Id
Element Name
DTP01
374
Date/Time Qualifier
Req
Type
Min/Max
Usage
M
ID
3/3
Required
Description: Code specifying type of date or time, or both date and time
Industry: Date Time Qualifier
CodeList Summary (Total Codes: 1112, Included: 1)
Code Name
439
DTP02
1250
Accident
Date Time Period Format Qualifier
M
ID
2/3
Required
Description: Code indicating the date format, time format, or date and time format
CodeList Summary (Total Codes: 39, Included: 2)
Code Name
D8
DT
DTP03
1251
Date Expressed in Format CCYYMMDD
Date and Time Expressed in Format CCYYMMDDHHMM
Required if accident hour is known.
Date Time Period
M
AN
1/35
Required
Description: Expression of a date, a time, or range of dates, times or dates and times
Industry: Accident Date
NSF Reference: EA0-07.0 - Accident Date, EA0-11.0 Accident Hour (no minutes)
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
Notes:
1. Required if CLM11-1, CLM11-2, or CLM11-3 = AA, AB, AP or OA.
Example:
DTP*439*D8*19970114~
837P_CG.ecs
115
For internal use only
12/1/2010
Health Care Claim: Professional - 837
DTP Date - Last Menstrual Period
Pos: 135
Max: 1
Detail - Optional
Loop: 2300
Elements: 3
User Option (Usage): Situational
Purpose: To specify any or all of a date, a time, or a time period
Element Summary:
Ref
Id
Element Name
DTP01
374
Date/Time Qualifier
Req
Type
Min/Max
Usage
M
ID
3/3
Required
Description: Code specifying type of date or time, or both date and time
Industry: Date Time Qualifier
CodeList Summary (Total Codes: 1112, Included: 1)
Code Name
484
DTP02
1250
Last Menstrual Period
Date Time Period Format Qualifier
M
ID
2/3
Required
Description: Code indicating the date format, time format, or date and time format
CodeList Summary (Total Codes: 39, Included: 1)
Code Name
D8
DTP03
1251
Date Expressed in Format CCYYMMDD
Date Time Period
M
AN
1/35
Required
Description: Expression of a date, a time, or range of dates, times or dates and times
Industry: Last Menstrual Period Date
NSF Reference: EA0-07.0
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
Notes:
1. Required when claim involves pregnancy.
Example:
DTP*484*D8*19961113~
837P_CG.ecs
116
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 135
DTP Date - Last X-ray
Max: 1
Detail - Optional
Loop: 2300
Elements: 3
User Option (Usage): Situational
Purpose: To specify any or all of a date, a time, or a time period
Element Summary:
Ref
Id
Element Name
DTP01
374
Date/Time Qualifier
Req
Type
Min/Max
Usage
M
ID
3/3
Required
Description: Code specifying type of date or time, or both date and time
Industry: Date Time Qualifier
CodeList Summary (Total Codes: 1112, Included: 1)
Code Name
455
DTP02
1250
Last X-Ray
Date Time Period Format Qualifier
M
ID
2/3
Required
Description: Code indicating the date format, time format, or date and time format
CodeList Summary (Total Codes: 39, Included: 1)
Code Name
D8
DTP03
1251
Date Expressed in Format CCYYMMDD
Date Time Period
M
AN
1/35
Required
Description: Expression of a date, a time, or range of dates, times or dates and times
Industry: Last X-Ray Date
NSF Reference: GC0-06.0
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
Notes:
1. Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in Loop
ID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300
for that service line only.
2. Required when claim involves spinal manipulation if an x-ray was taken.
Example:
DTP*455*D8*19970114~
837P_CG.ecs
117
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 135
DTP Date - Hearing and Vision
Max: 1
Detail - Optional
Prescription Date
Loop: 2300
Elements: 3
User Option (Usage): Situational
Purpose: To specify any or all of a date, a time, or a time period
Element Summary:
Ref
Id
Element Name
DTP01
374
Date/Time Qualifier
Req
Type
Min/Max
Usage
M
ID
3/3
Required
Description: Code specifying type of date or time, or both date and time
Industry: Date Time Qualifier
CodeList Summary (Total Codes: 1112, Included: 1)
Code Name
471
DTP02
1250
Prescription
Date Time Period Format Qualifier
M
ID
2/3
Required
Description: Code indicating the date format, time format, or date and time format
CodeList Summary (Total Codes: 39, Included: 1)
Code Name
D8
DTP03
1251
Date Expressed in Format CCYYMMDD
Date Time Period
M
AN
1/35
Required
Description: Expression of a date, a time, or range of dates, times or dates and times
Industry: Prescription Date
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
Notes:
1. Required on claims where a prescription has been written for hearing devices or vision frames and lenses and
it is being billed on this claim.
Example:
DTP*471*D8*19970115~
837P_CG.ecs
118
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 135
DTP Date - Disability Begin
Max: 5
Detail - Optional
Loop: 2300
Elements: 3
User Option (Usage): Situational
Purpose: To specify any or all of a date, a time, or a time period
Element Summary:
Ref
Id
Element Name
DTP01
374
Date/Time Qualifier
Req
Type
Min/Max
Usage
M
ID
3/3
Required
Description: Code specifying type of date or time, or both date and time
Industry: Date Time Qualifier
CodeList Summary (Total Codes: 1112, Included: 1)
Code Name
360
DTP02
1250
Disability Begin
Date Time Period Format Qualifier
M
ID
2/3
Required
Description: Code indicating the date format, time format, or date and time format
CodeList Summary (Total Codes: 39, Included: 1)
Code Name
D8
DTP03
1251
Date Expressed in Format CCYYMMDD
Date Time Period
M
AN
1/35
Required
Description: Expression of a date, a time, or range of dates, times or dates and times
Industry: Disability From Date
NSF Reference: EA0-18.0
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
Notes:
1. Required on claims involving disability where, in the opinion of the provider, the patient was or will be unable to
perform the duties normally associated with his/her work.
2. Not required for HIPAA but may be required for other uses. (The statutory definition of a health plan does not
specifically include workers compensation programs, property and casualty programs, or disability insurance
programs.)
Example:
DTP*360*D8*19970114~
837P_CG.ecs
119
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 135
DTP Date - Disability End
Max: 5
Detail - Optional
Loop: 2300
Elements: 3
User Option (Usage): Situational
Purpose: To specify any or all of a date, a time, or a time period
Element Summary:
Ref
Id
Element Name
DTP01
374
Date/Time Qualifier
Req
Type
Min/Max
Usage
M
ID
3/3
Required
Description: Code specifying type of date or time, or both date and time
Industry: Date Time Qualifier
CodeList Summary (Total Codes: 1112, Included: 1)
Code Name
361
DTP02
1250
Disability End
Date Time Period Format Qualifier
M
ID
2/3
Required
Description: Code indicating the date format, time format, or date and time format
CodeList Summary (Total Codes: 39, Included: 1)
Code Name
D8
DTP03
1251
Date Expressed in Format CCYYMMDD
Date Time Period
M
AN
1/35
Required
Description: Expression of a date, a time, or range of dates, times or dates and times
Industry: Disability To Date
NSF Reference: EA0-19.0
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
Notes:
1. Required on claims/encounters involving disability where, in the opinion of the provider, the patient, after
having been absent from work for reasons related to the disability, was or will be able to perform the duties
normally associated with his/her work.
2. Not required for HIPAA but may be required for other uses. (The statutory definition of a health plan does not
specifically include workers compensation programs, property and casualty programs, or disability insurance
programs.)
Example:
DTP*361*D8*19970613~
837P_CG.ecs
120
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 135
DTP Date - Last Worked
Max: 1
Detail - Optional
Loop: 2300
Elements: 3
User Option (Usage): Situational
Purpose: To specify any or all of a date, a time, or a time period
Element Summary:
Ref
Id
Element Name
DTP01
374
Date/Time Qualifier
Req
Type
Min/Max
Usage
M
ID
3/3
Required
Description: Code specifying type of date or time, or both date and time
Industry: Date Time Qualifier
CodeList Summary (Total Codes: 1112, Included: 1)
Code Name
297
DTP02
1250
Date Last Worked
Date Time Period Format Qualifier
M
ID
2/3
Required
Description: Code indicating the date format, time format, or date and time format
CodeList Summary (Total Codes: 39, Included: 1)
Code Name
D8
DTP03
1251
Date Expressed in Format CCYYMMDD
Date Time Period
M
AN
1/35
Required
Description: Expression of a date, a time, or range of dates, times or dates and times
Industry: Last Worked Date
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
Notes:
1. Required on claims where this information is necessary for adjudication of the claim (e.g., workers
compensation claims involving absence from work).
Example:
DTP*297*D8*19970114~
837P_CG.ecs
121
For internal use only
12/1/2010
Health Care Claim: Professional - 837
DTP Date - Authorized Return to
Work
Pos: 135
Max: 1
Detail - Optional
Loop: 2300
Elements: 3
User Option (Usage): Situational
Purpose: To specify any or all of a date, a time, or a time period
Element Summary:
Ref
Id
Element Name
DTP01
374
Date/Time Qualifier
Req
Type
Min/Max
Usage
M
ID
3/3
Required
Description: Code specifying type of date or time, or both date and time
Industry: Date Time Qualifier
CodeList Summary (Total Codes: 1112, Included: 1)
Code Name
296
DTP02
1250
Return to Work
This is the date the provider has authorized the patient to return to work.
Date Time Period Format Qualifier
M
ID
2/3
Required
Description: Code indicating the date format, time format, or date and time format
CodeList Summary (Total Codes: 39, Included: 1)
Code Name
D8
DTP03
1251
Date Expressed in Format CCYYMMDD
Date Time Period
M
AN
1/35
Required
Description: Expression of a date, a time, or range of dates, times or dates and times
Industry: Work Return Date
NSF Reference: EA1-12.0
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
Notes:
1. Required on claims where this information is necessary for adjudication of the claim (e.g., workers
compensation claims involving absence from work).
Example:
DTP*296*D8*19970620~
837P_CG.ecs
122
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 135
DTP Date - Admission
Max: 1
Detail - Optional
Loop: 2300
Elements: 3
User Option (Usage): Situational
Purpose: To specify any or all of a date, a time, or a time period
Element Summary:
Ref
Id
Element Name
DTP01
374
Date/Time Qualifier
Req
Type
Min/Max
Usage
M
ID
3/3
Required
Description: Code specifying type of date or time, or both date and time
Industry: Date Time Qualifier
CodeList Summary (Total Codes: 1112, Included: 1)
Code Name
435
DTP02
1250
Admission
Date Time Period Format Qualifier
M
ID
2/3
Required
Description: Code indicating the date format, time format, or date and time format
CodeList Summary (Total Codes: 39, Included: 1)
Code Name
D8
DTP03
1251
Date Expressed in Format CCYYMMDD
Date Time Period
M
AN
1/35
Required
Description: Expression of a date, a time, or range of dates, times or dates and times
Industry: Related Hospitalization Admission Date
NSF Reference: GA0-23.0 (for ambulance claims only), EA0-28.0
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
Notes:
1. Required on all ambulance claims/encounters when the patient was known to be admitted to the hospital. Also
required on inpatient medical visits claims/encounters.
Example:
DTP*435*D8*19970114~
837P_CG.ecs
123
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 135
DTP Date - Discharge
Max: 1
Detail - Optional
Loop: 2300
Elements: 3
User Option (Usage): Situational
Purpose: To specify any or all of a date, a time, or a time period
Element Summary:
Ref
Id
Element Name
DTP01
374
Date/Time Qualifier
Req
Type
Min/Max
Usage
M
ID
3/3
Required
Description: Code specifying type of date or time, or both date and time
Industry: Date Time Qualifier
CodeList Summary (Total Codes: 1112, Included: 1)
Code Name
096
DTP02
1250
Discharge
Date Time Period Format Qualifier
M
ID
2/3
Required
Description: Code indicating the date format, time format, or date and time format
CodeList Summary (Total Codes: 39, Included: 1)
Code Name
D8
DTP03
1251
Date Expressed in Format CCYYMMDD
Date Time Period
M
AN
1/35
Required
Description: Expression of a date, a time, or range of dates, times or dates and times
Industry: Related Hospitalization Discharge Date
NSF Reference: GA0-22.0 (for Ambulance Claims only), EA0-29.0
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
Notes:
1. Required for inpatient claims when the patient was discharged from the facility and the discharge date is
known.
Example:
DTP*096*D8*19970115~
837P_CG.ecs
124
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 135
DTP Date - Assumed and
Max: 2
Detail - Optional
Relinquished Care Dates
Loop: 2300
Elements: 3
User Option (Usage): Situational
Purpose: To specify any or all of a date, a time, or a time period
Element Summary:
Ref
Id
Element Name
DTP01
374
Date/Time Qualifier
Req
Type
Min/Max
Usage
M
ID
3/3
Required
Description: Code specifying type of date or time, or both date and time
Industry: Date Time Qualifier
CodeList Summary (Total Codes: 1112, Included: 2)
Code Name
DTP02
1250
090
Report Start
Assumed Care Date - Use code 090 to indicate the date the provider filing this
claim assumed care from another provider during post-operative care.
091
Report End
Relinquished Care Date - Use code 091 to indicate the date the provider filing this
claim relinquished post-operative care to another provider.
Date Time Period Format Qualifier
M
ID
2/3
Required
Description: Code indicating the date format, time format, or date and time format
CodeList Summary (Total Codes: 39, Included: 1)
Code Name
D8
DTP03
1251
Date Expressed in Format CCYYMMDD
Date Time Period
M
AN
1/35
Required
Description: Expression of a date, a time, or range of dates, times or dates and times
Industry: Assumed or Relinquished Care Date
NSF Reference: EA1-25.0 - Provider Assumed Care Date, HA0-05.0 - Provider
Relinquished Care Date
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
Notes:
1. Required on Medicare claims to indicate “assumed care date” and “relinquished care date” for situations where
providers share post-operative care (global surgery claims). Assumed Care Date is the date care was assumed
by another provider during post-operative care. Relinquished Care Date is the date the provider filing this claim
ceased post-operative care. See Medicare guidelines for further explanation of these dates.
2. Example: Surgeon “A” relinquished post-operative care to Physician “B” five days after surgery. When Surgeon
“A” submits a claim/encounter “A” will use code “091 - Report End” to indicate the day the surgeon relinquished
care of this patient to Physician “B”. When Physician “B” submits a claim/encounter “B” will use code “090 Report Start” to indicate the date they assumed care of this patient from Surgeon “A”.
Example:
DTP*090*D8*19970214~
837P_CG.ecs
125
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 155
PWK Claim Supplemental
Max: 10
Detail - Optional
Information
Loop: 2300
Elements: 4
User Option (Usage): Situational
Purpose: To identify the type or transmission or both of paperwork or supporting information
Element Summary:
Ref
Id
Element Name
PWK01
755
Report Type Code
Req
Type
Min/Max
Usage
M
ID
2/2
Required
Description: Code indicating the title or contents of a document, report or supporting item
Industry: Attachment Report Type Code
NSF Reference: EA0-41.0
CodeList Summary (Total Codes: 522, Included: 20)
Code Name
PWK02
756
77
Support Data for Verification
REFERRAL. Use this code to indicate a completed referral form.
AS
B2
B3
B4
CT
DA
DG
DS
EB
MT
NN
OB
OZ
PN
PO
PZ
RB
RR
RT
Admission Summary
Prescription
Physician Order
Referral Form
Certification
Dental Models
Diagnostic Report
Discharge Summary
Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payor)
Models
Nursing Notes
Operative Note
Support Data for Claim
Physical Therapy Notes
Prosthetics or Orthotic Certification
Physical Therapy Certification
Radiology Films
Radiology Reports
Report of Tests and Analysis Report
Report Transmission Code
O
ID
1/2
Required
Description: Code defining timing, transmission method or format by which reports are to
be sent
Industry: Attachment Transmission Code
NSF Reference: EA0-40.0
CodeList Summary (Total Codes: 51, Included: 5)
Code Name
AA
837P_CG.ecs
Available on Request at Provider Site
This means that the paperwork is not being sent with the claim at this time.
126
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Code Name
Instead, it is available to the payer (or appropriate entity) at their request.
PWK05
66
BM
EL
By Mail
Electronically Only
Use to indicate that attachment is being transmitted in a separate X12 functional
group.
EM
FX
E-Mail
By Fax
Identification Code Qualifier
C
ID
1/2
Situational
Description: Code designating the system/method of code structure used for Identification
Code (67)
Required if PWK02 = “BM”, “EL”, “EM” or “FX”.
CodeList Summary (Total Codes: 215, Included: 1)
Code Name
AC
PWK06
67
Attachment Control Number
Identification Code
C
AN
2/80
Situational
Description: Code identifying a party or other code
Industry: Attachment Control Number
Required if PWK02 = “BM”, “EL”, “EM” or “FX”.
Syntax Rules:
1. P0506 - If either PWK05 or PWK06 is present, then the other is required.
Comments:
1. PWK05 and PWK06 may be used to identify the addressee by a code number.
2. PWK07 may be used to indicate special information to be shown on the specified report.
3. PWK08 may be used to indicate action pertaining to a report.
Notes:
1. The PWK segment is required if there is paper documentation supporting this claim. The PWK segment should
not be used if the information related to the claim is being sent within the 837 ST-SE envelope.
2. The PWK segment is required to identify attachments that are sent electronically (PWK02 = EL) but are
transmitted in another functional group (e.g., 275) rather than by paper. PWK06 is used to identify the attached
electronic documentation. The number in PWK06 would be carried in the TRN of the electronic attachment.
3. The PWK segment can be used to identify paperwork that is being held at the provider’s office and is available
upon request by the payer (or appropriate entity), but that is not being sent with the claim. Use code AA in
PWK02 to convey this specific use of the PWK segment. See code note under PWK02, code AA.
Example:
PWK*OB*BM***AC*DMN0012~
User Note 6:
BSC's initial HIPAA implementation does not include PWK processing. Pending finalization of the HIPAA 275
transaction, BSC will add PWK processing to its inbound claims capabilities.
837P_CG.ecs
127
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 160
CN1 Contract Information
Max: 1
Detail - Optional
Loop: 2300
Elements: 6
User Option (Usage): Situational
Purpose: To specify basic data about the contract or contract line item
Element Summary:
Ref
Id
Element Name
CN101
1166
Contract Type Code
Req
Type
Min/Max
Usage
M
ID
2/2
Required
R
1/18
Situational
Description: Code identifying a contract type
Alias: Contract Type Code
CodeList Summary (Total Codes: 50, Included: 6)
Code Name
02
03
04
05
06
09
CN102
782
Per Diem
Variable Per Diem
Flat
Capitated
Percent
Other
Monetary Amount
O
Description: Monetary amount
Industry: Contract Amount
Required if the provider is required by contract to supply this information on the claim.
CN103
332
Percent
O
R
1/6
Situational
Description: Percent expressed as a percent
Industry: Contract Percentage
Alias: Contract Percent
Allowance or charge percent
Required if the provider is required by contract to supply this information on the claim.
CN104
127
Reference Identification
O
AN
1/30
Situational
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Contract Code
Required if the provider is required by contract to supply this information on the claim.
CN105
338
Terms Discount Percent
O
R
1/6
Situational
Description: Terms discount percentage, expressed as a percent, available to the
purchaser if an invoice is paid on or before the Terms Discount Due Date
Industry: Terms Discount Percentage
Alias: Terms Discount Percent
Required if the provider is required by contract to supply this information on the claim.
CN106
799
Version Identifier
O
AN
1/30
Situational
Description: Revision level of a particular format, program, technique or algorithm
837P_CG.ecs
128
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Ref
Id
Element Name
Industry: Contract Version Identifier
Req
Type
Min/Max
Usage
Required if the provider is required by contract to supply this information on the claim.
Semantics:
1.
2.
3.
4.
CN102
CN103
CN104
CN106
is the contract amount.
is the allowance or charge percent.
is the contract code.
is an additional identifying number for the contract.
Notes:
1. The developers of this implementation guide recommend that for non-capitated situations, contract information
be maintained in the receiver’s files and not be transmitted with each claim whenever possible. It is
recommended that submitters always include CN1 for encounters that include only capitated services.
2. Required if the provider is contractually obligated to provide contract information on this claim.
Example:
CN1*02*550~
837P_CG.ecs
129
For internal use only
12/1/2010
Health Care Claim: Professional - 837
AMT Credit/Debit Card Maximum
Amount
Pos: 175
Max: 1
Detail - Optional
Loop: 2300
Elements: 2
User Option (Usage): Situational
Purpose: To indicate the total monetary amount
Element Summary:
Ref
Id
Element Name
AMT01
522
Amount Qualifier Code
Req
Type
Min/Max
Usage
M
ID
1/3
Required
R
1/18
Required
Description: Code to qualify amount
CodeList Summary (Total Codes: 1473, Included: 1)
Code Name
MA
AMT02
782
Maximum Amount
Monetary Amount
M
Description: Monetary amount
Industry: Credit or Debit Card Maximum Amount
Notes:
1. Use this segment only for claims that contain credit/debit card information. This segment indicates the
maximum amount that can be credited to the account indicated in 2010BD - CREDIT/DEBIT CARD HOLDER
NAME.
2. The information carried under this segment must never be sent to the payer. This information is only for use
between a provider and a service organization offering patient collection services. In this case, it is the
responsibility of the collection service organization to remove this segment before forwarding the claim to the
payer.
Example:
AMT*MA*200~
837P_CG.ecs
130
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 175
AMT Patient Amount Paid
Max: 1
Detail - Optional
Loop: 2300
Elements: 2
User Option (Usage): Situational
Purpose: To indicate the total monetary amount
Element Summary:
Ref
Id
Element Name
AMT01
522
Amount Qualifier Code
Req
Type
Min/Max
Usage
M
ID
1/3
Required
R
1/18
Required
Description: Code to qualify amount
CodeList Summary (Total Codes: 1473, Included: 1)
Code Name
F5
AMT02
782
Patient Amount Paid
Monetary Amount
M
Description: Monetary amount
Industry: Patient Amount Paid
NSF Reference: XA0-19.0
Notes:
1. Required when patient has made payment specifically toward this claim.
2. Patient Amount Paid refers to the sum of all amounts paid on the claim by the patient or his/her
representative(s).
Example:
AMT*F5*152.45~
837P_CG.ecs
131
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 175
AMT Total Purchased Service
Max: 1
Detail - Optional
Amount
Loop: 2300
Elements: 2
User Option (Usage): Situational
Purpose: To indicate the total monetary amount
Element Summary:
Ref
Id
Element Name
AMT01
522
Amount Qualifier Code
Req
Type
Min/Max
Usage
M
ID
1/3
Required
Description: Code to qualify amount
CodeList Summary (Total Codes: 1473, Included: 1)
Code Name
NE
AMT02
782
Net Billed
Use this code to indicate Total Purchased Service Charges.
Monetary Amount
M
R
1/18
Required
Description: Monetary amount
Industry: Total Purchased Service Amount
NSF Reference: EA0-31.0
Notes:
1. Required if there are purchased service components to this claim.
2. Use this segment on vision claims when the acquisition cost of lenses is known to impact adjudication or
reimbursement.
3. Required on service lines when the purchased service charge amount is necessary for processing.
Example:
AMT*NE*57.35~
837P_CG.ecs
132
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 180
REF Service Authorization
Max: 1
Detail - Optional
Exception Code
Loop: 2300
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
1/30
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 1)
Code Name
4N
REF02
127
Special Payment Reference Number
Reference Identification
C
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Service Authorization Exception Code
CodeList Summary (Total Codes: 7, Included: 7)
Code Name
1
2
3
4
5
6
7
Immediate/Urgent Care
Services Rendered in a Retroactive Period
Emergency Care
Client as Temporary Medicaid
Request from County for Second Opinion to Recipient can Work
Request for Override Pending
Special Handling
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. Required when providers are required by state law (e.g., New York State Medicaid) to obtain authorization for
specific services but, for the reasons listed in REF02, performed the service without obtaining the service
authorization. Check with your state Medicaid to see if this applies in your state.
Example:
REF*4N*1~
837P_CG.ecs
133
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 180
REF Mandatory Medicare
Max: 1
Detail - Optional
(Section 4081) Crossover
Indicator
Loop: 2300
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
1/30
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 1)
Code Name
F5
REF02
127
Medicare Version Code
Reference Identification
C
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Medicare Section 4081 Indicator
NSF Reference: DA0-30.0
CodeList Summary (Total Codes: 2, Included: 2)
Code Name
N
Y
Regular crossover (NSF Value 2)
4081 (NSF Value 1)
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. Required for Medicare COB crossover claims when Beneficiary Assignment for mandatory Medicare (Section
4081) claim applies. This segment is only completed by Medicare; providers do not use this segment.
2. If this segment is not used that means this situation does not apply.
Example:
REF*F5*N~
837P_CG.ecs
134
For internal use only
12/1/2010
Health Care Claim: Professional - 837
REF Mammography Certification
Number
Pos: 180
Max: 1
Detail - Optional
Loop: 2300
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
1/30
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 1)
Code Name
EW
REF02
127
Mammography Certification Number
Reference Identification
C
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Mammography Certification Number
NSF Reference: FA0-31.0
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. Required when mammography services are rendered by a certified mammography provider.
Example:
REF*EW*T554~
837P_CG.ecs
135
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 180
REF Prior Authorization or
Max: 2
Detail - Optional
Referral Number
Loop: 2300
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
1/30
Required
Description: Code qualifying the Reference Identification
User Note 6:
AMBULANCE
Use "G1" for Prior Authorization Qualifer
CodeList Summary (Total Codes: 1503, Included: 2)
Code Name
9F
G1
REF02
127
Referral Number
Prior Authorization Number
Reference Identification
C
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Prior Authorization or Referral Number
NSF Reference: DA0-14.0
User Note 6:
AMBULANCE
911 plus any free form comments (upto 26 characters)
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
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.
2. Required where services on this claim were preauthorized or where a referral is involved. Generally,
preauthorization/referral numbers are those numbers assigned by the payer/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 referral or prior
authorization number carried in this REF is specific to the destination payer reported in the 2010BB loop. If other
payers have similar numbers for this claim, report that information in the 2330 loop REF which holds that payer’s
information.
Example:
837P_CG.ecs
136
For internal use only
12/1/2010
Health Care Claim: Professional - 837
REF*G1*13579~
837P_CG.ecs
137
For internal use only
12/1/2010
Health Care Claim: Professional - 837
REF Original Reference Number
(ICN/DCN)
Pos: 180
Max: 1
Detail - Optional
Loop: 2300
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
1/30
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 1)
Code Name
F8
REF02
127
Original Reference Number
Reference Identification
C
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Claim Original Reference Number
Alias: Claim Original Reference Number (ICN/DCN)
NSF Reference: EA0-47.0
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. Required when CLM05-3 (Claim Submission Reason Code) = “6", ”7", or “8" and the payer has assigned a
payer number to the claim. The resubmission number is assigned to a previously submitted claim/encounter by
the destination payer or receiver.
2. This segment can be used for the payer assigned Original Document Control Number/Internal Control Number
(DCN/ICN) assigned to this claim by the payer identified in the 2010BB loop of this claim. This number would be
received from a payer in a case where the payer had received the original claim and, for whatever reason, had (1)
asked the provider to resubmit the claim and (2) had given the provider the payer’s claim identification number. In
this case the payer is expecting the provider to give them back their (the payer’s) claim number so that the payer
can match it in their adjudication system. By matching this number in the adjudication system, the payer knows
this is not a duplicate claim. This information is specific to the destination payer reported in the 2010BB loop. If
other payers have a similar number, report that information in the 2330 loop which holds that payer’s information.
Example:
REF*F8*R555588~
User Note 6:
Corrected claims can be sent electronically to Blue Shield of California, however, please wait for the original claim
to finalize before sending a corrected claim to avoid denial as a duplicate.
Once the initial has finalized in our system, re-bill the corrected claim with the appropriate adjustment bill type. You
will also need to include the following EDI segments on your adjusted claim:
837P_CG.ecs
138
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Send "F8" in REF01 (Loop 2300)
Send "14 digit number BSC ICN of incorrect original claim in REF02 (Loop 2300).
Sample: REF*F8*12345678912345~
Note: 12345678912345 should be replaced with the original claim’s Blue Shield of California internal control
number (ICN).
You can obtain the Blue Shield of California internal control number (ICN) using the claim status option on
Provider Connection or from the explanation of benefits (EOB) or electronic remittance advice (ERA).
837P_CG.ecs
139
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 180
REF Clinical Laboratory
Max: 3
Detail - Optional
Improvement Amendment
(CLIA) Number
Loop: 2300
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
1/30
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 1)
Code Name
X4
REF02
127
Clinical Laboratory Improvement Amendment Number
Reference Identification
C
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Clinical Laboratory Improvement Amendment Number
NSF Reference: FA0-34.0
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. Required on Medicare and Medicaid claims for any laboratory performing tests covered by the CLIA Act.
2. If a CLIA number is indicated at the line level (Loop ID-2400) in addition to the claim level (Loop ID-2300), that
would indicate an exception to the CLIA number at the claim level for that individual line.
3. In cases where this claim contains both in-house and outsourced laboratory services: For laboratory services
preformed by the billing or rendering provider the CLIA number is reported here; for laboratory services which
were outsourced, report that CLIA number at the 2400 loop.
Example:
REF*X4*12D4567890~
837P_CG.ecs
140
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 180
REF Repriced Claim Number
Max: 1
Detail - Optional
Loop: 2300
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
1/30
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 1)
Code Name
9A
REF02
127
Repriced Claim Reference Number
Reference Identification
C
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Repriced Claim Reference Number
NSF Reference: FE0-06.0 (TPO Reference Number)
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. Used only by repricers as needed. This information is specific to the destination payer reported in the 2010BB
loop.
Example:
REF*9A*RJ55555~
837P_CG.ecs
141
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 180
REF Adjusted Repriced Claim
Max: 1
Detail - Optional
Number
Loop: 2300
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
1/30
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 1)
Code Name
9C
REF02
127
Adjusted Repriced Claim Reference Number
Reference Identification
C
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Adjusted Repriced Claim Reference Number
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. Used only by repricers as needed. This information is specific to the destination payer reported in the 2010BB
loop.
Example:
REF*9C*RP44444444~
837P_CG.ecs
142
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 180
REF Investigational Device
Max: 1
Detail - Optional
Exemption Number
Loop: 2300
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
1/30
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 1)
Code Name
LX
REF02
127
Qualified Products List
Reference Identification
C
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Investigational Device Exemption Identifier
NSF Reference: EA0-54.0
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. Required when claim involves an FDA assigned investigational device exemption (IDE) number. Only one IDE
per claim is to be reported.
Example:
REF*LX*TG334~
837P_CG.ecs
143
For internal use only
12/1/2010
Health Care Claim: Professional - 837
REF Claim Identification Number
for Clearing Houses and
Other Transmission
Intermediaries
Pos: 180
Max: 1
Detail - Optional
Loop: 2300
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
1/30
Required
Description: Code qualifying the Reference Identification
Number assigned by clearinghouse/van/etc.
CodeList Summary (Total Codes: 1503, Included: 1)
Code Name
D9
REF02
127
Claim Number
Reference Identification
C
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Clearinghouse Trace Number
The value carried in this element is limited to a maximum of 20 positions.
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. Used only by transmission intermediaries (Automated Clearing Houses, and others) who need to attach their
own unique claim number.
2. Although this REF is supplied for transmission intermediaries to attach their own unique claim number to a
claim/encounter, 837- recipients are not required under HIPAA to return this number in any HIPAA transaction.
Trading partners may voluntarily agree to this interaction if they wish.
Example:
REF*D9*TJ98UU321~
837P_CG.ecs
144
For internal use only
12/1/2010
Health Care Claim: Professional - 837
REF Ambulatory Patient Group
(APG)
Pos: 180
Max: 4
Detail - Optional
Loop: 2300
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
1/30
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 1)
Code Name
1S
REF02
127
Ambulatory Patient Group (APG) Number
Reference Identification
C
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Ambulatory Patient Group Number
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. Required if the contractual reimbursement arrangement between provider and payer is based on APG and
their contractual arrangement requires that the provider send APG information to the payer on each claim.
Example:
REF*1S*XXXXX~
837P_CG.ecs
145
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 180
REF Medical Record Number
Max: 1
Detail - Optional
Loop: 2300
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
1/30
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 1)
Code Name
EA
REF02
127
Medical Record Identification Number
Reference Identification
C
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Medical Record Number
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. Used at discretion of submitter.
Example:
REF*EA*44444TH56~
837P_CG.ecs
146
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 180
REF Demonstration Project
Max: 1
Detail - Optional
Identifier
Loop: 2300
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
1/30
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 1)
Code Name
P4
REF02
127
Project Code
Reference Identification
C
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Demonstration Project Identifier
NSF Reference: EA0-43.0
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. Required on claims/encounters where a demonstration project is being billed/reported. This information is
specific to the destination payer reported in the 2010BB loop. If other payers have a similar number, report that
information in the 2330 loop which holds that payer’s information.
Example:
REF*P4*THJ1222~
837P_CG.ecs
147
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 185
K3 File Information
Max: 10
Detail - Optional
Loop: 2300
Elements: 1
User Option (Usage): Situational
Purpose: To transmit a fixed-format record or matrix contents
Element Summary:
Ref
Id
Element Name
K301
449
Fixed Format Information
Req
Type
Min/Max
Usage
M
AN
1/80
Required
Description: Data in fixed format agreed upon by sender and receiver
NSF Reference: HA0-05.0
Semantics:
1. K303 identifies the value of the index.
Comments:
1. The default for K302 is content.
Notes:
1. At the time of publication K3 segments have no specific use. However, they have been included in this
implementation guide to be used as an emergency kludge (fix-it) in the case of an unexpected data requirement
by a state regulatory authority. This data element can only be required if the specific use is a result of a state law
or a regulation issued by a state agency after the publication of this implementation guide, and only if the
appropriate national body (X12N, HCPCS, NUBC, NUCC, etc) cannot offer an alternative solution within the
current structure of the implementation guide.
2. This segment may only be required if a state concludes it must use the K3 to meet an emergency legislative
requirement AND the administering state agency or other state organization has contacted the X12N workgroup,
requested a review of the K3 data requirement to ensure there is not an existing method within the
implementation guide to meet this requirement, and X12N determines that there is no method to meet the
requirement. Only then may the state require the temporary use of the K3 to meet the requirement. X12N will
submit the necessary data maintenance and refer the request to the appropriate data content committee.
Example:
K3*STATE DATA REQUIREMENT~
837P_CG.ecs
148
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 190
NTE Claim Note
Max: 1
Detail - Optional
Loop: 2300
Elements: 2
User Option (Usage): Situational
Purpose: To transmit information in a free-form format, if necessary, for comment or special instruction
Element Summary:
Ref
Id
Element Name
NTE01
363
Note Reference Code
Req
Type
Min/Max
Usage
O
ID
3/3
Required
Description: Code identifying the functional area or purpose for which the note applies
User Note 6:
AMBULANCE
Use ADD
Used in conjunction with NTE02 to identify the purpose of the notes in NTE02.
CodeList Summary (Total Codes: 241, Included: 6)
Code Name
ADD
CER
DCP
DGN
PMT
TPO
NTE02
352
Additional Information
Certification Narrative
Goals, Rehabilitation Potential, or Discharge Plans
Diagnosis Description
Payment
Third Party Organization Notes
Description
M
AN
1/80
Required
Description: A free-form description to clarify the related data elements and their content
Industry: Claim Note Text
NSF Reference: HA0-05.0
User Note 6:
AMBULANCE
Report location where patient was transported to. Include facility name, city and zip.
Comments:
1. The NTE segment permits free-form information/data which, under ANSI X12 standard implementations, is not
machine processable. The use of the NTE segment should therefore be avoided, if at all possible, in an
automated environment.
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. The developers of this implementation guide
discourage using narrative information within the 837. Trading partners who require narrative information with
claims are encouraged to codify that information within the ASC X12 environment.
2. Required when: (1) State regulations mandate information not identified elsewhere within the claim set; or (2) 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.
Example:
NTE*ADD*SURGERY WAS UNUSUALLY LONG BECAUSE [FILL INREASON*~
837P_CG.ecs
149
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 195
CR1 Ambulance Transport
Max: 1
Detail - Optional
Information
Loop: 2300
Elements: 8
User Option (Usage): Situational
Purpose: To supply information related to the ambulance service rendered to a patient
Element Summary:
Ref
Id
Element Name
CR101
355
Unit or Basis for Measurement Code
Req
Type
Min/Max
Usage
C
ID
2/2
Situational
Description: Code specifying the units in which a value is being expressed, or manner in
which a measurement has been taken
Required if needed to justify extra ambulance services.
CodeList Summary (Total Codes: 794, Included: 1)
Code Name
LB
CR102
81
Pound
Weight
C
R
1/10
Situational
1/1
Required
1/1
Required
Description: Numeric value of weight
Industry: Patient Weight
NSF Reference: GA0-05.0
Required if needed to justify extra ambulance services.
CR103
1316
Ambulance Transport Code
O
ID
Description: Code indicating the type of ambulance transport
Alias: Ambulance Transport Code
NSF Reference: GA0-07.0
User Note 6:
AMBULANCE
Use for ‘Transport Information’ – all values are accepted:
I, R, T, X
All valid standard codes are used. (Total Codes: 4)
CR104
1317
Ambulance Transport Reason Code
O
ID
Description: Code indicating the reason for ambulance transport
Alias: Ambulance Transport Reason Code
NSF Reference: GA0-15.0
User Note 6:
AMBULANCE
Use for ‘Transport Information’ – all values are accepted
A, B, C, D, E
CodeList Summary (Total Codes: 5, Included: 5)
Code Name
837P_CG.ecs
A
Patient was transported to nearest facility for care of symptoms, complaints, or both
Can be used to indicate that the patient was transferred to a residential facility.
B
Patient was transported for the benefit of a preferred physician
150
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Code Name
C
D
E
CR105
355
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
C
ID
2/2
Required
Description: Code specifying the units in which a value is being expressed, or manner in
which a measurement has been taken
CodeList Summary (Total Codes: 794, Included: 1)
Code Name
DH
CR106
380
Miles
Quantity
C
R
1/15
Required
Description: Numeric value of quantity
Industry: Transport Distance
NSF Reference: GA0-17.0, FA0-50.0
NSF crosswalk to FA0-50.0 is used only in Medicare payer-to-payer COB situations.
User Note 6:
AMBULANCE
Use to report transport distance.
CR109
352
Description
O
AN
1/80
Situational
Description: A free-form description to clarify the related data elements and their content
Industry: Round Trip Purpose Description
NSF Reference: GA0-20.0
Required if CR103 (Ambulance Transport Code) = “X - Round Trip”; otherwise not used.
User Note 6:
AMBULANCE
Free format field to clarify the purpose for the round trip service.
CR110
352
Description
O
AN
1/80
Situational
Description: A free-form description to clarify the related data elements and their content
Industry: Stretcher Purpose Description
NSF Reference: GA0-21.0
Required if needed to justify usage of stretcher.
Syntax Rules:
1. P0102 - If either CR101 or CR102 is present, then the other is required.
2. P0506 - If either CR105 or CR106 is present, then the other is required.
Semantics:
1.
2.
3.
4.
5.
CR102 is the weight of the patient at time of transport.
CR106 is the distance traveled during transport.
CR107 is the address of origin.
CR108 is the address of destination.
CR109 is the purpose for the round trip ambulance service.
837P_CG.ecs
151
For internal use only
12/1/2010
Health Care Claim: Professional - 837
6. CR110 is the purpose for the usage of a stretcher during ambulance service.
Notes:
1. The CR1 segment in Loop ID-2300 applies to the entire claim unless an exception is reported in the CR1
segment in Loop ID-2400.
2. Required on all claims involving ambulance services.
Example:
CR1*LB*140*I*A*DH*12****UNCONSCIOUS~
837P_CG.ecs
152
For internal use only
12/1/2010
Health Care Claim: Professional - 837
CR2 Spinal Manipulation Service
Information
Pos: 200
Max: 1
Detail - Optional
Loop: 2300
Elements: 4
User Option (Usage): Situational
Purpose: To supply information related to the chiropractic service rendered to a patient
Element Summary:
Ref
Id
Element Name
CR208
1342
Nature of Condition Code
Req
Type
Min/Max
Usage
O
ID
1/1
Required
1/80
Situational
Description: Code indicating the nature of a patient's condition
Industry: Patient Condition Code
Alias: Nature of Condition Code. Spinal Manipulation
NSF Reference: GC0-11.0
All valid standard codes are used. (Total Codes: 7)
CR210
352
Description
O
AN
Description: A free-form description to clarify the related data elements and their content
Industry: Patient Condition Description
NSF Reference: GC0-14.0
Used at discretion of submitter.
CR211
352
Description
O
AN
1/80
Situational
Description: A free-form description to clarify the related data elements and their content
Industry: Patient Condition Description
Alias: Patient Condition Description. Spinal Manipulation
NSF Reference: GC0-14.0
Used at discretion of submitter.
CR212
1073
Yes/No Condition or Response Code
O
ID
1/1
Situational
Description: Code indicating a Yes or No condition or response
Industry: X-ray Availability Indicator
Alias: X-ray Availability Indicator. Spinal Manipulation
NSF Reference: GC0-15.0
Required for service dates prior to January 1, 2000.
CodeList Summary (Total Codes: 4, Included: 2)
Code Name
N
Y
No
Yes
Syntax Rules:
1. P0102 - If either CR201 or CR202 is present, then the other is required.
2. C0403 - If CR204 is present, then CR203 is required.
3. P0506 - If either CR205 or CR206 is present, then the other is required.
Semantics:
837P_CG.ecs
153
For internal use only
12/1/2010
Health Care Claim: Professional - 837
1.
2.
3.
4.
5.
CR201 is the number this treatment is in the series.
CR202 is the total number of treatments in the series.
CR206 is the time period involved in the treatment series.
CR207 is the number of treatments rendered in the month of service.
CR209 is complication indicator. A "Y" value indicates a complicated condition; an "N" value indicates an
uncomplicated condition.
6. CR210 is a description of the patient's condition.
7. CR211 is an additional description of the patient's condition.
8. CR212 is X-rays availability indicator. A "Y" value indicates X-rays are maintained and available for carrier
review; an "N" value indicates X-rays are not maintained and available for carrier review.
Comments:
1. When both CR203 and CR204 are present, CR203 is the beginning level of subluxation and CR204 is the
ending level of subluxation.
Notes:
1. The CR2 segment in Loop ID-2300 applies to the entire claim unless overridden by the presence of a CR2
segment in Loop ID-2400.
2. Required on chiropractic claims involving spinal manipulation and known to impact payer’s adjudication
process.
Example:
CR2********M****Y~
837P_CG.ecs
154
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 220
CRC Ambulance Certification
Max: 3
Detail - Optional
Loop: 2300
Elements: 7
User Option (Usage): Situational
Purpose: To supply information on conditions
Element Summary:
Ref
Id
Element Name
Req
Type
Min/Max
Usage
CRC01
1136
Code Category
M
ID
2/2
Required
Description: Specifies the situation or category to which the code applies
CodeList Summary (Total Codes: 341, Included: 1)
Code Name
07
CRC02
1073
Ambulance Certification
Yes/No Condition or Response Code
M
ID
1/1
Required
2/2
Required
Description: Code indicating a Yes or No condition or response
Industry: Certification Condition Indicator
Alias: Certification Condition Code Applies Indicator
CodeList Summary (Total Codes: 4, Included: 2)
Code Name
N
Y
CRC03
1321
No
Yes
Condition Indicator
M
ID
Description: Code indicating a condition
Industry: Condition Code
Alias: Condition Indicator
The codes for CRC03 also can be used for CRC04 through CRC07.
User Note 6:
AMBULANCE
Reported Condition – all values are accepted. Codes for CRC03 can be used for
CRC04-CRC07 to indicate multiple conditions that apply.
Codes: 01-09, 60
CodeList Summary (Total Codes: 1079, Included: 10)
Code Name
01
Patient was admitted to a hospital
NSF Reference:
GA0-06.0
02
Patient was bed confined before the ambulance service
NSF Reference:
GA0-08.0
03
837P_CG.ecs
Patient was bed confined after the ambulance service
NSF Reference:
155
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Code Name
GA0-09.0
04
Patient was moved by stretcher
NSF Reference:
GA0-10.0
05
Patient was unconscious or in shock
NSF Reference:
GA0-11.0
06
Patient was transported in an emergency situation
NSF Reference:
GA0-12.0
07
Patient had to be physically restrained
NSF Reference:
GA0-13.0
08
Patient had visible hemorrhaging
NSF Reference:
GA0-14.0
09
Ambulance service was medically necessary
NSF Reference:
GA0-16.0
60
Transportation Was To the Nearest Facility
NSF Reference:
GA0-24.0
CRC04
1321
Condition Indicator
O
ID
2/2
Situational
Description: Code indicating a condition
Industry: Condition Code
Alias: Condition Indicator
Required if additional condition codes are needed.
Use the codes listed in CRC03.
CodeList Summary (Total Codes: 1079, Included: 10)
Code Name
01
Patient was admitted to a hospital
NSF Reference:
02
Patient was bed confined before the ambulance service
NSF Reference:
GA0-06.0
GA0-08.0
03
Patient was bed confined after the ambulance service
NSF Reference:
04
Patient was moved by stretcher
NSF Reference:
GA0-09.0
GA0-10.0
05
837P_CG.ecs
Patient was unconscious or in shock
NSF Reference:
156
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Code Name
GA0-11.0
06
Patient was transported in an emergency situation
NSF Reference:
GA0-12.0
07
Patient had to be physically restrained
NSF Reference:
GA0-13.0
08
Patient had visible hemorrhaging
NSF Reference:
GA0-14.0
09
Ambulance service was medically necessary
NSF Reference:
GA0-16.0
60
Transportation Was To the Nearest Facility
NSF Reference:
GA0-24.0
CRC05
1321
Condition Indicator
O
ID
2/2
Situational
Description: Code indicating a condition
Industry: Condition Code
Alias: Condition Indicator
Required if additional condition codes are needed.
Use the codes listed in CRC03.
CodeList Summary (Total Codes: 1079, Included: 10)
Code Name
01
Patient was admitted to a hospital
NSF Reference:
02
Patient was bed confined before the ambulance service
NSF Reference:
GA0-06.0
GA0-08.0
03
Patient was bed confined after the ambulance service
NSF Reference:
04
Patient was moved by stretcher
NSF Reference:
GA0-09.0
GA0-10.0
05
Patient was unconscious or in shock
NSF Reference:
06
Patient was transported in an emergency situation
NSF Reference:
GA0-11.0
GA0-12.0
07
837P_CG.ecs
Patient had to be physically restrained
NSF Reference:
157
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Code Name
GA0-13.0
08
Patient had visible hemorrhaging
NSF Reference:
GA0-14.0
09
Ambulance service was medically necessary
NSF Reference:
GA0-16.0
60
Transportation Was To the Nearest Facility
NSF Reference:
GA0-24.0
CRC06
1321
Condition Indicator
O
ID
2/2
Situational
Description: Code indicating a condition
Industry: Condition Code
Alias: Condition Indicator
Required if additional condition codes are needed.
Use the codes listed in CRC03.
CodeList Summary (Total Codes: 1079, Included: 10)
Code Name
01
Patient was admitted to a hospital
NSF Reference:
02
Patient was bed confined before the ambulance service
NSF Reference:
GA0-06.0
GA0-08.0
03
Patient was bed confined after the ambulance service
NSF Reference:
04
Patient was moved by stretcher
NSF Reference:
GA0-09.0
GA0-10.0
05
Patient was unconscious or in shock
NSF Reference:
06
Patient was transported in an emergency situation
NSF Reference:
GA0-11.0
GA0-12.0
07
Patient had to be physically restrained
NSF Reference:
08
Patient had visible hemorrhaging
NSF Reference:
GA0-13.0
GA0-14.0
09
837P_CG.ecs
Ambulance service was medically necessary
NSF Reference:
158
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Code Name
GA0-16.0
60
Transportation Was To the Nearest Facility
NSF Reference:
GA0-24.0
CRC07
1321
Condition Indicator
O
ID
2/2
Situational
Description: Code indicating a condition
Industry: Condition Code
Alias: Condition Indicator
Required if additional condition codes are needed.
Use the codes listed in CRC03.
CodeList Summary (Total Codes: 1079, Included: 10)
Code Name
01
Patient was admitted to a hospital
NSF Reference:
02
Patient was bed confined before the ambulance service
NSF Reference:
GA0-06.0
GA0-08.0
03
Patient was bed confined after the ambulance service
NSF Reference:
04
Patient was moved by stretcher
NSF Reference:
GA0-09.0
GA0-10.0
05
Patient was unconscious or in shock
NSF Reference:
06
Patient was transported in an emergency situation
NSF Reference:
GA0-11.0
GA0-12.0
07
Patient had to be physically restrained
NSF Reference:
08
Patient had visible hemorrhaging
NSF Reference:
GA0-13.0
GA0-14.0
09
Ambulance service was medically necessary
NSF Reference:
60
Transportation Was To the Nearest Facility
NSF Reference:
GA0-16.0
GA0-24.0
Semantics:
837P_CG.ecs
159
For internal use only
12/1/2010
Health Care Claim: Professional - 837
1. CRC01 qualifies CRC03 through CRC07.
2. CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03
through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply.
Notes:
1. The CRC segment in Loop ID-2300 applies to the entire claim unless overridden by a CRC segment at the
service line level in Loop ID-2400 with the same value in CRC01.
2. Required on ambulance claims/encounters, i.e. when CR1 segment is used.
Example:
CRC*07*Y*01~
837P_CG.ecs
160
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 220
CRC Patient Condition
Max: 3
Detail - Optional
Information: Vision
Loop: 2300
Elements: 7
User Option (Usage): Situational
Purpose: To supply information on conditions
Element Summary:
Ref
Id
Element Name
Req
Type
Min/Max
Usage
CRC01
1136
Code Category
M
ID
2/2
Required
Description: Specifies the situation or category to which the code applies
CodeList Summary (Total Codes: 341, Included: 3)
Code Name
E1
E2
E3
CRC02
1073
Spectacle Lenses
Contact Lenses
Spectacle Frames
Yes/No Condition or Response Code
M
ID
1/1
Required
2/2
Required
Description: Code indicating a Yes or No condition or response
Industry: Certification Condition Indicator
Alias: Certification Condition Code Applies Indicator
CodeList Summary (Total Codes: 4, Included: 2)
Code Name
N
Y
CRC03
1321
No
Yes
Condition Indicator
M
ID
Description: Code indicating a condition
Industry: Condition Code
Alias: Condition Indicator
CodeList Summary (Total Codes: 1079, Included: 5)
Code Name
L1
L2
L3
L4
L5
CRC04
1321
General Standard of 20 Degree or .5 Diopter Sphere or Cylinder Change Met
Replacement Due to Loss or Theft
Replacement Due to Breakage or Damage
Replacement Due to Patient Preference
Replacement Due to Medical Reason
Condition Indicator
O
ID
2/2
Situational
Description: Code indicating a condition
Industry: Condition Code
Use codes listed in CRC03.
Required if additional condition codes are needed.
CodeList Summary (Total Codes: 1079, Included: 5)
837P_CG.ecs
161
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Code Name
L1
L2
L3
L4
L5
CRC05
1321
General Standard of 20 Degree or .5 Diopter Sphere or Cylinder Change Met
Replacement Due to Loss or Theft
Replacement Due to Breakage or Damage
Replacement Due to Patient Preference
Replacement Due to Medical Reason
Condition Indicator
O
ID
2/2
Situational
Description: Code indicating a condition
Industry: Condition Code
Use codes listed in CRC03.
Required if additional condition codes are needed.
CodeList Summary (Total Codes: 1079, Included: 5)
Code Name
L1
L2
L3
L4
L5
CRC06
1321
General Standard of 20 Degree or .5 Diopter Sphere or Cylinder Change Met
Replacement Due to Loss or Theft
Replacement Due to Breakage or Damage
Replacement Due to Patient Preference
Replacement Due to Medical Reason
Condition Indicator
O
ID
2/2
Situational
Description: Code indicating a condition
Industry: Condition Code
Use codes listed in CRC03.
Required if additional condition codes are needed.
CodeList Summary (Total Codes: 1079, Included: 5)
Code Name
L1
L2
L3
L4
L5
CRC07
1321
General Standard of 20 Degree or .5 Diopter Sphere or Cylinder Change Met
Replacement Due to Loss or Theft
Replacement Due to Breakage or Damage
Replacement Due to Patient Preference
Replacement Due to Medical Reason
Condition Indicator
O
ID
2/2
Situational
Description: Code indicating a condition
Industry: Condition Code
Use codes listed in CRC03.
Required if additional condition codes are needed.
CodeList Summary (Total Codes: 1079, Included: 5)
Code Name
L1
L2
L3
L4
L5
General Standard of 20 Degree or .5 Diopter Sphere or Cylinder Change Met
Replacement Due to Loss or Theft
Replacement Due to Breakage or Damage
Replacement Due to Patient Preference
Replacement Due to Medical Reason
Semantics:
837P_CG.ecs
162
For internal use only
12/1/2010
Health Care Claim: Professional - 837
1. CRC01 qualifies CRC03 through CRC07.
2. CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03
through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply.
Notes:
1. Required on vision claims/encounters involving replacement lenses or frames when this information is known
to impact reimbursement.
Example:
CRC*E1*Y*L1~
837P_CG.ecs
163
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 220
CRC Homebound Indicator
Max: 1
Detail - Optional
Loop: 2300
Elements: 3
User Option (Usage): Situational
Purpose: To supply information on conditions
Element Summary:
Ref
Id
Element Name
Req
Type
Min/Max
Usage
CRC01
1136
Code Category
M
ID
2/2
Required
Description: Specifies the situation or category to which the code applies
CodeList Summary (Total Codes: 341, Included: 1)
Code Name
75
CRC02
1073
Functional Limitations
Yes/No Condition or Response Code
M
ID
1/1
Required
2/2
Required
Description: Code indicating a Yes or No condition or response
CodeList Summary (Total Codes: 4, Included: 1)
Code Name
Y
CRC03
1321
Yes
Condition Indicator
M
ID
Description: Code indicating a condition
Industry: Homebound Indicator
CodeList Summary (Total Codes: 1079, Included: 1)
Code Name
IH
Independent at Home
NSF Reference:
EA0-50.0
Semantics:
1. CRC01 qualifies CRC03 through CRC07.
2. CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03
through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply.
Notes:
1. Required for Medicare claims/encounters when an independent laboratory renders an EKG tracing or obtains a
specimen from a homebound or institutionalized patient.
Example:
CRC*75*Y*IH~
837P_CG.ecs
164
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 220
CRC EPSDT Referral
Max: 1
Detail - Optional
Loop: 2300
Elements: 5
User Option (Usage): Situational
Purpose: To supply information on conditions
Element Summary:
Ref
Id
Element Name
Req
Type
Min/Max
Usage
CRC01
1136
Code Category
M
ID
2/2
Required
Description: Specifies the situation or category to which the code applies
CodeList Summary (Total Codes: 341, Included: 1)
Code Name
ZZ
CRC02
1073
Mutually Defined
EPSDT Screening referral information.
Yes/No Condition or Response Code
M
ID
1/1
Required
Description: Code indicating a Yes or No condition or response
Industry: Certification Condition Indicator
Alias: Certification Condition Code Applies Indicator
Was an EPSDT referral given to the patient?
CodeList Summary (Total Codes: 4, Included: 2)
Code Name
CRC03
1321
N
No
If no, then choose “NU” in CRC03 indicating no referral given.
Y
Yes
Condition Indicator
M
ID
2/2
Required
Description: Code indicating a condition
Industry: Condition Code
Alias: Condition Indicator
The codes for CRC03 also can be used for CRC04 through CRC07.
CodeList Summary (Total Codes: 1079, Included: 4)
Code Name
837P_CG.ecs
AV
Available - Not Used
Patient refused referral.
NU
Not Used
This conditioner indicator must be used when the submitter answers “N” in CRC02.
S2
Under Treatment
Patient is currently under treatment for referred diagnostic or corrective health
problem.
ST
New Services Requested
Referral to another provider for diagnostic or corrective treatment/scheduled for
another appointment with screening provider for diagnostic or corrective treatment
for at least one health problem identified during an initial or periodic screening
service (not including dental referrals).
165
For internal use only
12/1/2010
CRC04
Health Care Claim: Professional - 837
1321
Condition Indicator
O
ID
2/2
Situational
Description: Code indicating a condition
Industry: Condition Code
Use codes listed in CRC03.
Required if additional condition codes are needed.
CodeList Summary (Total Codes: 1079, Included: 4)
Code Name
CRC05
1321
AV
Available - Not Used
Patient refused referral.
NU
Not Used
This conditioner indicator must be used when the submitter answers “N” in CRC02.
S2
Under Treatment
Patient is currently under treatment for referred diagnostic or corrective health
problem.
ST
New Services Requested
Referral to another provider for diagnostic or corrective treatment/scheduled for
another appointment with screening provider for diagnostic or corrective treatment
for at least one health problem identified during an initial or periodic screening
service (not including dental referrals).
Condition Indicator
O
ID
2/2
Situational
Description: Code indicating a condition
Industry: Condition Code
Use codes listed in CRC03.
Required if additional condition codes are needed.
CodeList Summary (Total Codes: 1079, Included: 4)
Code Name
AV
Available - Not Used
Patient refused referral.
NU
Not Used
This conditioner indicator must be used when the submitter answers “N” in CRC02.
S2
Under Treatment
Patient is currently under treatment for referred diagnostic or corrective health
problem.
ST
New Services Requested
Referral to another provider for diagnostic or corrective treatment/scheduled for
another appointment with screening provider for diagnostic or corrective treatment
for at least one health problem identified during an initial or periodic screening
service (not including dental referrals).
Semantics:
1. CRC01 qualifies CRC03 through CRC07.
2. CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03
through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply.
Notes:
1. Required on Early & Periodic Screening, Diagnosis, and Treatment (EPSDT) claims/encounters.
Example:
837P_CG.ecs
166
For internal use only
12/1/2010
Health Care Claim: Professional - 837
CRC*ZZ*Y*ST~
837P_CG.ecs
167
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 231
HI Health Care Diagnosis Code
Max: 1
Detail - Optional
Loop: 2300
Elements: 8
User Option (Usage): Situational
Purpose: To supply information related to the delivery of health care
Element Summary:
Ref
Id
Element Name
HI01
C022
Health Care Code Information
Req
Type
M
Comp
Min/Max
Usage
Required
Description: To send health care codes and their associated dates, amounts and
quantities
Alias: Principal Diagnosis
With a few exceptions, it is not recommended to put E codes in HI01. E codes may be put
in any other HI element using BF as the qualifier.
The diagnosis listed in this element is assumed to be the principal diagnosis.
HI01-01
1270
Code List Qualifier Code
M
ID
1/3
Required
Description: Code identifying a specific industry code list
Industry: Diagnosis Type Code
CodeList Summary (Total Codes: 558, Included: 1)
Code Name
BK
Principal Diagnosis
ICD-9 Codes
CODE SOURCE:
131: International Classification of Diseases Clinical Mod (ICD-9-CM) Procedure
HI01-02
1271
Industry Code
M
AN
1/30
Required
Description: Code indicating a code from a specific industry code list
Industry: Diagnosis Code
NSF Reference: EA0-32.0, GX0-31.0, GU0-12.0
ExternalCodeList
Name: 131D
Description: International Classification of Diseases Clinical Mod (ICD-9-CM) Diagnosis
HI02
C022
Health Care Code Information
O
Comp
Situational
Description: To send health care codes and their associated dates, amounts and
quantities
Alias: Diagnosis
Refer to HI01-1(C022-01) and HI01-3(C022-03) for C022-01 and C022-03.
Required if needed to report an additional diagnoses and if the preceeding HI data
elements have been used to report other diagnoses.
HI02-01
1270
Code List Qualifier Code
M
ID
1/3
Required
Description: Code identifying a specific industry code list
Industry: Diagnosis Type Code
CodeList Summary (Total Codes: 558, Included: 1)
837P_CG.ecs
168
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Code Name
BF
Diagnosis
ICD-9 Codes
CODE SOURCE:
131: International Classification of Diseases Clinical Mod (ICD-9-CM) Procedure
HI02-02
1271
Industry Code
M
AN
1/30
Required
Description: Code indicating a code from a specific industry code list
Industry: Diagnosis Code
NSF Reference: EA0-33.0, GX0-32.0, GU0-13.0
ExternalCodeList
Name: 131D
Description: International Classification of Diseases Clinical Mod (ICD-9-CM) Diagnosis
HI03
C022
Health Care Code Information
O
Comp
Situational
Description: To send health care codes and their associated dates, amounts and
quantities
Alias: Diagnosis
Refer to HI01-1(C022-01) and HI01-3(C022-03) for C022-01 and C022-03.
Required if needed to report an additional diagnoses and if the preceeding HI data
elements have been used to report other diagnoses.
HI03-01
1270
Code List Qualifier Code
M
ID
1/3
Required
Description: Code identifying a specific industry code list
Industry: Diagnosis Type Code
CodeList Summary (Total Codes: 558, Included: 1)
Code Name
BF
Diagnosis
ICD-9 Codes
CODE SOURCE:
131: International Classification of Diseases Clinical Mod (ICD-9-CM) Procedure
HI03-02
1271
Industry Code
M
AN
1/30
Required
Description: Code indicating a code from a specific industry code list
Industry: Diagnosis Code
NSF Reference: EA0-34.0, GX0-33.0, GU0-14.0
ExternalCodeList
Name: 131D
Description: International Classification of Diseases Clinical Mod (ICD-9-CM) Diagnosis
HI04
C022
Health Care Code Information
O
Comp
Situational
Description: To send health care codes and their associated dates, amounts and
quantities
Alias: Diagnosis
Refer to HI01-1(C022-01) and HI01-3(C022-03) for C022-01 and C022-03.
Required if needed to report an additional diagnoses and if the preceeding HI data
elements have been used to report other diagnoses.
837P_CG.ecs
169
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Ref
Id
Element Name
HI04-01
1270
Code List Qualifier Code
Req
Type
Min/Max
Usage
M
ID
1/3
Required
Description: Code identifying a specific industry code list
Industry: Diagnosis Type Code
CodeList Summary (Total Codes: 558, Included: 1)
Code Name
BF
Diagnosis
ICD-9 Codes
CODE SOURCE:
131: International Classification of Diseases Clinical Mod (ICD-9-CM) Procedure
HI04-02
1271
Industry Code
M
AN
1/30
Required
Description: Code indicating a code from a specific industry code list
Industry: Diagnosis Code
NSF Reference: EA0-35.0, GX0-34.0, GU0-15.0
ExternalCodeList
Name: 131D
Description: International Classification of Diseases Clinical Mod (ICD-9-CM) Diagnosis
HI05
C022
Health Care Code Information
O
Comp
Situational
Description: To send health care codes and their associated dates, amounts and
quantities
Alias: Diagnosis
Refer to HI01-1(C022-01) and HI01-3(C022-03) for C022-01 and C022-03.
Required if needed to report an additional diagnoses and if the preceeding HI data
elements have been used to report other diagnoses.
HI05-01
1270
Code List Qualifier Code
M
ID
1/3
Required
Description: Code identifying a specific industry code list
Industry: Diagnosis Type Code
CodeList Summary (Total Codes: 558, Included: 1)
Code Name
BF
Diagnosis
ICD-9 Codes
CODE SOURCE:
131: International Classification of Diseases Clinical Mod (ICD-9-CM) Procedure
HI05-02
1271
Industry Code
M
AN
1/30
Required
Description: Code indicating a code from a specific industry code list
Industry: Diagnosis Code
ExternalCodeList
Name: 131D
Description: International Classification of Diseases Clinical Mod (ICD-9-CM) Diagnosis
HI06
C022
Health Care Code Information
O
Comp
Situational
Description: To send health care codes and their associated dates, amounts and
837P_CG.ecs
170
For internal use only
12/1/2010
Ref
Health Care Claim: Professional - 837
Id
Element Name
quantities
Alias: Diagnosis
Req
Type
Min/Max
Usage
Refer to HI01-1(C022-01) and HI01-3(C022-03) for C022-01 and C022-03.
Required if needed to report an additional diagnoses and if the preceeding HI data
elements have been used to report other diagnoses.
HI06-01
1270
Code List Qualifier Code
M
ID
1/3
Required
Description: Code identifying a specific industry code list
Industry: Diagnosis Type Code
CodeList Summary (Total Codes: 558, Included: 1)
Code Name
BF
Diagnosis
ICD-9 Codes
CODE SOURCE:
131: International Classification of Diseases Clinical Mod (ICD-9-CM) Procedure
HI06-02
1271
Industry Code
M
AN
1/30
Required
Description: Code indicating a code from a specific industry code list
Industry: Diagnosis Code
ExternalCodeList
Name: 131D
Description: International Classification of Diseases Clinical Mod (ICD-9-CM) Diagnosis
HI07
C022
Health Care Code Information
O
Comp
Situational
Description: To send health care codes and their associated dates, amounts and
quantities
Alias: Diagnosis
Refer to HI01-1(C022-01) and HI01-3(C022-03) for C022-01 and C022-03.
Required if needed to report an additional diagnoses and if the preceeding HI data
elements have been used to report other diagnoses.
HI07-01
1270
Code List Qualifier Code
M
ID
1/3
Required
Description: Code identifying a specific industry code list
Industry: Diagnosis Type Code
CodeList Summary (Total Codes: 558, Included: 1)
Code Name
BF
Diagnosis
ICD-9 Codes
CODE SOURCE:
131: International Classification of Diseases Clinical Mod (ICD-9-CM) Procedure
HI07-02
1271
Industry Code
M
AN
1/30
Required
Description: Code indicating a code from a specific industry code list
Industry: Diagnosis Code
ExternalCodeList
Name: 131D
837P_CG.ecs
171
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Description: International Classification of Diseases Clinical Mod (ICD-9-CM) Diagnosis
HI08
C022
Health Care Code Information
O
Comp
Situational
Description: To send health care codes and their associated dates, amounts and
quantities
Alias: Diagnosis
Refer to HI01-1(C022-01) and HI01-3(C022-03) for C022-01 and C022-03.
Required if needed to report an additional diagnoses and if the preceeding HI data
elements have been used to report other diagnoses.
HI08-01
1270
Code List Qualifier Code
M
ID
1/3
Required
Description: Code identifying a specific industry code list
Industry: Diagnosis Type Code
CodeList Summary (Total Codes: 558, Included: 1)
Code Name
BF
Diagnosis
ICD-9 Codes
CODE SOURCE:
131: International Classification of Diseases Clinical Mod (ICD-9-CM) Procedure
HI08-02
1271
Industry Code
M
AN
1/30
Required
Description: Code indicating a code from a specific industry code list
Industry: Diagnosis Code
ExternalCodeList
Name: 131D
Description: International Classification of Diseases Clinical Mod (ICD-9-CM) Diagnosis
Notes:
1. Required on all claims/encounters except claims for which there are no diagnoses (e.g., taxi claims).
2. Do not transmit the decimal points in the diagnosis codes. The decimal point is assumed.
Example:
HI*BK:8901*BF:87200*BF:5559~
837P_CG.ecs
172
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 241
HCP Claim Pricing/Repricing
Max: 1
Detail - Optional
Information
Loop: 2300
Elements: 10
User Option (Usage): Situational
Purpose: To specify pricing or repricing information about a health care claim or line item
Element Summary:
Ref
Id
Element Name
HCP01
1473
Pricing Methodology
Req
Type
Min/Max
Usage
C
ID
2/2
Required
Description: Code specifying pricing methodology at which the claim or line item has been
priced or repriced
Alias: Pricing/repricing methodology
Trading partners need to agree on the codes to use in this element. There do not appear to
be standard definitions for the code elements.
CodeList Summary (Total Codes: 15, Included: 14)
Code Name
00
01
02
03
04
05
07
08
09
10
11
12
13
14
HCP02
782
Zero Pricing (Not Covered Under Contract)
Priced as Billed at 100%
Priced at the Standard Fee Schedule
Priced at a Contractual Percentage
Bundled Pricing
Peer Review Pricing
Flat Rate Pricing
Combination Pricing
Maternity Pricing
Other Pricing
Lower of Cost
Ratio of Cost
Cost Reimbursed
Adjustment Pricing
Monetary Amount
O
R
1/18
Required
Description: Monetary amount
Industry: Repriced Allowed Amount
Alias: Allowed amount, Pricing
Used only by repricers as needed. This information is specific to the destination payer
reported in the 2010BB loop.
HCP03
782
Monetary Amount
O
R
1/18
Situational
Description: Monetary amount
Industry: Repriced Saving Amount
Alias: Savings amount, Pricing
Used only by repricers as needed. This information is specific to the destination payer
reported in the 2010BB loop.
HCP04
837P_CG.ecs
127
Reference Identification
O
173
AN
1/30
Situational
For internal use only
12/1/2010
Ref
Health Care Claim: Professional - 837
Id
Element Name
Req
Type
Min/Max
Usage
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Repricing Organization Identifier
Used only by repricers as needed. This information is specific to the destination payer
reported in the 2010BB loop.
HCP05
118
Rate
O
R
1/9
Situational
Description: Rate expressed in the standard monetary denomination for the currency
specified
Industry: Repricing Per Diem or Flat Rate Amount
Alias: Pricing rate
Used only by repricers as needed. This information is specific to the destination payer
reported in the 2010BB loop.
HCP06
127
Reference Identification
O
AN
1/30
Situational
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Repriced Approved Ambulatory Patient Group Code
Alias: Approved APG code, Pricing
Used only by repricers as needed. This information is specific to the destination payer
reported in the 2010BB loop.
HCP07
782
Monetary Amount
O
R
1/18
Situational
Description: Monetary amount
Industry: Repriced Approved Ambulatory Patient Group Amount
Alias: Approved APG amount, Pricing
Used only by repricers as needed. This information is specific to the destination payer
reported in the 2010BB loop.
HCP13
901
Reject Reason Code
C
ID
2/2
Situational
Description: Code assigned by issuer to identify reason for rejection
Alias: Reject reason code
Used only by repricers as needed. This information is specific to the destination payer
reported in the 2010BB loop.
CodeList Summary (Total Codes: 181, Included: 6)
Code Name
T1
T2
T3
T4
T5
T6
HCP14
1526
Cannot Identify Provider as TPO (Third Party Organization) Participant
Cannot Identify Payer as TPO (Third Party Organization) Participant
Cannot Identify Insured as TPO (Third Party Organization) Participant
Payer Name or Identifier Missing
Certification Information Missing
Claim does not contain enough information for re-pricing
Policy Compliance Code
O
ID
1/2
Situational
Description: Code specifying policy compliance
Alias: Policy compliance code
Used only by repricers as needed. This information is specific to the destination payer
reported in the 2010BB loop.
837P_CG.ecs
174
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Ref
Id
Element Name
Req
Type
All valid standard codes are used. (Total Codes: 5)
HCP15
1527
Exception Code
O
ID
Min/Max
Usage
1/2
Situational
Description: Code specifying the exception reason for consideration of out-of-network
health care services
Alias: Exception code
Used only by repricers as needed. This information is specific to the destination payer
reported in the 2010BB loop.
All valid standard codes are used. (Total Codes: 6)
Syntax Rules:
1. R0113 - At least one of HCP01 or HCP13 is required.
2. P0910 - If either HCP09 or HCP10 is present, then the other is required.
3. P1112 - If either HCP11 or HCP12 is present, then the other is required.
Semantics:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
HCP02 is the allowed amount.
HCP03 is the savings amount.
HCP04 is the repricing organization identification number.
HCP05 is the pricing rate associated with per diem or flat rate repricing.
HCP06 is the approved DRG code.
HCP07 is the approved DRG amount.
HCP08 is the approved revenue code.
HCP10 is the approved procedure code.
HCP12 is the approved service units or inpatient days.
HCP13 is the rejection message returned from the third party organization.
HCP15 is the exception reason generated by a third party organization.
Comments:
1. HCP06, HCP07, HCP08, HCP10, and HCP12 are fields that will contain different values from the original
submitted values.
Notes:
1. Used only by repricers as needed. This information is specific to the destination payer reported in the 2010BB
loop.
2. For capitated encounters, pricing or repricing information usually is not applicable and is provided to qualify
other information within the claim.
Example:
HCP*03*100*10*RPO12345~
837P_CG.ecs
175
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 242
Loop Home Health Care Plan
Information
Repeat: 6
Optional
Loop: 2305 Elements: N/A
User Option (Usage): Situational
Purpose: To supply information related to the home health care plan of treatment and services
Loop Summary:
Pos
Id
Segment Name
242
243
CR7
HSD
Home Health Care Plan Information
Health Care Services Delivery
Req
Max Use
O
O
1
3
Repeat
Usage
Situational
Situational
Semantics:
1. CR702 is the total visits on this bill rendered prior to the recertification "to" date.
2. CR703 is the total visits projected during this certification period.
Notes:
1. Required on home health claims/encounters that involve billing/reporting home health visits.
Example:
CR7*PT*4*12~
837P_CG.ecs
176
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 242
CR7 Home Health Care Plan
Max: 1
Detail - Optional
Information
Loop: 2305
Elements: 3
User Option (Usage): Situational
Purpose: To supply information related to the home health care plan of treatment and services
Element Summary:
Ref
Id
Element Name
CR701
921
Discipline Type Code
Req
Type
Min/Max
Usage
M
ID
2/2
Required
Description: Code indicating disciplines ordered by a physician
Alias: Discipline type code
All valid standard codes are used. (Total Codes: 6)
CR702
1470
Number
M
N0
1/9
Required
M
N0
1/9
Required
Description: A generic number
Industry: Total Visits Rendered Count
Alias: Total visits rendered, home health
CR703
1470
Number
Description: A generic number
Industry: Certification Period Projected Visit Count
Alias: Total visits projected, home health
Semantics:
1. CR702 is the total visits on this bill rendered prior to the recertification "to" date.
2. CR703 is the total visits projected during this certification period.
Notes:
1. Required on home health claims/encounters that involve billing/reporting home health visits.
Example:
CR7*PT*4*12~
837P_CG.ecs
177
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 243
HSD Health Care Services
Max: 3
Detail - Optional
Delivery
Loop: 2305
Elements: 8
User Option (Usage): Situational
Purpose: To specify the delivery pattern of health care services
Element Summary:
Ref
Id
Element Name
HSD01
673
Quantity Qualifier
Req
Type
Min/Max
Usage
C
ID
2/2
Situational
Description: Code specifying the type of quantity
Industry: Visits
Required if the order/prescription for the service contains the data.
CodeList Summary (Total Codes: 832, Included: 1)
Code Name
VS
HSD02
380
Visits
Quantity
C
R
1/15
Situational
Description: Numeric value of quantity
Industry: Number of Visits
Required if the order/prescription for the service contains the data.
HSD03
355
Unit or Basis for Measurement Code
O
ID
2/2
Situational
Description: Code specifying the units in which a value is being expressed, or manner in
which a measurement has been taken
Industry: Frequency Period
Alias: Modulus, Unit
Required if the order/prescription for the service contains the data.
CodeList Summary (Total Codes: 794, Included: 4)
Code Name
HSD04
1167
DA
MO
Days
Months
Month
Q1
WK
Quarter (Time)
Week
Sample Selection Modulus
O
R
1/6
Situational
Description: To specify the sampling frequency in terms of a modulus of the Unit of
Measure, e.g., every fifth bag, every 1.5 minutes
Industry: Frequency Count
Alias: Modulus, Amount
Required if the order/prescription for the service contains the data.
HSD05
615
Time Period Qualifier
C
ID
1/2
Situational
Description: Code defining periods
Industry: Duration of Visits Units
837P_CG.ecs
178
For internal use only
12/1/2010
Ref
Health Care Claim: Professional - 837
Id
Element Name
Req
Type
Min/Max
Usage
Required if the order/prescription for the service contains the data.
CodeList Summary (Total Codes: 36, Included: 2)
Code Name
7
35
HSD06
616
Day
Week
Number of Periods
O
N0
1/3
Situational
Description: Total number of periods
Industry: Duration of Visits, Number of Units
Required if the order/prescription for the service contains the data.
HSD07
678
Ship/Delivery or Calendar Pattern Code
O
ID
1/2
Situational
Description: Code which specifies the routine shipments, deliveries, or calendar pattern
Industry: Ship, Delivery or Calendar Pattern Code
Alias: Pattern Code
Required if the order/prescription for the service contains the data.
CodeList Summary (Total Codes: 44, Included: 32)
Code Name
1
2
3
4
5
6
7
A
B
C
D
E
F
G
H
J
K
L
N
O
S
W
SA
SB
SC
SD
SG
SL
837P_CG.ecs
1st Week of the Month
2nd Week of the Month
3rd Week of the Month
4th Week of the Month
5th Week of the Month
1st & 3rd Weeks of the Month
2nd & 4th Weeks of the Month
Monday through Friday
Monday through Saturday
Monday through Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Monday through Thursday
As Directed
Daily Mon. through Fri.
Once Anytime Mon. through Fri.
Whenever Necessary
Sunday, Monday, Thursday, Friday, Saturday
Tuesday through Saturday
Sunday, Wednesday, Thursday, Friday, Saturday
Monday, Wednesday, Thursday, Friday, Saturday
Tuesday through Friday
Monday, Tuesday and Thursday
179
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Code Name
SP
SX
SY
SZ
HSD08
679
Monday, Tuesday and Friday
Wednesday and Thursday
Monday, Wednesday and Thursday
Tuesday, Thursday and Friday
Ship/Delivery Pattern Time Code
O
ID
1/1
Situational
Description: Code which specifies the time for routine shipments or deliveries
Industry: Delivery Pattern Time Code
Alias: Time Code
Required if the order/prescription for the service contains the data.
CodeList Summary (Total Codes: 9, Included: 3)
Code Name
D
E
F
A.M.
P.M.
As Directed
Syntax Rules:
1. P0102 - If either HSD01 or HSD02 is present, then the other is required.
2. C0605 - If HSD06 is present, then HSD05 is required.
Notes:
1. Required on claims/encounters billing/reporting home health visits where further detail is necessary to clearly
substantiate medical treatment.
2. The HSD segment is used to specify the delivery pattern of the health care services. This is how it is used:
HSD01 qualifies HSD02: If the value in HSD02=1 and the value in HSD01=VS (Visits), this means “one visit”.
Between HSD02 and HSD03 verbally insert a “per every.”
HSD03 qualifies HSD04: If the value in HSD04=3 and the value in HSD03=DA (Day), this means “three days.”
Between HSD04 and HSD05 verbally insert a “for.”
HSD05 qualifies HSD06: If the value in HSD06=21 and the value in HSD05=7 (Days), this means “21 days.”
The total message reads:
HSD*VS*1*DA*3*7*21~ = “One visit per every three days for 21 days.”
Another similar data string of HSD*VS*2*DA*4*7*20~ = Two visits per every four days for 20 days.
An alternate way to use HSD is to employ HSD07 and/or HSD08. A data string of HSD*VS*1*****SX*D~ means “1
visit on Wednesday and Thursday morning.”
Example:
HSD*VS*1*DA*1*7*10~ (This indicates ''1 visit every (per) 1 day (daily) for 10 days'')
HSD*VS*1*DA****W~ (This indicates ''1 visit per day whenever necessary'')
837P_CG.ecs
180
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 250
Loop Referring Provider Name
Repeat: 2
Optional
Loop:
2310A
Elements: N/A
User Option (Usage): Situational
Purpose: To supply the full name of an individual or organizational entity
Loop Summary:
Pos
Id
Segment Name
250
255
271
NM1
PRV
REF
Referring Provider Name
Referring Provider Specialty Information
Referring Provider Secondary Identification
Req
Max Use
O
O
O
1
1
5
Repeat
Usage
Situational
Situational
Situational
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
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.
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. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,
then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.
4. Required if claim involved a referral.
5. When reporting the provider who ordered services such as diagnostic and lab utilize the 2310A loop at the
claim level. For ordered services such as DMERC utilize the 2420E Loop at the line level.
Example:
NM1*DN*1*WELBY*MARCUS*W**JR*34*444332222~
837P_CG.ecs
181
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 250
NM1 Referring Provider Name
Max: 1
Detail - Optional
Loop:
2310A
Elements: 8
User Option (Usage): Situational
Purpose: To supply the full name of an individual or organizational entity
Element Summary:
Ref
Id
Element Name
NM101
98
Entity Identifier Code
Req
Type
Min/Max
Usage
M
ID
2/3
Required
Description: Code identifying an organizational entity, a physical location, property or an
individual
The entity identifier in NM101 applies to all segments in this Loop ID-2310.
User Note 6:
Use code DN for Self Referral claims.
CodeList Summary (Total Codes: 1312, Included: 2)
Code Name
NM102
1065
DN
Referring Provider
Use on first iteration of this loop. Use if loop is used only once.
P3
Primary Care Provider
Use only if loop is used twice. Use only on second iteration of this loop.
Entity Type Qualifier
M
ID
1/1
Required
AN
1/35
Required
Description: Code qualifying the type of entity
User Note 6:
Use code 2 for Self Referral claims.
CodeList Summary (Total Codes: 14, Included: 2)
Code Name
1
2
NM103
1035
Person
Non-Person Entity
Name Last or Organization Name
O
Description: Individual last name or organizational name
Industry: Referring Provider Last Name
NSF Reference: EA0-24.0
User Note 6:
For Self Referral claims send NM103 as follows: SELFREFERRAL
Example: NM1*DN*2*SELFREFERRAL*****XX*1002233777~
NM104
1036
Name First
O
AN
1/25
Situational
Description: Individual first name
Industry: Referring Provider First Name
837P_CG.ecs
182
For internal use only
12/1/2010
Ref
Health Care Claim: Professional - 837
Id
Element Name
Req
Type
Min/Max
Usage
O
AN
1/25
Situational
NSF Reference: EA0-25.0
Required if NM102=1 (person).
NM105
1037
Name Middle
Description: Individual middle name or initial
Industry: Referring Provider Middle Name
NSF Reference: EA0-26.0
Required if NM102=1 and the middle name/initial of the person is known.
NM107
1039
Name Suffix
O
AN
1/10
Situational
C
ID
1/2
Situational
Description: Suffix to individual name
Industry: Referring Provider Name Suffix
Alias: Referring Provider Generation
Required if known.
NM108
66
Identification Code Qualifier
Description: Code designating the system/method of code structure used for Identification
Code (67)
Required if Employer’s Identification/Social Security number (Tax ID) or National Provider
Identifier is known.
User Note 6:
XX
CodeList Summary (Total Codes: 215, Included: 3)
Code Name
24
34
XX
NM109
67
Employer's Identification Number
Social Security Number
Health Care Financing Administration National Provider Identifier
Identification Code
C
AN
2/80
Situational
Description: Code identifying a party or other code
Industry: Referring Provider Identifier
Alias: Referring Provider Primary Identifier
NSF Reference: EA0-20.0
Required if Employer’s Identification/Social Security number (Tax ID) or National Provider
Identifier is known.
User Note 6:
Some practice management systems require NM109 (PER BSCA guidelines, use NPI as
referenced below). Example: XX*1002233777~
ExternalCodeList
Name: 537
Description: Health Care Financing Administration National Provider Identifier
Syntax Rules:
1. P0809 - If either NM108 or NM109 is present, then the other is required.
2. C1110 - If NM111 is present, then NM110 is required.
837P_CG.ecs
183
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
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.
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. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,
then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.
4. Required if claim involved a referral.
5. When reporting the provider who ordered services such as diagnostic and lab utilize the 2310A loop at the
claim level. For ordered services such as DMERC utilize the 2420E Loop at the line level.
Example:
NM1*DN*1*WELBY*MARCUS*W**JR*34*444332222~
837P_CG.ecs
184
For internal use only
12/1/2010
Health Care Claim: Professional - 837
PRV Referring Provider Specialty
Information
Pos: 255
Max: 1
Detail - Optional
Loop:
2310A
Elements: 3
User Option (Usage): Situational
Purpose: To specify the identifying characteristics of a provider
Element Summary:
Ref
Id
Element Name
Req
Type
Min/Max
Usage
PRV01
1221
Provider Code
M
ID
1/3
Required
ID
2/3
Required
Description: Code identifying the type of provider
CodeList Summary (Total Codes: 26, Included: 1)
Code Name
RF
PRV02
128
Referring
Reference Identification Qualifier
M
Description: Code qualifying the Reference Identification
ZZ is used to indicate the “Health Care Provider Taxonomy” code list (provider specialty
code) which is available on the Washington Publishing Company web site:
http://www.wpc-edi.com. This taxonomy is maintained by the Blue Cross Blue Shield
Association and ASC X12N TG2 WG15.
CodeList Summary (Total Codes: 1503, Included: 1)
Code Name
ZZ
PRV03
127
Mutually Defined
Health Care Provider Taxonomy Code list
Reference Identification
M
AN
1/30
Required
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Provider Taxonomy Code
Alias: Provider Specialty Code
ExternalCodeList
Name: HCPT
Description: Health Care Provider Taxonomy
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.
2. Required when adjudication is known to be impacted by provider taxonomy code.
3. PRV02 qualifies PRV03.
Example:
PRV*RF*ZZ*363LP0200N~
837P_CG.ecs
185
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 271
REF Referring Provider
Max: 5
Detail - Optional
Secondary Identification
Loop:
2310A
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
Description: Code qualifying the Reference Identification
User Note 6:
Use 0B for CA State license #
Use 1B for BSC Provider ID
CodeList Summary (Total Codes: 1503, Included: 12)
Code Name
REF02
127
0B
1B
1C
1D
1G
1H
EI
G2
LU
N5
SY
State License Number
Blue Shield Provider Number
Medicare Provider Number
Medicaid Provider Number
Provider UPIN Number
CHAMPUS Identification Number
Employer's Identification Number
Provider Commercial Number
Location Number
Provider Plan Network Identification Number
Social Security Number
The social security number may not be used for Medicare.
X5
State Industrial Accident Provider Number
Reference Identification
C
AN
1/30
Required
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Referring Provider Secondary Identifier
NSF Reference: EA0-20.0
User Note 6:
Use only California State License Number or BSC Provider ID with the appropriate REF01
qualifier.
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
837P_CG.ecs
186
For internal use only
12/1/2010
Health Care Claim: Professional - 837
1. Required if NM108/09 in this loop is not used or if a secondary number is necessary to identify the provider.
Until the NPI is mandated for use, this REF may be required if necessary to adjudicate the claim.
Example:
REF*1D*A12345~
837P_CG.ecs
187
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 250
Loop Rendering Provider Name
Repeat: 1
Optional
Loop:
2310B
Elements: N/A
User Option (Usage): Situational
Purpose: To supply the full name of an individual or organizational entity
Loop Summary:
Pos
Id
Segment Name
250
255
271
NM1
PRV
REF
Rendering Provider Name
Rendering Provider Specialty Information
Rendering Provider Secondary
Identification
Req
Max Use
O
O
O
1
1
5
Repeat
Usage
Situational
Situational
Situational
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
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.
2. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,
then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.
3. Required when the Rendering Provider NM1 information is different than that carried in either the Billing
Provider NM1 or the Pay-to Provider NM1 in the 2010AA/AB loops respectively.
4. 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 subsitute provider (locum
tenans) was used, that person should be entered here.
Example:
NM1*82*1*BEATTY*GARY*C**SR*XX*12345678~
837P_CG.ecs
188
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 250
NM1 Rendering Provider Name
Max: 1
Detail - Optional
Loop:
2310B
Elements: 8
User Option (Usage): Situational
Purpose: To supply the full name of an individual or organizational entity
Element Summary:
Ref
Id
Element Name
NM101
98
Entity Identifier Code
Req
Type
Min/Max
Usage
M
ID
2/3
Required
Description: Code identifying an organizational entity, a physical location, property or an
individual
The entity identifier in NM101 applies to all segments in this Loop ID-2310.
CodeList Summary (Total Codes: 1312, Included: 1)
Code Name
82
NM102
1065
Rendering Provider
Entity Type Qualifier
M
ID
1/1
Required
AN
1/35
Required
Description: Code qualifying the type of entity
CodeList Summary (Total Codes: 14, Included: 2)
Code Name
1
2
NM103
1035
Person
Non-Person Entity
Name Last or Organization Name
O
Description: Individual last name or organizational name
Industry: Rendering Provider Last or Organization Name
Alias: Rendering Provider Last Name
NSF Reference: FB1-14.0
NM104
1036
Name First
O
AN
1/25
Situational
O
AN
1/25
Situational
Description: Individual first name
Industry: Rendering Provider First Name
NSF Reference: FB1-15.0
Required if NM102=1 (person).
NM105
1037
Name Middle
Description: Individual middle name or initial
Industry: Rendering Provider Middle Name
NSF Reference: FB1-16.0
Required if NM102=1 and the middle name/initial of the person is known.
NM107
1039
Name Suffix
O
AN
1/10
Situational
Description: Suffix to individual name
Industry: Rendering Provider Name Suffix
Alias: Rendering Provider Generation
837P_CG.ecs
189
For internal use only
12/1/2010
Ref
Health Care Claim: Professional - 837
Id
Element Name
Req
Type
Min/Max
Usage
C
ID
1/2
Required
Required if known.
NM108
66
Identification Code Qualifier
Description: Code designating the system/method of code structure used for Identification
Code (67)
NSF Reference: FA0-57.0
FA0-57.0 crosswalk is only used in Medicare COB payer-to-payer claims.
CodeList Summary (Total Codes: 215, Included: 3)
Code Name
24
34
XX
NM109
67
Employer's Identification Number
Social Security Number
Health Care Financing Administration National Provider Identifier
Identification Code
C
AN
2/80
Required
Description: Code identifying a party or other code
Industry: Rendering Provider Identifier
Alias: Rendering Provider Primary Identifier
NSF Reference: FA0-23.0, FA0-58.0
FA0-58.0 crosswalk is only used in Medicare COB payer-to-payer claims.
User Note 6:
The rendering provider information must be provided when the services are being billed by
someone other than the billing or pay to provider.
NM108=XX
NM109=NPI
(i.e., group, clinic, etc)
ExternalCodeList
Name: 537
Description: Health Care Financing Administration National Provider Identifier
Syntax Rules:
1. P0809 - If either NM108 or NM109 is present, then the other is required.
2. C1110 - If NM111 is present, then NM110 is required.
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
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.
2. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,
then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.
3. Required when the Rendering Provider NM1 information is different than that carried in either the Billing
Provider NM1 or the Pay-to Provider NM1 in the 2010AA/AB loops respectively.
837P_CG.ecs
190
For internal use only
12/1/2010
Health Care Claim: Professional - 837
4. 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 subsitute provider (locum
tenans) was used, that person should be entered here.
Example:
NM1*82*1*BEATTY*GARY*C**SR*XX*12345678~
User Note 6:
The rendering provider information must be provided when the services are being billed by someone other than the
billing or pay to provider. NM108=XX,NM109=NPI (i.e., group, clinic, etc.)
837P_CG.ecs
191
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 255
PRV Rendering Provider
Max: 1
Detail - Optional
Specialty Information
Loop:
2310B
Elements: 3
User Option (Usage): Situational
Purpose: To specify the identifying characteristics of a provider
Element Summary:
Ref
Id
Element Name
Req
Type
Min/Max
Usage
PRV01
1221
Provider Code
M
ID
1/3
Required
Description: Code identifying the type of provider
User Note 6:
PRV01=PE
To specify the identifying characteristics of a provider. BSCA is requesting the taxonomy to
identify the rendering provider’s specialty.
ZZ is used to indicate the “Health Care Provider Taxonomy” code list (provider specialty
code) which is available on the Washington Publishing Company web site:
http://www.wpc-edi.com.
This taxonomy is maintained by the Blue Cross Blue Shield association and ASC X12N
TG2 WG15.
CodeList Summary (Total Codes: 26, Included: 1)
Code Name
PE
PRV02
128
Performing
Reference Identification Qualifier
M
ID
2/3
Required
Description: Code qualifying the Reference Identification
ZZ is used to indicate the “Health Care Provider Taxonomy” code list (provider specialty
code) which is available on the Washington Publishing Company web site:
http://www.wpc-edi.com. This taxonomy is maintained by the Blue Cross Blue Shield
Association and ASC X12N TG2 WG15.
CodeList Summary (Total Codes: 1503, Included: 1)
Code Name
ZZ
PRV03
127
Mutually Defined
Health Care Provider Taxonomy Code list
Reference Identification
M
AN
1/30
Required
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Provider Taxonomy Code
Alias: Provider Specialty Code
NSF Reference: FA0-37.0
User Note 6:
PRV03=Taxonomy Code
ExternalCodeList
Name: HCPT
837P_CG.ecs
192
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Description: Health Care Provider Taxonomy
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.
2. PRV02 qualifies PRV03.
3. Required when adjudication is known to be impacted by provider taxonomy code.
Example:
PRV*PE*ZZ*203BA0200N~
837P_CG.ecs
193
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 271
REF Rendering Provider
Max: 5
Detail - Optional
Secondary Identification
Loop:
2310B
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
Description: Code qualifying the Reference Identification
NSF Reference: FA0-57.0
CodeList Summary (Total Codes: 1503, Included: 12)
Code Name
REF02
127
0B
1B
1C
1D
1G
1H
EI
G2
LU
N5
SY
State License Number
Blue Shield Provider Number
Medicare Provider Number
Medicaid Provider Number
Provider UPIN Number
CHAMPUS Identification Number
Employer's Identification Number
Provider Commercial Number
Location Number
Provider Plan Network Identification Number
Social Security Number
The social security number may not be used for Medicare.
X5
State Industrial Accident Provider Number
Reference Identification
C
AN
1/30
Required
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Rendering Provider Secondary Identifier
NSF Reference: FA0-58.0
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. Required when a secondary identification number is necessary to identify the entity. The primary identification
number should be carried in NM109 in this loop.
Example:
REF*1D*A12345~
837P_CG.ecs
194
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Loop Purchased Service Provider
Name
Pos: 250
Repeat: 1
Optional
Loop:
2310C
Elements: N/A
User Option (Usage): Situational
Purpose: To supply the full name of an individual or organizational entity
Loop Summary:
Pos
Id
Segment Name
250
271
NM1
REF
Purchased Service Provider Name
Purchased Service Provider Secondary
Identification
Req
Max Use
O
O
1
5
Repeat
Usage
Situational
Situational
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
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.
2. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,
then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.
3. Required if purchased services are being billed/reported on this claim. Purchased services are situations where
(for example) a physician purchases a diagnostic exam from an outside entity. Purchased services do not include
substitute (locum tenens) provider situations. All payer-specific identifying numbers belong to the destination
payer identified in the 2010BB loop.
Example:
NM1*QB*2******FI*111223333~
837P_CG.ecs
195
For internal use only
12/1/2010
Health Care Claim: Professional - 837
NM1 Purchased Service Provider
Name
Pos: 250
Max: 1
Detail - Optional
Loop:
2310C
Elements: 7
User Option (Usage): Situational
Purpose: To supply the full name of an individual or organizational entity
Element Summary:
Ref
Id
Element Name
NM101
98
Entity Identifier Code
Req
Type
Min/Max
Usage
M
ID
2/3
Required
Description: Code identifying an organizational entity, a physical location, property or an
individual
CodeList Summary (Total Codes: 1312, Included: 1)
Code Name
QB
NM102
1065
Purchase Service Provider
Entity Type Qualifier
M
ID
1/1
Required
AN
1/35
Required
Description: Code qualifying the type of entity
CodeList Summary (Total Codes: 14, Included: 2)
Code Name
1
2
NM103
1035
Person
Non-Person Entity
Name Last or Organization Name
O
Description: Individual last name or organizational name
NM104
1036
Name First
O
AN
1/25
Situational
O
AN
1/25
Situational
Description: Individual first name
Required if NM102 = 1.
NM105
1037
Name Middle
Description: Individual middle name or initial
Required if NM102=1 and the middle name/initial of the person is known.
NM108
66
Identification Code Qualifier
C
ID
1/2
Situational
Description: Code designating the system/method of code structure used for Identification
Code (67)
Required if either Employer’s Identification/Social Security Number or National Provider
Identifier is known.
CodeList Summary (Total Codes: 215, Included: 3)
Code Name
24
34
XX
NM109
67
Employer's Identification Number
Social Security Number
Health Care Financing Administration National Provider Identifier
Identification Code
C
AN
2/80
Situational
Description: Code identifying a party or other code
837P_CG.ecs
196
For internal use only
12/1/2010
Ref
Health Care Claim: Professional - 837
Id
Element Name
Req
Industry: Purchased Service Provider Identifier
Type
Min/Max
Usage
Alias: Purchased Service Provider Primary Identifier
NSF Reference: FB0-11.0
Required if either Employer’s Identification/Social Security Number or National Provider
Identifier is known.
ExternalCodeList
Name: 537
Description: Health Care Financing Administration National Provider Identifier
Syntax Rules:
1. P0809 - If either NM108 or NM109 is present, then the other is required.
2. C1110 - If NM111 is present, then NM110 is required.
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
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.
2. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,
then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.
3. Required if purchased services are being billed/reported on this claim. Purchased services are situations where
(for example) a physician purchases a diagnostic exam from an outside entity. Purchased services do not include
substitute (locum tenens) provider situations. All payer-specific identifying numbers belong to the destination
payer identified in the 2010BB loop.
Example:
NM1*QB*2******FI*111223333~
837P_CG.ecs
197
For internal use only
12/1/2010
Health Care Claim: Professional - 837
REF Purchased Service Provider
Secondary Identification
Pos: 271
Max: 5
Detail - Optional
Loop:
2310C
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 14)
Code Name
REF02
127
0B
1A
1B
1C
1D
1G
1H
EI
G2
LU
N5
SY
State License Number
Blue Cross Provider Number
Blue Shield Provider Number
Medicare Provider Number
Medicaid Provider Number
Provider UPIN Number
CHAMPUS Identification Number
Employer's Identification Number
Provider Commercial Number
Location Number
Provider Plan Network Identification Number
Social Security Number
The social security number may not be used for Medicare.
U3
X5
Unique Supplier Identification Number (USIN)
State Industrial Accident Provider Number
Reference Identification
C
AN
1/30
Required
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Purchased Service Provider Secondary Identifier
NSF Reference: FB0-11.0
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. Required when a secondary identification number is necessary to identify the entity. The primary identification
number should be carried in NM108/9 in this loop.
Example:
REF*1D*A12345~
837P_CG.ecs
198
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 250
Loop Service Facility Location
Repeat: 1
Optional
Loop:
2310D
Elements: N/A
User Option (Usage): Situational
Purpose: To supply the full name of an individual or organizational entity
Loop Summary:
Pos
Id
Segment Name
Req
Max Use
250
265
270
271
NM1
N3
N4
REF
Service Facility
Service Facility
Service Facility
Service Facility
Identification
O
O
O
O
1
1
1
5
Location
Location Address
Location City/State/ZIP
Location Secondary
Repeat
Usage
Situational
Required
Required
Situational
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
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.
2. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,
then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.
3. This loop is required when the location of health care service is different than that carried in the 2010AA (Billing
Provider) or 2010AB (Pay-to Provider) loops.
4. Required if the service was rendered in a Health Professional Shortage Area (QB or QU modifier billed) and the
place of service is different than the HPSA billing address.
5. The purpose of this loop is to identify specifically where the service was rendered. In cases where it was
rendered at the patient’s home, do not use this loop. In that case, the place of service code in CLM05- 1 should
indicate that the service occurred in the patient’s home.
Example:
NM1*TL*2*A-OK MOBILE CLINIC*****24*11122333~
837P_CG.ecs
199
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 250
NM1 Service Facility Location
Max: 1
Detail - Optional
Loop:
2310D
Elements: 5
User Option (Usage): Situational
Purpose: To supply the full name of an individual or organizational entity
Element Summary:
Ref
Id
Element Name
NM101
98
Entity Identifier Code
Req
Type
Min/Max
Usage
M
ID
2/3
Required
Description: Code identifying an organizational entity, a physical location, property or an
individual
User Note 6:
AMBULANCE
Service Location Qualifies patient pick-up location.
Use 77
CodeList Summary (Total Codes: 1312, Included: 4)
Code Name
NM102
1065
77
Service Location
Use when other codes in this element do not apply.
FA
LI
TL
Facility
Independent Lab
Testing Laboratory
Entity Type Qualifier
M
ID
1/1
Required
AN
1/35
Situational
Description: Code qualifying the type of entity
User Note 6:
AMBULANCE
Non person entity qualifier
Use 2
CodeList Summary (Total Codes: 14, Included: 1)
Code Name
2
NM103
1035
Non-Person Entity
Name Last or Organization Name
O
Description: Individual last name or organizational name
Industry: Laboratory or Facility Name
Alias: Laboratory/Facility Name
NSF Reference: EA0-39.0
Required except when service was rendered in the patient’s home.
User Note 6:
AMBULANCE
Report location name where patient was picked-up, i.e. RESIDENCE (upto 35 characters)
NM108
837P_CG.ecs
66
Identification Code Qualifier
C
200
ID
1/2
Situational
For internal use only
12/1/2010
Ref
Health Care Claim: Professional - 837
Id
Element Name
Req
Type
Min/Max
Usage
Description: Code designating the system/method of code structure used for Identification
Code (67)
Required if either Employer’s Identification/Social Security Number or National Provider
Identifier is known.
CodeList Summary (Total Codes: 215, Included: 3)
Code Name
24
34
XX
NM109
67
Employer's Identification Number
Social Security Number
Health Care Financing Administration National Provider Identifier
Identification Code
C
AN
2/80
Situational
Description: Code identifying a party or other code
Industry: Laboratory or Facility Primary Identifier
Alias: Laboratory/Facility Primary Identifier
NSF Reference: EA1-04.0, EA0-53.0
Required if either Employer’s Identification/Social Security Number or National Provider
Identifier is known.
ExternalCodeList
Name: 537
Description: Health Care Financing Administration National Provider Identifier
Syntax Rules:
1. P0809 - If either NM108 or NM109 is present, then the other is required.
2. C1110 - If NM111 is present, then NM110 is required.
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
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.
2. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,
then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.
3. This loop is required when the location of health care service is different than that carried in the 2010AA (Billing
Provider) or 2010AB (Pay-to Provider) loops.
4. Required if the service was rendered in a Health Professional Shortage Area (QB or QU modifier billed) and the
place of service is different than the HPSA billing address.
5. The purpose of this loop is to identify specifically where the service was rendered. In cases where it was
rendered at the patient’s home, do not use this loop. In that case, the place of service code in CLM05- 1 should
indicate that the service occurred in the patient’s home.
Example:
NM1*TL*2*A-OK MOBILE CLINIC*****24*11122333~
837P_CG.ecs
201
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 265
N3 Service Facility Location
Max: 1
Detail - Optional
Address
Loop:
2310D
Elements: 2
User Option (Usage): Required
Purpose: To specify the location of the named party
Element Summary:
Ref
Id
Element Name
N301
166
Address Information
Req
Type
Min/Max
Usage
M
AN
1/55
Required
O
AN
1/55
Situational
Description: Address information
Industry: Laboratory or Facility Address Line
Alias: Laboratory/Facility Address 1
NSF Reference: EA1-06.0
User Note 6:
AMBULANCE
Address of where patient was picked-up.
N302
166
Address Information
Description: Address information
Industry: Laboratory or Facility Address Line
Alias: Laboratory/Facility Address 2
NSF Reference: EA1-07.0
Required if a second address line exists.
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 (e.g., “crossroad of State Road 34 and 45" or ”Exit near Mile marker 265 on Interstate 80".)
Example:
N3*123 MAIN STREET~
837P_CG.ecs
202
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 270
N4 Service Facility Location
Max: 1
Detail - Optional
City/State/ZIP
Loop:
2310D
Elements: 4
User Option (Usage): Required
Purpose: To specify the geographic place of the named party
Element Summary:
Ref
Id
Element Name
N401
19
City Name
Req
Type
Min/Max
Usage
O
AN
2/30
Required
O
ID
2/2
Required
Description: Free-form text for city name
Industry: Laboratory or Facility City Name
Alias: Laboratory/Facility City
NSF Reference: EA1-08.0
User Note 6:
AMBULANCE
City of where patient was picked-up.
N402
156
State or Province Code
Description: Code (Standard State/Province) as defined by appropriate government
agency
Industry: Laboratory or Facility State or Province Code
Alias: Laboratory/Facility State
CODE SOURCE: 22: States and Outlying Areas of the U.S.
NSF Reference: EA1-09.0
User Note 6:
AMBULANCE
State of where patient was picked-up.
ExternalCodeList
Name: 22
Description: States and Outlying Areas of the U.S.
N403
116
Postal Code
O
ID
3/15
Required
Description: Code defining international postal zone code excluding punctuation and
blanks (zip code for United States)
Industry: Laboratory or Facility Postal Zone or ZIP Code
Alias: Laboratory/Facility Zip Code
CODE SOURCE: 51: ZIP Code
NSF Reference: EA1-10.0
User Note 6:
AMBULANCE
Zip Code of where patient was picked-up.
ExternalCodeList
Name: 51
Description: ZIP Code
837P_CG.ecs
203
For internal use only
12/1/2010
N404
Health Care Claim: Professional - 837
26
Country Code
O
ID
2/3
Situational
Description: Code identifying the country
Alias: Laboratory/Facility Country Code
CODE SOURCE: 5: Countries, Currencies and Funds
Required if the address is out of the U.S.
ExternalCodeList
Name: 5
Description: Countries, Currencies and Funds
Syntax Rules:
1. C0605 - If N406 is present, then N405 is required.
Comments:
1. A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
2. N402 is required only if city name (N401) is in the U.S. or Canada.
Notes:
1. If service facility location is in an area where there are no street addresses, enter the name of the nearest town,
state and zip of where the service was rendered.
Example:
N4*ANY TOWN*TX*75123~
837P_CG.ecs
204
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 271
REF Service Facility Location
Max: 5
Detail - Optional
Secondary Identification
Loop:
2310D
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
1/30
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 13)
Code Name
0B
1A
1B
1C
1D
1G
1H
G2
LU
N5
TJ
X4
X5
REF02
127
State License Number
Blue Cross Provider Number
Blue Shield Provider Number
Medicare Provider Number
Medicaid Provider Number
Provider UPIN Number
CHAMPUS Identification Number
Provider Commercial Number
Location Number
Provider Plan Network Identification Number
Federal Taxpayer's Identification Number
Clinical Laboratory Improvement Amendment Number
State Industrial Accident Provider Number
Reference Identification
C
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Laboratory or Facility Secondary Identifier
Alias: Laboratory/Facility Secondary Identification Number
NSF Reference: EA1-04.0, EA0-53.0
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. Required when a secondary identification number is necessary to identify the entity. The primary identification
number should be carried in NM109 in this loop.
Example:
REF*1D*A12345~
837P_CG.ecs
205
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 250
Loop Supervising Provider Name
Repeat: 1
Optional
Loop:
2310E
Elements: N/A
User Option (Usage): Situational
Purpose: To supply the full name of an individual or organizational entity
Loop Summary:
Pos
Id
Segment Name
250
271
NM1
REF
Supervising Provider Name
Supervising Provider Secondary
Identification
Req
Max Use
O
O
1
5
Repeat
Usage
Situational
Situational
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
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.
2. Required when the rendering provider is supervised by a physician.
3. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,
then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.
Example:
NM1*DQ*1*KILLIAN*BART*B**II*24*222334444~
837P_CG.ecs
206
For internal use only
12/1/2010
Health Care Claim: Professional - 837
NM1 Supervising Provider Name
Pos: 250
Max: 1
Detail - Optional
Loop:
2310E
Elements: 8
User Option (Usage): Situational
Purpose: To supply the full name of an individual or organizational entity
Element Summary:
Ref
Id
Element Name
NM101
98
Entity Identifier Code
Req
Type
Min/Max
Usage
M
ID
2/3
Required
Description: Code identifying an organizational entity, a physical location, property or an
individual
CodeList Summary (Total Codes: 1312, Included: 1)
Code Name
DQ
NM102
1065
Supervising Physician
Entity Type Qualifier
M
ID
1/1
Required
AN
1/35
Required
Description: Code qualifying the type of entity
CodeList Summary (Total Codes: 14, Included: 1)
Code Name
1
NM103
1035
Person
Name Last or Organization Name
O
Description: Individual last name or organizational name
Industry: Supervising Provider Last Name
NSF Reference: EA1-18.0
NM104
1036
Name First
O
AN
1/25
Required
O
AN
1/25
Situational
Description: Individual first name
Industry: Supervising Provider First Name
NSF Reference: EA1-19.0
NM105
1037
Name Middle
Description: Individual middle name or initial
Industry: Supervising Provider Middle Name
NSF Reference: EA1-20.0
Required if NM102=1 and the middle name/initial of the person is known.
NM107
1039
Name Suffix
O
AN
1/10
Situational
C
ID
1/2
Situational
Description: Suffix to individual name
Industry: Supervising Provider Name Suffix
Alias: Supervising Provider Generation
Required if known.
NM108
66
Identification Code Qualifier
Description: Code designating the system/method of code structure used for Identification
837P_CG.ecs
207
For internal use only
12/1/2010
Ref
Health Care Claim: Professional - 837
Id
Element Name
Req
Type
Min/Max
Usage
Code (67)
Required if either Employer’s Identification/Social Security Number or National Provider
Identifier is known.
CodeList Summary (Total Codes: 215, Included: 3)
Code Name
NM109
67
24
34
Employer's Identification Number
Social Security Number
The social security number may not be used for Medicare.
XX
Health Care Financing Administration National Provider Identifier
Identification Code
C
AN
2/80
Situational
Description: Code identifying a party or other code
Industry: Supervising Provider Identifier
Alias: Supervising Provider Primary Identifier
NSF Reference: EA1-16.0
Required if either Employer’s Identification/Social Security Number or National Provider
Identifier is known.
ExternalCodeList
Name: 537
Description: Health Care Financing Administration National Provider Identifier
Syntax Rules:
1. P0809 - If either NM108 or NM109 is present, then the other is required.
2. C1110 - If NM111 is present, then NM110 is required.
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
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.
2. Required when the rendering provider is supervised by a physician.
3. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,
then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.
Example:
NM1*DQ*1*KILLIAN*BART*B**II*24*222334444~
837P_CG.ecs
208
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 271
REF Supervising Provider
Max: 5
Detail - Optional
Secondary Identification
Loop:
2310E
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 12)
Code Name
REF02
127
0B
1B
1C
1D
1G
1H
EI
G2
LU
N5
SY
State License Number
Blue Shield Provider Number
Medicare Provider Number
Medicaid Provider Number
Provider UPIN Number
CHAMPUS Identification Number
Employer's Identification Number
Provider Commercial Number
Location Number
Provider Plan Network Identification Number
Social Security Number
The social security number may not be used for Medicare.
X5
State Industrial Accident Provider Number
Reference Identification
C
AN
1/30
Required
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Supervising Provider Secondary Identifier
NSF Reference: EA1-16.0
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. Required when a secondary identification number is necessary to identify the entity. The primary identification
number should be carried in NM108/9 in this loop.
Example:
REF*1D*A12345~
837P_CG.ecs
209
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Loop Other Subscriber Information
Pos: 290
Repeat: 10
Optional
Loop: 2320 Elements: N/A
User Option (Usage): Situational
Purpose: To record information specific to the primary insured and the insurance carrier for that insured
Loop Summary:
Pos
Id
Segment Name
290
295
300
SBR
CAS
AMT
300
AMT
300
AMT
300
AMT
300
AMT
300
AMT
300
AMT
300
AMT
300
AMT
300
AMT
305
310
320
DMG
OI
MOA
Other Subscriber Information
Claim Level Adjustments
Coordination of Benefits (COB) Payer Paid
Amount
Coordination of Benefits (COB) Approved
Amount
Coordination of Benefits (COB) Allowed
Amount
Coordination of Benefits (COB) Patient
Responsibility Amount
Coordination of Benefits (COB) Covered
Amount
Coordination of Benefits (COB) Discount
Amount
Coordination of Benefits (COB) Per Day
Limit Amount
Coordination of Benefits (COB) Patient
Paid Amount
Coordination of Benefits (COB) Tax
Amount
Coordination of Benefits (COB) Total Claim
Before Taxes Amount
Subscriber Demographic Information
Other Insurance Coverage Information
Medicare Outpatient Adjudication
Information
Loop 2330A
Loop 2330B
Loop 2330C
Loop 2330D
Loop 2330E
Loop 2330F
Loop 2330G
Loop 2330H
325
325
325
325
325
325
325
325
Req
Max Use
O
O
O
1
5
1
Situational
Situational
Situational
O
1
Situational
O
1
Situational
O
1
Situational
O
1
Situational
O
1
Situational
O
1
Situational
O
1
Situational
O
1
Situational
O
1
Situational
O
O
O
1
1
1
Situational
Required
Situational
O
O
O
O
O
O
O
O
Repeat
1
1
1
2
1
1
1
1
Usage
Required
Required
Situational
Situational
Situational
Situational
Situational
Situational
Semantics:
1.
2.
3.
4.
SBR02 specifies the relationship to the person insured.
SBR03 is policy or group number.
SBR04 is plan name.
SBR07 is destination payer code. A "Y" value indicates the payer is the destination payer; an "N" value
indicates the payer is not the destination payer.
837P_CG.ecs
210
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Notes:
1. Required if other payers are known to potentially be involved in paying on this claim.
2. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,
then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.
3. 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, run the 2320 Loop again with it’s respective 2330 Loops.
See Section 1.4.4 for more information on handling COB.
4. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.
Example:
SBR*S*01*GR00786**MC****OF~
837P_CG.ecs
211
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 290
SBR Other Subscriber
Max: 1
Detail - Optional
Information
Loop: 2320
Elements: 6
User Option (Usage): Situational
Purpose: To record information specific to the primary insured and the insurance carrier for that insured
Element Summary:
Ref
Id
Element Name
SBR01
1138
Payer Responsibility Sequence Number
Code
Req
Type
Min/Max
Usage
M
ID
1/1
Required
Description: Code identifying the insurance carrier's level of responsibility for a payment
of a claim
Alias: Payer responsibility sequence number code
NSF Reference: DA0-02.0, DA1-02.0, DA2-02.0
CodeList Summary (Total Codes: 6, Included: 3)
Code Name
P
S
T
SBR02
1069
Primary
Secondary
Tertiary
Individual Relationship Code
O
ID
2/2
Required
Description: Code indicating the relationship between two individuals or entities
Alias: Individual relationship code
NSF Reference: DA0-17.0
CodeList Summary (Total Codes: 153, Included: 24)
Code Name
01
04
05
07
10
15
17
18
19
20
21
22
23
24
29
32
33
36
39
837P_CG.ecs
Spouse
Grandfather or Grandmother
Grandson or Granddaughter
Nephew or Niece
Foster Child
Ward
Stepson or Stepdaughter
Self
Child
Employee
Unknown
Handicapped Dependent
Sponsored Dependent
Dependent of a Minor Dependent
Significant Other
Mother
Father
Emancipated Minor
Organ Donor
212
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Code Name
40
41
43
53
G8
SBR03
127
Cadaver Donor
Injured Plaintiff
Child Where Insured Has No Financial Responsibility
Life Partner
Other Relationship
Reference Identification
O
AN
1/30
Situational
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Insured Group or Policy Number
Alias: Group or Policy Number
NSF Reference: DA0-10.0
Required if the subscriber’s payer identification includes Group or Plan Number. This data
element is intended to carry the subscriber’s Group Number, not the number that uniquely
identifies the subscriber (Subscriber ID, Loop 2010BA-NM109).
SBR04
93
Name
O
AN
1/60
Situational
Description: Free-form name
Industry: Other Insured Group Name
Alias: Group or Plan Name
NSF Reference: DA0-11.0
Required if the subscriber’s payer identification includes a Group or Plan Name.
SBR05
1336
Insurance Type Code
O
ID
1/3
Required
Description: Code identifying the type of insurance policy within a specific insurance
program
Alias: Insurance type code
NSF Reference: DA0-06.0
CodeList Summary (Total Codes: 45, Included: 15)
Code Name
AP
C1
CP
GP
HM
IP
LD
LT
MB
MC
MI
MP
OT
PP
SP
SBR09
837P_CG.ecs
1032
Auto Insurance Policy
Commercial
Medicare Conditionally Primary
Group Policy
Health Maintenance Organization (HMO)
Individual Policy
Long Term Policy
Litigation
Medicare Part B
Medicaid
Medigap Part B
Medicare Primary
Other
Personal Payment (Cash - No Insurance)
Supplemental Policy
Claim Filing Indicator Code
O
213
ID
1/2
Situational
For internal use only
12/1/2010
Ref
Health Care Claim: Professional - 837
Id
Element Name
Req
Type
Min/Max
Usage
Description: Code identifying type of claim
Alias: Claim filing indicator code
NSF Reference: DA0-05.0
Required prior to mandated used of PlanID. Not used after PlanID is mandated.
CodeList Summary (Total Codes: 45, Included: 23)
Code Name
09
10
Self-pay
Central Certification
NSF Reference:
CA0-23.0 (K), DA0-05.0 (K)
11
12
13
14
15
16
AM
BL
CH
CI
DS
HM
LI
LM
MB
MC
OF
TV
VA
Other Non-Federal Programs
Preferred Provider Organization (PPO)
Point of Service (POS)
Exclusive Provider Organization (EPO)
Indemnity Insurance
Health Maintenance Organization (HMO) Medicare Risk
Automobile Medical
Blue Cross/Blue Shield
Champus
Commercial Insurance Co.
Disability
Health Maintenance Organization
Liability
Liability Medical
Medicare Part B
Medicaid
Other Federal Program
Title V
Veteran Administration Plan
Refers to Veterans Affairs Plan.
WC
ZZ
Workers' Compensation Health Claim
Mutually Defined
Unknown
Semantics:
1.
2.
3.
4.
SBR02 specifies the relationship to the person insured.
SBR03 is policy or group number.
SBR04 is plan name.
SBR07 is destination payer code. A "Y" value indicates the payer is the destination payer; an "N" value
indicates the payer is not the destination payer.
Notes:
1. Required if other payers are known to potentially be involved in paying on this claim.
2. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,
then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.
3. 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
837P_CG.ecs
214
For internal use only
12/1/2010
Health Care Claim: Professional - 837
carried, run the 2320 Loop again with it’s respective 2330 Loops.
See Section 1.4.4 for more information on handling COB.
4. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.
Example:
SBR*S*01*GR00786**MC****OF~
837P_CG.ecs
215
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 295
CAS Claim Level Adjustments
Max: 5
Detail - Optional
Loop: 2320
Elements: 19
User Option (Usage): Situational
Purpose: To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service
within the claim being paid
Element Summary:
Ref
Id
Element Name
CAS01
1033
Claim Adjustment Group Code
Req
Type
Min/Max
Usage
M
ID
1/2
Required
Description: Code identifying the general category of payment adjustment
Alias: Claim Adjustment Group Code
CodeList Summary (Total Codes: 8, Included: 5)
Code Name
CO
CR
OA
PI
PR
CAS02
1034
Contractual Obligations
Correction and Reversals
Other adjustments
Payor Initiated Reductions
Patient Responsibility
Claim Adjustment Reason Code
M
ID
1/5
Required
Description: Code identifying the detailed reason the adjustment was made
Industry: Adjustment Reason Code
Alias: Adjustment Reason Code - Claim Level
CODE SOURCE: 139: Claim Adjustment Reason Code
NSF Reference: DA3-04.0, DA3-06.0, DA3-08.0, DA3-10.0, DA3-12.0, DA3-14.0,
DA3-16.0, DA1-16.0, DA1-30.0
ExternalCodeList
Name: 139
Description: Claim Adjustment Reason Code
CAS03
782
Monetary Amount
M
R
1/18
Required
Description: Monetary amount
Industry: Adjustment Amount
Alias: Adjusted Amount - Claim Level
NSF Reference: DA1-09.0, DA1-10.0, DA1-11.0, DA1-12.0, DA1-13.0, DA3-05.0,
DA3-07.0, DA3-09.0, DA3-11.0, DA3-13.0, DA3-15.0, DA3-17.0, DA1-30.0, DA1-33.0,
DA3-25.0, DA3-26.0
CAS04
380
Quantity
O
R
1/15
Situational
C
ID
1/5
Situational
Description: Numeric value of quantity
Industry: Adjustment Quantity
Alias: Adjusted Units - Claim Level
Use as needed to show payer adjustment.
CAS05
837P_CG.ecs
1034
Claim Adjustment Reason Code
216
For internal use only
12/1/2010
Ref
Health Care Claim: Professional - 837
Id
Element Name
Req
Type
Min/Max
Usage
Description: Code identifying the detailed reason the adjustment was made
Industry: Adjustment Reason Code
Alias: Adjustment Reason Code - Claim Level
CODE SOURCE: 139: Claim Adjustment Reason Code
NSF Reference: DA3-04.0, DA3-06.0, DA3-08.0, DA3-10.0, DA3-12.0, DA3-14.0,
DA3-16.0, DA1-17.0, DA1-30.0
Use as needed to show payer adjustment.
ExternalCodeList
Name: 139
Description: Claim Adjustment Reason Code
CAS06
782
Monetary Amount
C
R
1/18
Situational
Description: Monetary amount
Industry: Adjustment Amount
Alias: Adjusted Amount - Claim Level
NSF Reference: DA3-05.0, DA3-07.0, DA3-09.0, DA3-11.0, DA3-13.0, DA3-15.0,
DA3-17.0, DA1-30.0, DA1-33.0, DA3-25.0, DA3-26.0
Use as needed to show payer adjustment.
CAS07
380
Quantity
C
R
1/15
Situational
C
ID
1/5
Situational
Description: Numeric value of quantity
Industry: Adjustment Quantity
Alias: Adjusted Units - Claim Level
Use as needed to show payer adjustment.
CAS08
1034
Claim Adjustment Reason Code
Description: Code identifying the detailed reason the adjustment was made
Industry: Adjustment Reason Code
Alias: Adjustment Reason Code - Claim Level
CODE SOURCE: 139: Claim Adjustment Reason Code
NSF Reference: DA3-04.0, DA3-06.0, DA3-08.0, DA3-10.0, DA3-12.0, DA3-14.0,
DA3-16.0, DA1-30.0, DA1-18.0
Use as needed to show payer adjustment.
ExternalCodeList
Name: 139
Description: Claim Adjustment Reason Code
CAS09
782
Monetary Amount
C
R
1/18
Situational
Description: Monetary amount
Industry: Adjustment Amount
Alias: Adjusted Amount - Claim Level
NSF Reference: DA3-05.0, DA3-07.0, DA3-09.0, DA3-11.0, DA3-13.0, DA3-15.0, DA3-17.
0, DA1-30.0, DA1-33.0, DA3-25.0, DA3-26.0
Use as needed to show payer adjustment.
837P_CG.ecs
217
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Ref
Id
Element Name
CAS10
380
Quantity
Req
Type
Min/Max
Usage
C
R
1/15
Situational
C
ID
1/5
Situational
Description: Numeric value of quantity
Industry: Adjustment Quantity
Alias: Adjusted Units - Claim Level
Use as needed to show payer adjustment.
CAS11
1034
Claim Adjustment Reason Code
Description: Code identifying the detailed reason the adjustment was made
Industry: Adjustment Reason Code
Alias: Adjustment Reason Code - Claim Level
CODE SOURCE: 139: Claim Adjustment Reason Code
NSF Reference: DA3-04.0, DA3-06.0, DA3-08.0, DA3-10.0, DA3-12.0, DA3-14.0,
DA3-16.0, DA1-30.0
Use as needed to show payer adjustment.
ExternalCodeList
Name: 139
Description: Claim Adjustment Reason Code
CAS12
782
Monetary Amount
C
R
1/18
Situational
Description: Monetary amount
Industry: Adjustment Amount
Alias: Adjusted Amount - Claim Level
NSF Reference: DA3-05.0, DA3-07.0, DA3-09.0, DA3-11.0, DA3-13.0, DA3-15.0,
DA3-17.0, DA1-30.0, DA1-33.0, DA3-25.0, DA3-26.0
Use as needed to show payer adjustment.
CAS13
380
Quantity
C
R
1/15
Situational
C
ID
1/5
Situational
Description: Numeric value of quantity
Industry: Adjustment Quantity
Alias: Adjusted Units - Claim Level
Use as needed to show payer adjustment.
CAS14
1034
Claim Adjustment Reason Code
Description: Code identifying the detailed reason the adjustment was made
Industry: Adjustment Reason Code
Alias: Adjustment Reason Code - Claim Level
CODE SOURCE: 139: Claim Adjustment Reason Code
NSF Reference: DA3-04.0, DA3-06.0, DA3-08.0, DA3-10.0, DA3-12.0, DA3-14.0,
DA3-16.0, DA1-30.0
Use as needed to show payer adjustment.
ExternalCodeList
Name: 139
Description: Claim Adjustment Reason Code
CAS15
837P_CG.ecs
782
Monetary Amount
C
218
R
1/18
Situational
For internal use only
12/1/2010
Ref
Health Care Claim: Professional - 837
Id
Element Name
Req
Type
Min/Max
Usage
Description: Monetary amount
Industry: Adjustment Amount
Alias: Adjusted Amount - Claim Level
NSF Reference: DA3-05.0, DA3-07.0, DA3-09.0, DA3-11.0, DA3-13.0, DA3-15.0,
DA3-17.0, DA1-30.0, DA1-33.0, DA3-25.0, DA3-26.0
Use as needed to show payer adjustment.
CAS16
380
Quantity
C
R
1/15
Situational
C
ID
1/5
Situational
Description: Numeric value of quantity
Industry: Adjustment Quantity
Alias: Adjusted Units - Claim Level
Use as needed to show payer adjustment.
CAS17
1034
Claim Adjustment Reason Code
Description: Code identifying the detailed reason the adjustment was made
Industry: Adjustment Reason Code
Alias: Adjustment Reason Code - Claim Level
CODE SOURCE: 139: Claim Adjustment Reason Code
NSF Reference: DA3-04.0, DA3-06.0, DA3-08.0, DA3-10.0, DA3-12.0, DA3-14.0,
DA3-16.0, DA1-30.0
Use as needed to show payer adjustment.
ExternalCodeList
Name: 139
Description: Claim Adjustment Reason Code
CAS18
782
Monetary Amount
C
R
1/18
Situational
Description: Monetary amount
Industry: Adjustment Amount
Alias: Adjusted Amount - Claim Level
NSF Reference: DA3-05.0, DA3-07.0, DA3-09.0, DA3-11.0, DA3-13.0, DA3-15.0,
DA3-17.0, DA1-30.0, DA1-33.0, DA3-25.0, DA3-26.0
Use as needed to show payer adjustment.
CAS19
380
Quantity
C
R
1/15
Situational
Description: Numeric value of quantity
Industry: Adjustment Quantity
Alias: Adjusted Units - Claim Level
Use as needed to show payer adjustment.
Syntax Rules:
1.
2.
3.
4.
5.
6.
L050607 - If CAS05 is present, then at least one of CAS06 or CAS07 is required.
C0605 - If CAS06 is present, then CAS05 is required.
C0705 - If CAS07 is present, then CAS05 is required.
L080910 - If CAS08 is present, then at least one of CAS09 or CAS10 is required.
C0908 - If CAS09 is present, then CAS08 is required.
C1008 - If CAS10 is present, then CAS08 is required.
837P_CG.ecs
219
For internal use only
12/1/2010
7.
8.
9.
10.
11.
12.
13.
14.
15.
Health Care Claim: Professional - 837
L111213 - If CAS11 is present, then at least one of CAS12 or CAS13 is required.
C1211 - If CAS12 is present, then CAS11 is required.
C1311 - If CAS13 is present, then CAS11 is required.
L141516 - If CAS14 is present, then at least one of CAS15 or CAS16 is required.
C1514 - If CAS15 is present, then CAS14 is required.
C1614 - If CAS16 is present, then CAS14 is required.
L171819 - If CAS17 is present, then at least one of CAS18 or CAS19 is required.
C1817 - If CAS18 is present, then CAS17 is required.
C1917 - If CAS19 is present, then CAS17 is required.
Semantics:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
CAS03
CAS04
CAS06
CAS07
CAS09
CAS10
CAS12
CAS13
CAS15
CAS16
CAS18
CAS19
is
is
is
is
is
is
is
is
is
is
is
is
the amount of adjustment.
the units of service being adjusted.
the amount of the adjustment.
the units of service being adjusted.
the amount of the adjustment.
the units of service being adjusted.
the amount of the adjustment.
the units of service being adjusted.
the amount of the adjustment.
the units of service being adjusted.
the amount of the adjustment.
the units of service being adjusted.
Comments:
1. Adjustment information is intended to help the provider balance the remittance information. Adjustment
amounts should fully explain the difference between submitted charges and the amount paid.
2. When the submitted charges are paid in full, the value for CAS03 should be zero.
Notes:
1. Submitters should 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.
3. Codes and associated amounts should come from 835s (Remittance Advice) received on the claim. If no
previous payments have been made, omit this segment.
4. Required if claim has been adjudicated by payer identified in this loop and has claim level adjustment
information.
5. To locate the claim adjustment group codes (CAS01) and claim adjustment reason codes (CAS02, 05, 08, 11,
14, and 17) see the Washington Publishing Company web site: http://www.wpc-edi.com. Follow the buttons to
Code Lists - Claim Adjustment Reason Codes.
6. There several NSF fields which are not directly crosswalked from the 837 to NSF, particularly with respect to
payer-to-payer COB situations. Below is a list of some of these NSF fields and some suggestions regarding how
to handle them in the 837. Provider Adjustment Amt (DA3-25.0). This would equal the sum of all the adjustment
amounts in CAS03, 06, 09, 12, 15, and 18 at both the claim and the line level. See the 835 for how to balance the
CAS adjustments against the total billed amount. Beneficiary liability amount (FA0-53.0) This amount would equal
the sum of all the adjustment amounts in CAS03, 06, 09, 12, 15, and 18 at both the claim and the line level when
CAS01 = PR (patient responsibility).
Amount paid to Provider (DA1-33.0). This would be calculated through the use of the CAS codes. Please see the
detail on the codes and the discussion of how to use them in the 835 implementation guide. Balance bill limit
charge (FA0-54.0). This would equal any CAS adjustment where CAS01=CO and one of the adjustment reason
code elements equaled “45".
Beneficiary Adjustment Amt (DA3-26.0) Amount paid to beneficiary (DA1-30.0)). The amount paid to the
837P_CG.ecs
220
For internal use only
12/1/2010
Health Care Claim: Professional - 837
beneficiary is indicated by the use of CAS code ”100 - Payment made to patient/insured/responsible party."
Original Paid Amount (DA3-28.0): The original paid amount can be calculated from the original COB claim by
subtracting all claim adjustments carried in the claim and line level CAS from the original billed amount.
Example:
CAS*PR*1*7.93~
CAS*OA*93*15.06~
837P_CG.ecs
221
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 300
AMT Coordination of Benefits
Max: 1
Detail - Optional
(COB) Payer Paid Amount
Loop: 2320
Elements: 2
User Option (Usage): Situational
Purpose: To indicate the total monetary amount
Element Summary:
Ref
Id
Element Name
AMT01
522
Amount Qualifier Code
Req
Type
Min/Max
Usage
M
ID
1/3
Required
R
1/18
Required
Description: Code to qualify amount
CodeList Summary (Total Codes: 1473, Included: 1)
Code Name
D
AMT02
782
Payor Amount Paid
Monetary Amount
M
Description: Monetary amount
Industry: Payer Paid Amount
This is a crosswalk from CLP04 in 835 when doing COB.
Notes:
1. Required if claim has been adjudicated by payer identified in this loop. It is acceptable to show “0" amount paid.
Example:
AMT*D*411~
837P_CG.ecs
222
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 300
AMT Coordination of Benefits
Max: 1
Detail - Optional
(COB) Approved Amount
Loop: 2320
Elements: 2
User Option (Usage): Situational
Purpose: To indicate the total monetary amount
Element Summary:
Ref
Id
Element Name
AMT01
522
Amount Qualifier Code
Req
Type
Min/Max
Usage
M
ID
1/3
Required
R
1/18
Required
Description: Code to qualify amount
CodeList Summary (Total Codes: 1473, Included: 1)
Code Name
AAE
AMT02
782
Approved Amount
Monetary Amount
M
Description: Monetary amount
Industry: Approved Amount
NSF Reference: DA1-37.0
Notes:
1. Used primarily in payer-to-payer COB situations by the payer who is sending this claim to another payer.
Providers (in a provider-to-payer COB situation) do not usually complete this information but may do so if the
information is available.
2. The approved amount equals the amount for the total claim that was approved by the payer sending this 837 to
another payer.
Example:
AMT*AAE*500.35~
837P_CG.ecs
223
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 300
AMT Coordination of Benefits
Max: 1
Detail - Optional
(COB) Allowed Amount
Loop: 2320
Elements: 2
User Option (Usage): Situational
Purpose: To indicate the total monetary amount
Element Summary:
Ref
Id
Element Name
AMT01
522
Amount Qualifier Code
Req
Type
Min/Max
Usage
M
ID
1/3
Required
R
1/18
Required
Description: Code to qualify amount
CodeList Summary (Total Codes: 1473, Included: 1)
Code Name
B6
AMT02
782
Allowed - Actual
Monetary Amount
M
Description: Monetary amount
Industry: Allowed Amount
Notes:
1. Used primarily in payer-to-payer COB situations by the payer who is sending this claim to another payer.
Providers (in a provider-to-payer COB situation) do not usually complete this information but may do so if the
information is available.
2. The allowed amount equals the amount for the total claim that was allowed by the payer sending this 837 to
another payer.
Example:
AMT*B6*519.21~
837P_CG.ecs
224
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 300
AMT Coordination of Benefits
Max: 1
Detail - Optional
(COB) Patient Responsibility Loop: 2320
Amount
Elements: 2
User Option (Usage): Situational
Purpose: To indicate the total monetary amount
Element Summary:
Ref
Id
Element Name
AMT01
522
Amount Qualifier Code
Req
Type
Min/Max
Usage
M
ID
1/3
Required
R
1/18
Required
Description: Code to qualify amount
CodeList Summary (Total Codes: 1473, Included: 1)
Code Name
F2
AMT02
782
Patient Responsibility - Actual
Monetary Amount
M
Description: Monetary amount
Industry: Other Payer Patient Responsibility Amount
This is a crosswalk from CLP05 in 835 when doing COB.
Notes:
1. Required if patient is responsible for payment according to another payer’s adjudication. This is the amount of
money which is the responsibility of the patient according to the payer identified in this loop (2330B NM1).
Example:
AMT*F2*15~
837P_CG.ecs
225
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 300
AMT Coordination of Benefits
Max: 1
Detail - Optional
(COB) Covered Amount
Loop: 2320
Elements: 2
User Option (Usage): Situational
Purpose: To indicate the total monetary amount
Element Summary:
Ref
Id
Element Name
AMT01
522
Amount Qualifier Code
Req
Type
Min/Max
Usage
M
ID
1/3
Required
R
1/18
Required
Description: Code to qualify amount
CodeList Summary (Total Codes: 1473, Included: 1)
Code Name
AU
AMT02
782
Coverage Amount
Monetary Amount
M
Description: Monetary amount
Industry: Other Payer Covered Amount
This is a crosswalk from AMT in 835 (Loop CLP, position 062) when AMT01 = AU.
Notes:
1. Used primarily in payer-to-payer COB situations by the payer who is sending this claim to another payer.
Providers (in a provider-to-payer COB situation) do not usually complete this information but may do so if the
information is available.
2. The covered amount equals the amount for the total claim that was covered by the payer sending this 837 to
another payer.
Example:
AMT*AU*50~
837P_CG.ecs
226
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 300
AMT Coordination of Benefits
Max: 1
Detail - Optional
(COB) Discount Amount
Loop: 2320
Elements: 2
User Option (Usage): Situational
Purpose: To indicate the total monetary amount
Element Summary:
Ref
Id
Element Name
AMT01
522
Amount Qualifier Code
Req
Type
Min/Max
Usage
M
ID
1/3
Required
R
1/18
Required
Description: Code to qualify amount
CodeList Summary (Total Codes: 1473, Included: 1)
Code Name
D8
AMT02
782
Discount Amount
Monetary Amount
M
Description: Monetary amount
Industry: Other Payer Discount Amount
This is a crosswalk from AMT in 835 (Loop CLP, position 062) when AMT01 = D8.
Notes:
1. Required if claim has been adjudicated by the payer identified in this loop and if this information was included
in the remittance advice reporting those adjudication results.
Example:
AMT*D8*35~
837P_CG.ecs
227
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 300
AMT Coordination of Benefits
Max: 1
Detail - Optional
(COB) Per Day Limit Amount Loop: 2320
Elements: 2
User Option (Usage): Situational
Purpose: To indicate the total monetary amount
Element Summary:
Ref
Id
Element Name
AMT01
522
Amount Qualifier Code
Req
Type
Min/Max
Usage
M
ID
1/3
Required
R
1/18
Required
Description: Code to qualify amount
CodeList Summary (Total Codes: 1473, Included: 1)
Code Name
DY
AMT02
782
Per Day Limit
Monetary Amount
M
Description: Monetary amount
Industry: Other Payer Per Day Limit Amount
This is a crosswalk from AMT in 835 (Loop CLP, position 062) when AMT01 = DY.
Notes:
1. Required if claim has been adjudicated by the payer identified in this loop and if this information was included
in the remittance advice reporting those adjudication results.
Example:
AMT*DY*46~
837P_CG.ecs
228
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 300
AMT Coordination of Benefits
Max: 1
Detail - Optional
(COB) Patient Paid Amount
Loop: 2320
Elements: 2
User Option (Usage): Situational
Purpose: To indicate the total monetary amount
Element Summary:
Ref
Id
Element Name
AMT01
522
Amount Qualifier Code
Req
Type
Min/Max
Usage
M
ID
1/3
Required
R
1/18
Required
Description: Code to qualify amount
CodeList Summary (Total Codes: 1473, Included: 1)
Code Name
F5
AMT02
782
Patient Amount Paid
Monetary Amount
M
Description: Monetary amount
Industry: Other Payer Patient Paid Amount
This is a crosswalk from AMT in 835 (Loop CLP, position 062) when AMT01 = F5.
Notes:
1. Required if claim has been adjudicated by the payer identified in this loop and if this information was included
in the remittance advice reporting those adjudication results.
2. The amount carried in this segment is the total amount of money paid by the payer to the patient (rather than to
the provider) on this claim.
Example:
AMT*F5*152.45~
837P_CG.ecs
229
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 300
AMT Coordination of Benefits
Max: 1
Detail - Optional
(COB) Tax Amount
Loop: 2320
Elements: 2
User Option (Usage): Situational
Purpose: To indicate the total monetary amount
Element Summary:
Ref
Id
Element Name
AMT01
522
Amount Qualifier Code
Req
Type
Min/Max
Usage
M
ID
1/3
Required
R
1/18
Required
Description: Code to qualify amount
CodeList Summary (Total Codes: 1473, Included: 1)
Code Name
T
AMT02
782
Tax
Monetary Amount
M
Description: Monetary amount
Industry: Other Payer Tax Amount
This is a crosswalk from AMT in 835 (Loop CLP, position 062) when AMT01 = T.
Notes:
1. Required if claim has been adjudicated by the payer identified in this loop and if this information was included
in the remittance advice reporting those adjudication results.
Example:
AMT*T*45~
837P_CG.ecs
230
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 300
AMT Coordination of Benefits
Max: 1
Detail - Optional
(COB) Total Claim Before
Taxes Amount
Loop: 2320
Elements: 2
User Option (Usage): Situational
Purpose: To indicate the total monetary amount
Element Summary:
Ref
Id
Element Name
AMT01
522
Amount Qualifier Code
Req
Type
Min/Max
Usage
M
ID
1/3
Required
R
1/18
Required
Description: Code to qualify amount
CodeList Summary (Total Codes: 1473, Included: 1)
Code Name
T2
AMT02
782
Total Claim Before Taxes
Monetary Amount
M
Description: Monetary amount
Industry: Other Payer Pre-Tax Claim Total Amount
This is a crosswalk from AMT in 835 (Loop CLP, position 062) when AMT01 = T2.
Notes:
1. Required if claim has been adjudicated by the payer identified in this loop and if this information was included
in the remittance advice reporting those adjudication results.
Example:
AMT*T2*456~
837P_CG.ecs
231
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 305
DMG Subscriber Demographic
Max: 1
Detail - Optional
Information
Loop: 2320
Elements: 3
User Option (Usage): Situational
Purpose: To supply demographic information
Element Summary:
Ref
Id
Element Name
DMG01
1250
Date Time Period Format Qualifier
Req
Type
Min/Max
Usage
C
ID
2/3
Required
Description: Code indicating the date format, time format, or date and time format
CodeList Summary (Total Codes: 39, Included: 1)
Code Name
D8
DMG02
1251
Date Expressed in Format CCYYMMDD
Date Time Period
C
AN
1/35
Required
Description: Expression of a date, a time, or range of dates, times or dates and times
Industry: Other Insured Birth Date
Alias: Date of Birth - Subscriber
NSF Reference: DA0-24.0
DMG03
1068
Gender Code
O
ID
1/1
Required
Description: Code indicating the sex of the individual
Industry: Other Insured Gender Code
Alias: Gender - Subscriber
NSF Reference: DA0-23.0
CodeList Summary (Total Codes: 7, Included: 3)
Code Name
F
M
U
Female
Male
Unknown
Syntax Rules:
1. P0102 - If either DMG01 or DMG02 is present, then the other is required.
Semantics:
1. DMG02 is the date of birth.
2. DMG07 is the country of citizenship.
3. DMG09 is the age in years.
Notes:
1. Required when 2330A NM102 = 1 (person).
2. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.
Example:
DMG*D8*19671105*F~
837P_CG.ecs
232
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 310
OI Other Insurance Coverage
Max: 1
Detail - Optional
Information
Loop: 2320
Elements: 3
User Option (Usage): Required
Purpose: To specify information associated with other health insurance coverage
Element Summary:
Ref
Id
Element Name
OI03
1073
Yes/No Condition or Response Code
Req
Type
Min/Max
Usage
O
ID
1/1
Required
1/1
Situational
Description: Code indicating a Yes or No condition or response
Industry: Benefits Assignment Certification Indicator
Alias: Assignment of Benefits Indicator
NSF Reference: DA0-15.0
This is a crosswalk from CLM08 when doing COB.
CodeList Summary (Total Codes: 4, Included: 2)
Code Name
N
Y
OI04
1351
No
Yes
Patient Signature Source Code
O
ID
Description: Code indicating how the patient or subscriber authorization signatures were
obtained and how they are being retained by the provider
Alias: Patient Signature Source Code
NSF Reference: DA0-16.0
Required except in cases where ‘‘N’’ is used in OI06.
This is a crosswalk from CLM10 when doing COB.
All valid standard codes are used. (Total Codes: 5)
OI06
1363
Release of Information Code
O
ID
1/1
Required
Description: Code indicating whether the provider has on file a signed statement by the
patient authorizing the release of medical data to other organizations
Alias: Release of Information Code
This is a crosswalk from CLM09 when doing COB.
All valid standard codes are used. (Total Codes: 6)
Semantics:
1. OI03 is the assignment of benefits indicator. A "Y" value indicates insured or authorized person authorizes
benefits to be assigned to the provider; an "N" value indicates benefits have not been assigned to the
provider.
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. It is specific only to that payer.
2. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.
Example:
OI***Y*B**Y~
837P_CG.ecs
233
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 320
MOA Medicare Outpatient
Max: 1
Detail - Optional
Adjudication Information
Loop: 2320
Elements: 9
User Option (Usage): Situational
Purpose: To convey claim-level data related to the adjudication of Medicare claims not related to an inpatient setting
Element Summary:
Ref
Id
Element Name
MOA01
954
Percent
Req
Type
Min/Max
Usage
O
R
1/10
Situational
1/18
Situational
1/30
Situational
Description: Percentage expressed as a decimal
Industry: Reimbursement Rate
Alias: Outpatient Reimbursement Rate
Required if returned in the electronic remittance advice (835).
MOA02
782
Monetary Amount
O
R
Description: Monetary amount
Industry: HCPCS Payable Amount
Required if returned in the electronic remittance advice (835).
MOA03
127
Reference Identification
O
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Remark Code
Alias: Remarks Code
NSF Reference: DA3-18.0, DA3-19.0, DA3-20.0, DA3-21.0, DA3-22.0
Required if returned in the electronic remittance advice (835).
ExternalCodeList
Name: 411
Description: Remittance Remark Codes
MOA04
127
Reference Identification
O
AN
1/30
Situational
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Remark Code
Alias: Remarks Code
NSF Reference: DA3-18.0, DA3-19.0, DA3-20.0, DA3-21.0, DA3-22.0
Required if returned in the electronic remittance advice (835).
ExternalCodeList
Name: 411
Description: Remittance Remark Codes
MOA05
127
Reference Identification
O
AN
1/30
Situational
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Remark Code
837P_CG.ecs
234
For internal use only
12/1/2010
Ref
Health Care Claim: Professional - 837
Id
Element Name
Req
Type
Min/Max
Usage
Alias: Remarks Code
NSF Reference: DA3-18.0, DA3-19.0, DA3-20.0, DA3-21.0, DA3-22.0
Required if returned in the electronic remittance advice (835).
ExternalCodeList
Name: 411
Description: Remittance Remark Codes
MOA06
127
Reference Identification
O
AN
1/30
Situational
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Remark Code
Alias: Remarks Code
NSF Reference: DA3-18.0, DA3-19.0, DA3-20.0, DA3-21.0, DA3-22.0
Required if returned in the electronic remittance advice (835).
ExternalCodeList
Name: 411
Description: Remittance Remark Codes
MOA07
127
Reference Identification
O
AN
1/30
Situational
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Remark Code
Alias: Remarks Code
NSF Reference: DA3-18.0, DA3-19.0, DA3-20.0, DA3-21.0, DA3-22.0
Required if returned in the electronic remittance advice (835).
ExternalCodeList
Name: 411
Description: Remittance Remark Codes
MOA08
782
Monetary Amount
O
R
1/18
Situational
1/18
Situational
Description: Monetary amount
Industry: End Stage Renal Disease Payment Amount
Alias: ESRD Paid Amount
Required if returned in the electronic remittance advice (835).
MOA09
782
Monetary Amount
O
R
Description: Monetary amount
Industry: Non-Payable Professional Component Billed Amount
Alias: Professional Component
Required if returned in the electronic remittance advice (835).
Semantics:
1. MOA01 is the reimbursement rate.
2. MOA02 is the claim Health Care Financing Administration Common Procedural Coding System (HCPCS)
payable amount.
837P_CG.ecs
235
For internal use only
12/1/2010
3.
4.
5.
6.
7.
8.
9.
Health Care Claim: Professional - 837
MOA03 is the Claim Payment Remark Code. See Code Source 411.
MOA04 is the Claim Payment Remark Code. See Code Source 411.
MOA05 is the Claim Payment Remark Code. See Code Source 411.
MOA06 is the Claim Payment Remark Code. See Code Source 411.
MOA07 is the Claim Payment Remark Code. See Code Source 411.
MOA08 is the End Stage Renal Disease (ESRD) payment amount.
MOA09 is the professional component amount billed but not payable.
Notes:
1. Required if returned in the electronic remittance advice (835).
Example:
MOA***A4~
837P_CG.ecs
236
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 325
Loop Other Subscriber Name
Repeat: 1
Optional
Loop:
2330A
Elements: N/A
User Option (Usage): Required
Purpose: To supply the full name of an individual or organizational entity
Loop Summary:
Pos
Id
Segment Name
325
332
340
355
NM1
N3
N4
REF
Other
Other
Other
Other
Subscriber Name
Subscriber Address
Subscriber City/State/ZIP Code
Subscriber Secondary Identification
Req
Max Use
O
O
O
O
1
1
1
3
Repeat
Usage
Required
Situational
Situational
Situational
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
Notes:
1. Submitters are required to send information on all known other subscribers in Loop ID-2330.
2. This 2330 loop is required when Loop ID-2320 - Other Subscriber Information is used. Otherwise, this loop is
not used.
3. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.
Example:
NM1*IL*1*DOE*JOHN*T**JR*MI*123456~
837P_CG.ecs
237
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 325
NM1 Other Subscriber Name
Max: 1
Detail - Optional
Loop:
2330A
Elements: 8
User Option (Usage): Required
Purpose: To supply the full name of an individual or organizational entity
Element Summary:
Ref
Id
Element Name
NM101
98
Entity Identifier Code
Req
Type
Min/Max
Usage
M
ID
2/3
Required
Description: Code identifying an organizational entity, a physical location, property or an
individual
CodeList Summary (Total Codes: 1312, Included: 1)
Code Name
IL
NM102
1065
Insured or Subscriber
Entity Type Qualifier
M
ID
1/1
Required
AN
1/35
Required
Description: Code qualifying the type of entity
CodeList Summary (Total Codes: 14, Included: 2)
Code Name
1
2
NM103
1035
Person
Non-Person Entity
Name Last or Organization Name
O
Description: Individual last name or organizational name
Industry: Other Insured Last Name
Alias: Subscriber Last Name
NSF Reference: DA0-19.0
NM104
1036
Name First
O
AN
1/25
Situational
O
AN
1/25
Situational
Description: Individual first name
Industry: Other Insured First Name
Alias: Subscriber First Name
NSF Reference: DA0-20.0
Required if NM102=1 (person).
NM105
1037
Name Middle
Description: Individual middle name or initial
Industry: Other Insured Middle Name
Alias: Subscriber Middle Name
NSF Reference: DA0-21.0
Required if NM102=1 and the middle name/initial of the person is known.
NM107
1039
Name Suffix
O
AN
1/10
Situational
Description: Suffix to individual name
Industry: Other Insured Name Suffix
837P_CG.ecs
238
For internal use only
12/1/2010
Ref
Health Care Claim: Professional - 837
Id
Element Name
Req
Type
Min/Max
Usage
C
ID
1/2
Required
Alias: Subscriber Generation
NSF Reference: DA0-22.0
Required if known.
Examples: I, II, III, IV, Jr, Sr
NM108
66
Identification Code Qualifier
Description: Code designating the system/method of code structure used for Identification
Code (67)
CodeList Summary (Total Codes: 215, Included: 2)
Code Name
NM109
67
MI
Member Identification Number
The code MI is intended to be the subscriber’s identification number as assigned
by the payer. Payers use different terminology to convey the
same number. Therefore the 837 Professional Workgroup recommends using MI Member Identification Number to convey the following terms: Insured’s ID,
Subscriber’s ID, Health Insurance Claim Number (HIC), etc.
ZZ
Mutually Defined
The value ‘ZZ’, when used in this data element shall be defined as “HIPAA
Individual Identifier” once this identifier has been adopted. Under the Health
Insurance Portability and Accountability Act of 1996, the Secretary of the
Department of Health and Human Services must adopt a standard individual
identifier for use in this transaction.
Identification Code
C
AN
2/80
Required
Description: Code identifying a party or other code
Industry: Other Insured Identifier
Alias: Other Subscriber Primary Identifier
NSF Reference: DA0-18.0
Syntax Rules:
1. P0809 - If either NM108 or NM109 is present, then the other is required.
2. C1110 - If NM111 is present, then NM110 is required.
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
Notes:
1. Submitters are required to send information on all known other subscribers in Loop ID-2330.
2. This 2330 loop is required when Loop ID-2320 - Other Subscriber Information is used. Otherwise, this loop is
not used.
3. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.
Example:
NM1*IL*1*DOE*JOHN*T**JR*MI*123456~
837P_CG.ecs
239
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 332
N3 Other Subscriber Address
Max: 1
Detail - Optional
Loop:
2330A
Elements: 2
User Option (Usage): Situational
Purpose: To specify the location of the named party
Element Summary:
Ref
Id
Element Name
N301
166
Address Information
Req
Type
Min/Max
Usage
M
AN
1/55
Required
O
AN
1/55
Situational
Description: Address information
Industry: Other Insured Address Line
Alias: Subscriber Address 1
NSF Reference: DA2-04.0
N302
166
Address Information
Description: Address information
Industry: Other Insured Address Line
Alias: Subscriber Address 2
NSF Reference: DA2-05.0
Required if a second address line exists.
Notes:
1. Required when information is available.
2. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.
Example:
N3*4320 WASHINGTON ST*SUITE 100~
837P_CG.ecs
240
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 340
N4 Other Subscriber
Max: 1
Detail - Optional
City/State/ZIP Code
Loop:
2330A
Elements: 4
User Option (Usage): Situational
Purpose: To specify the geographic place of the named party
Element Summary:
Ref
Id
Element Name
N401
19
City Name
Req
Type
Min/Max
Usage
O
AN
2/30
Situational
O
ID
2/2
Situational
Description: Free-form text for city name
Industry: Other Insured City Name
Alias: Subscriber City Name
NSF Reference: DA2-06.0
Required when information is available.
N402
156
State or Province Code
Description: Code (Standard State/Province) as defined by appropriate government
agency
Industry: Other Insured State Code
Alias: Subscriber State Code
CODE SOURCE: 22: States and Outlying Areas of the U.S.
NSF Reference: DA2-07.0
Required when information is available.
ExternalCodeList
Name: 22
Description: States and Outlying Areas of the U.S.
N403
116
Postal Code
O
ID
3/15
Situational
Description: Code defining international postal zone code excluding punctuation and
blanks (zip code for United States)
Industry: Other Insured Postal Zone or ZIP Code
Alias: Subscriber Zip Code
CODE SOURCE: 51: ZIP Code
NSF Reference: DA2-08.0
Required when information is available.
ExternalCodeList
Name: 51
Description: ZIP Code
N404
26
Country Code
O
ID
2/3
Situational
Description: Code identifying the country
Alias: Subscriber Country Code
CODE SOURCE: 5: Countries, Currencies and Funds
Required if the address is out of the U.S.
837P_CG.ecs
241
For internal use only
12/1/2010
Ref
Health Care Claim: Professional - 837
Id
Element Name
Req
Type
Min/Max
Usage
ExternalCodeList
Name: 5
Description: Countries, Currencies and Funds
Syntax Rules:
1. C0605 - If N406 is present, then N405 is required.
Comments:
1. A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
2. N402 is required only if city name (N401) is in the U.S. or Canada.
Notes:
1. Required when information is available.
2. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.
Example:
N4*PALISADES*OR*23119~
837P_CG.ecs
242
For internal use only
12/1/2010
Health Care Claim: Professional - 837
REF Other Subscriber Secondary
Identification
Pos: 355
Max: 3
Detail - Optional
Loop:
2330A
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 4)
Code Name
REF02
127
1W
23
Member Identification Number
Client Number
This code is intended to be used only in claims submitted to the Indian Health
Service/Contract Health Services (IHC/CHS) Fiscal Intermediary for the purpose
of reporting the Health Record Number.
IG
SY
Insurance Policy Number
Social Security Number
The social security number may not be used for Medicare.
Reference Identification
C
AN
1/30
Required
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Other Insured Additional Identifier
Alias: Other Subscriber Secondary Identification
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. Required if additional identification numbers are necessary to adjudicate the claim/encounter.
2. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.
Example:
REF*SY*528446666~
837P_CG.ecs
243
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 325
Loop Other Payer Name
Repeat: 1
Optional
Loop:
2330B
Elements: N/A
User Option (Usage): Required
Purpose: To supply the full name of an individual or organizational entity
Loop Summary:
Pos
Id
Segment Name
325
345
350
355
355
NM1
PER
DTP
REF
REF
355
REF
Other Payer Name
Other Payer Contact Information
Claim Adjudication Date
Other Payer Secondary Identifier
Other Payer Prior Authorization or Referral
Number
Other Payer Claim Adjustment Indicator
Req
Max Use
Repeat
Usage
O
O
O
O
O
1
2
1
2
2
Required
Situational
Situational
Situational
Situational
O
2
Situational
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
Notes:
1. Submitters are required to send all known information on other payers in this Loop ID-2330.
2. This 2330 loop is required when Loop ID-2320 - Other Subscriber Information is used. Otherwise, this loop is
not used.
3. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.
Example:
NM1*PR*2*UNION MUTUAL OF OREGON*****PI*11122333~
837P_CG.ecs
244
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 325
NM1 Other Payer Name
Max: 1
Detail - Optional
Loop:
2330B
Elements: 5
User Option (Usage): Required
Purpose: To supply the full name of an individual or organizational entity
Element Summary:
Ref
Id
Element Name
NM101
98
Entity Identifier Code
Req
Type
Min/Max
Usage
M
ID
2/3
Required
Description: Code identifying an organizational entity, a physical location, property or an
individual
CodeList Summary (Total Codes: 1312, Included: 1)
Code Name
PR
NM102
1065
Payer
Entity Type Qualifier
M
ID
1/1
Required
AN
1/35
Required
1/2
Required
Description: Code qualifying the type of entity
CodeList Summary (Total Codes: 14, Included: 1)
Code Name
2
NM103
1035
Non-Person Entity
Name Last or Organization Name
O
Description: Individual last name or organizational name
Industry: Other Payer Last or Organization Name
Alias: Payer Name
NSF Reference: DA0-09.0
NM108
66
Identification Code Qualifier
C
ID
Description: Code designating the system/method of code structure used for Identification
Code (67)
CodeList Summary (Total Codes: 215, Included: 2)
Code Name
PI
XV
Payor Identification
Health Care Financing Administration National Payer Identification Number
(PAYERID)
CODE SOURCE:
540: Health Care Financing Administration National PlanID
NM109
67
Identification Code
C
AN
2/80
Required
Description: Code identifying a party or other code
Industry: Other Payer Primary Identifier
Alias: Other Payer Primary Identification Number
NSF Reference: DA0-07.0
This number must be identical to SVD01 (Loop ID-2430) for COB.
837P_CG.ecs
245
For internal use only
12/1/2010
Health Care Claim: Professional - 837
ExternalCodeList
Name: 540
Description: Health Care Financing Administration National PlanID
Syntax Rules:
1. P0809 - If either NM108 or NM109 is present, then the other is required.
2. C1110 - If NM111 is present, then NM110 is required.
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
Notes:
1. Submitters are required to send all known information on other payers in this Loop ID-2330.
2. This 2330 loop is required when Loop ID-2320 - Other Subscriber Information is used. Otherwise, this loop is
not used.
3. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.
Example:
NM1*PR*2*UNION MUTUAL OF OREGON*****PI*11122333~
837P_CG.ecs
246
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 345
PER Other Payer Contact
Max: 2
Detail - Optional
Information
Loop:
2330B
Elements: 8
User Option (Usage): Situational
Purpose: To identify a person or office to whom administrative communications should be directed
Element Summary:
Ref
Id
Element Name
PER01
366
Contact Function Code
Req
Type
Min/Max
Usage
M
ID
2/2
Required
Description: Code identifying the major duty or responsibility of the person or group
named
CodeList Summary (Total Codes: 230, Included: 1)
Code Name
IC
PER02
93
Information Contact
Name
O
AN
1/60
Required
C
ID
2/2
Required
Description: Free-form name
Industry: Other Payer Contact Name
PER03
365
Communication Number Qualifier
Description: Code identifying the type of communication number
CodeList Summary (Total Codes: 40, Included: 4)
Code Name
ED
EM
FX
TE
PER04
364
Electronic Data Interchange Access Number
Electronic Mail
Facsimile
Telephone
Communication Number
C
AN
1/80
Required
Description: Complete communications number including country or area code when
applicable
PER05
365
Communication Number Qualifier
C
ID
2/2
Situational
Description: Code identifying the type of communication number
Used at the discretion of the submitter.
CodeList Summary (Total Codes: 40, Included: 5)
Code Name
ED
EM
EX
FX
TE
PER06
364
Electronic Data Interchange Access Number
Electronic Mail
Telephone Extension
Facsimile
Telephone
Communication Number
C
AN
1/80
Situational
Description: Complete communications number including country or area code when
837P_CG.ecs
247
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Ref
Id
Element Name
applicable
Used at the discretion of the submitter.
PER07
365
Communication Number Qualifier
Req
Type
Min/Max
Usage
C
ID
2/2
Situational
Description: Code identifying the type of communication number
Used at the discretion of the submitter.
CodeList Summary (Total Codes: 40, Included: 5)
Code Name
ED
EM
EX
FX
TE
PER08
364
Electronic Data Interchange Access Number
Electronic Mail
Telephone Extension
Facsimile
Telephone
Communication Number
C
AN
1/80
Situational
Description: Complete communications number including country or area code when
applicable
Used at the discretion of the submitter.
Syntax Rules:
1. P0304 - If either PER03 or PER04 is present, then the other is required.
2. P0506 - If either PER05 or PER06 is present, then the other is required.
3. P0708 - If either PER07 or PER08 is present, then the other is required.
Notes:
1. This segment is used only in payer-to-payer COB situations. This segment may be completed by a payer who
has adjudicated the claim and is passing it on to a secondary payer. It is not completed by submitting providers.
2. 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 should 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 (e.g., (534) 224-2525 would be represented as
5342242525). The extension, when applicable, should be included in the communication number immediately
after the telephone number.
3. There are 2 repetitions of the PER segment to allow for six possible combination of communication numbers
including extensions.
Example:
PER*IC*SHELLY*TE*5552340000~
837P_CG.ecs
248
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 350
DTP Claim Adjudication Date
Max: 1
Detail - Optional
Loop:
2330B
Elements: 3
User Option (Usage): Situational
Purpose: To specify any or all of a date, a time, or a time period
Element Summary:
Ref
Id
Element Name
DTP01
374
Date/Time Qualifier
Req
Type
Min/Max
Usage
M
ID
3/3
Required
Description: Code specifying type of date or time, or both date and time
Industry: Date Time Qualifier
CodeList Summary (Total Codes: 1112, Included: 1)
Code Name
573
DTP02
1250
Date Claim Paid
Date Time Period Format Qualifier
M
ID
2/3
Required
Description: Code indicating the date format, time format, or date and time format
CodeList Summary (Total Codes: 39, Included: 1)
Code Name
D8
DTP03
1251
Date Expressed in Format CCYYMMDD
Date Time Period
M
AN
1/35
Required
Description: Expression of a date, a time, or range of dates, times or dates and times
Industry: Adjudication or Payment Date
NSF Reference: DA1-27.0
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
Notes:
1. This segment is required when the payer identified in this iteration of the 2330 loop has previously adjudicated
the claim and Loop-ID 2430 (Line Adjudication Information) is not used.
Example:
DTP*573*D8*19980314~
837P_CG.ecs
249
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 355
REF Other Payer Secondary
Max: 2
Detail - Optional
Identifier
Loop:
2330B
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 5)
Code Name
2U
F8
Payer Identification Number
Original Reference Number
Use to indicate the payer’s claim number for this claim for the payer identified in
this iteration of the 2330B loop.
FY
NF
Claim Office Number
National Association of Insurance Commissioners (NAIC) Code
CODE SOURCE:
TJ
Federal Taxpayer's Identification Number
245: National Association of Insurance Commissioners (NAIC) Code
REF02
127
Reference Identification
C
AN
1/30
Required
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Other Payer Secondary Identifier
NSF Reference: DA3-29.0
The DA3-29.0 crosswalk is only used in payer-to-payer COB situations.
ExternalCodeList
Name: 245
Description: National Association of Insurance Commissioners (NAIC) Code
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. Required when a secondary identification number is necessary to identify the entity. The primary identification
number should be carried in NM109 in this loop.
2. Used when it is necessary to identify the ’other’ payer’s claim number in a payer-to-payer COB situation (use
code F8). Code F8 is not used by providers.
3. There can only be a maximum of three REF segments in any one iteration of the 2330 loop.
4. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.
Example:
837P_CG.ecs
250
For internal use only
12/1/2010
Health Care Claim: Professional - 837
REF*FY*435261708~
837P_CG.ecs
251
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 355
REF Other Payer Prior
Max: 2
Detail - Optional
Authorization or Referral
Number
Loop:
2330B
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
1/30
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 2)
Code Name
9F
G1
REF02
127
Referral Number
Prior Authorization Number
Reference Identification
C
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Other Payer Prior Authorization or Referral Number
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. Used when the payer identified in this loop has given a prior authorization or referral number to this claim. This
element is primarily used in payer-to-payer COB situations.
2. There can only be a maximum of three REF segments in any one iteration of the 2330 loop.
3. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.
Example:
REF*G1*AB333-Y5~
837P_CG.ecs
252
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 355
REF Other Payer Claim
Max: 2
Detail - Optional
Adjustment Indicator
Loop:
2330B
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
1/30
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 1)
Code Name
T4
REF02
127
Signal Code
Reference Identification
C
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Other Payer Claim Adjustment Indicator
NSF Reference: DA3-24.0
Allowable values are “Y” indicating that the payer in this loop has previously adjudicated
this claim and sent a record of that adjudication to the destination payer identified in the
2010BB loop. The claim being transmitted in this iteration of the 2300 loop is a
re-adjudicated version of that claim.
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. Used only in payer-to-payer COB. In that situation, the destination payer is secondary to the payer identified in
this loop. Providers/other submitters do not use this segment.
2. Required when the payer identified in this loop has previously paid this claim and has indicated so to the
destination payer. In this case the payer identified in this loop has readjudicated the claim and is sending the
adjusted payment information to the destination payer. This REF segment is used to indicate that this claim is an
adjustment of a previously adjudicated claim. If the claim has not been previously adjudicated this REF is not
used.
3. There can only be a maximum of three REF segments in any one iteration of the 2330 loop.
Example:
REF*T4*Y~
837P_CG.ecs
253
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 325
Loop Other Payer Patient
Information
Repeat: 1
Optional
Loop:
2330C
Elements: N/A
User Option (Usage): Situational
Purpose: To supply the full name of an individual or organizational entity
Loop Summary:
Pos
Id
Segment Name
325
355
NM1
REF
Other Payer Patient Information
Other Payer Patient Identification
Req
Max Use
O
O
1
3
Repeat
Usage
Situational
Situational
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
Notes:
1. Required when it is necessary, in COB situations, to send one or more payer-specific patient identification
numbers. The patient identification number(s) carried in this iteration of the 2330 loop are those patient ID’s which
belong to non-destination (COB) payers. The patient ID(s) forr the destination payer are carried in the 2010CA
loop NM1 and REF segments. See Section 1.4.5 Crosswalking COB Data Elements for more information on
handling non-destination payer patient identifiers and other COB elements.
2. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,
then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.
Example:
NM1*QC*1******MI*6677U801~
837P_CG.ecs
254
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 325
NM1 Other Payer Patient
Max: 1
Detail - Optional
Information
Loop:
2330C
Elements: 4
User Option (Usage): Situational
Purpose: To supply the full name of an individual or organizational entity
Element Summary:
Ref
Id
Element Name
NM101
98
Entity Identifier Code
Req
Type
Min/Max
Usage
M
ID
2/3
Required
Description: Code identifying an organizational entity, a physical location, property or an
individual
CodeList Summary (Total Codes: 1312, Included: 1)
Code Name
QC
NM102
1065
Patient
Entity Type Qualifier
M
ID
1/1
Required
ID
1/2
Required
Description: Code qualifying the type of entity
CodeList Summary (Total Codes: 14, Included: 1)
Code Name
1
NM108
66
Person
Identification Code Qualifier
C
Description: Code designating the system/method of code structure used for Identification
Code (67)
CodeList Summary (Total Codes: 215, Included: 1)
Code Name
MI
NM109
67
Member Identification Number
The code MI is intended to be the subscriber’s identification number as assigned
by the payer. Payers use different terminology to convey the
same number. Therefore the 837 Professional Workgroup recommends using MI Member Identification Number to convey the following terms: Insured’s ID,
Subscriber’s ID, Health Insurance Claim Number (HIC), etc.
Identification Code
C
AN
2/80
Required
Description: Code identifying a party or other code
Industry: Other Payer Patient Primary Identifier
Alias: Patient’s Other Payer Primary Identification Number
Syntax Rules:
1. P0809 - If either NM108 or NM109 is present, then the other is required.
2. C1110 - If NM111 is present, then NM110 is required.
Semantics:
1. NM102 qualifies NM103.
Comments:
837P_CG.ecs
255
For internal use only
12/1/2010
Health Care Claim: Professional - 837
1. NM110 and NM111 further define the type of entity in NM101.
Notes:
1. Required when it is necessary, in COB situations, to send one or more payer-specific patient identification
numbers. The patient identification number(s) carried in this iteration of the 2330 loop are those patient ID’s which
belong to non-destination (COB) payers. The patient ID(s) forr the destination payer are carried in the 2010CA
loop NM1 and REF segments. See Section 1.4.5 Crosswalking COB Data Elements for more information on
handling non-destination payer patient identifiers and other COB elements.
2. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,
then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.
Example:
NM1*QC*1******MI*6677U801~
837P_CG.ecs
256
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 355
REF Other Payer Patient
Max: 3
Detail - Optional
Identification
Loop:
2330C
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 4)
Code Name
REF02
127
1W
Member Identification Number
If NM108 = M1 do not use this code.
23
Client Number
This code is intended to be used only in claims submitted to the Indian Health
Service/Contract Health Services (IHC/CHS) Fiscal Intermediary for the purpose
of reporting the Health Record Number.
IG
SY
Insurance Policy Number
Social Security Number
Do not use for Medicare.
Reference Identification
C
AN
1/30
Required
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Other Payer Patient Secondary Identifier
Alias: Patient’s Other Payer Secondary Identifier
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. Used when a COB payer (listed in 2330B loop) has one or more proprietary patient identification numbers for
this claim. The patient (name, DOB, etc) is identified in the 2010BA or 2010CA loop.
2. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.
Example:
REF*AZ*B333-Y5~
837P_CG.ecs
257
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 325
Loop Other Payer Referring
Provider
Repeat: 2
Optional
Loop:
2330D
Elements: N/A
User Option (Usage): Situational
Purpose: To supply the full name of an individual or organizational entity
Loop Summary:
Pos
Id
Segment Name
325
355
NM1
REF
Other Payer Referring Provider
Other Payer Referring Provider
Identification
Req
Max Use
O
O
1
3
Repeat
Usage
Situational
Required
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
Notes:
1. Used when it is necessary to send an additional payer-specific provider identification number for
non-destination (COB) payers.
2. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,
then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.
3. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.
Example:
NM1*DN*1~
837P_CG.ecs
258
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 325
NM1 Other Payer Referring
Max: 1
Detail - Optional
Provider
Loop:
2330D
Elements: 2
User Option (Usage): Situational
Purpose: To supply the full name of an individual or organizational entity
Element Summary:
Ref
Id
Element Name
NM101
98
Entity Identifier Code
Req
Type
Min/Max
Usage
M
ID
2/3
Required
Description: Code identifying an organizational entity, a physical location, property or an
individual
CodeList Summary (Total Codes: 1312, Included: 2)
Code Name
NM102
1065
DN
Referring Provider
Use on first iteration of this loop. Use if loop is used only once.
P3
Primary Care Provider
Use only if loop is used twice. Use only on second iteration of this loop.
Entity Type Qualifier
M
ID
1/1
Required
Description: Code qualifying the type of entity
CodeList Summary (Total Codes: 14, Included: 2)
Code Name
1
2
Person
Non-Person Entity
Syntax Rules:
1. P0809 - If either NM108 or NM109 is present, then the other is required.
2. C1110 - If NM111 is present, then NM110 is required.
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
Notes:
1. Used when it is necessary to send an additional payer-specific provider identification number for
non-destination (COB) payers.
2. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,
then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.
3. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.
Example:
NM1*DN*1~
837P_CG.ecs
259
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 355
REF Other Payer Referring
Max: 3
Detail - Optional
Provider Identification
Loop:
2330D
Elements: 2
User Option (Usage): Required
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
1/30
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 7)
Code Name
1B
1C
1D
EI
G2
LU
N5
REF02
127
Blue Shield Provider Number
Medicare Provider Number
Medicaid Provider Number
Employer's Identification Number
Provider Commercial Number
Location Number
Provider Plan Network Identification Number
Reference Identification
C
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Other Payer Referring Provider Identifier
Alias: Other Payer Referring Provider Identification
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. Non-destination (COB) payers’ provider identification number(s).
2. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.
Example:
REF*N5*RF446~
837P_CG.ecs
260
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 325
Loop Other Payer Rendering
Provider
Repeat: 1
Optional
Loop:
2330E
Elements: N/A
User Option (Usage): Situational
Purpose: To supply the full name of an individual or organizational entity
Loop Summary:
Pos
Id
Segment Name
325
355
NM1
REF
Other Payer Rendering Provider
Other Payer Rendering Provider
Secondary Identification
Req
Max Use
O
O
1
3
Repeat
Usage
Situational
Required
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
Notes:
1. Used when it is necessary to send an additional payer-specific provider identification number for
non-destination (COB) payers.
2. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,
then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.
3. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.
Example:
NM1*82*1~
837P_CG.ecs
261
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 325
NM1 Other Payer Rendering
Max: 1
Detail - Optional
Provider
Loop:
2330E
Elements: 2
User Option (Usage): Situational
Purpose: To supply the full name of an individual or organizational entity
Element Summary:
Ref
Id
Element Name
NM101
98
Entity Identifier Code
Req
Type
Min/Max
Usage
M
ID
2/3
Required
Description: Code identifying an organizational entity, a physical location, property or an
individual
CodeList Summary (Total Codes: 1312, Included: 1)
Code Name
82
NM102
1065
Rendering Provider
Entity Type Qualifier
M
ID
1/1
Required
Description: Code qualifying the type of entity
CodeList Summary (Total Codes: 14, Included: 2)
Code Name
1
2
Person
Non-Person Entity
Syntax Rules:
1. P0809 - If either NM108 or NM109 is present, then the other is required.
2. C1110 - If NM111 is present, then NM110 is required.
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
Notes:
1. Used when it is necessary to send an additional payer-specific provider identification number for
non-destination (COB) payers.
2. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,
then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.
3. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.
Example:
NM1*82*1~
837P_CG.ecs
262
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 355
REF Other Payer Rendering
Max: 3
Detail - Optional
Provider Secondary
Identification
Loop:
2330E
Elements: 2
User Option (Usage): Required
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
1/30
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 7)
Code Name
1B
1C
1D
EI
G2
LU
N5
REF02
127
Blue Shield Provider Number
Medicare Provider Number
Medicaid Provider Number
Employer's Identification Number
Provider Commercial Number
Location Number
Provider Plan Network Identification Number
Reference Identification
C
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Other Payer Rendering Provider Secondary Identifier
Other Payer Rendering Provider Secondary Identification
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. Non-destination (COB) payers’ provider identification number(s).
2. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.
Example:
REF*LU*SLC987~
837P_CG.ecs
263
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 325
Loop Other Payer Purchased
Service Provider
Repeat: 1
Optional
Loop:
2330F
Elements: N/A
User Option (Usage): Situational
Purpose: To supply the full name of an individual or organizational entity
Loop Summary:
Pos
Id
Segment Name
325
355
NM1
REF
Other Payer Purchased Service Provider
Other Payer Purchased Service Provider
Identification
Req
Max Use
O
O
1
3
Repeat
Usage
Situational
Required
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
Notes:
1. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,
then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.
2. Used when it is necessary to send an additional payer-specific provider identification number for
non-destination (COB) payers.
3. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.
Example:
NM1*QB*2~
837P_CG.ecs
264
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 325
NM1 Other Payer Purchased
Max: 1
Detail - Optional
Service Provider
Loop:
2330F
Elements: 2
User Option (Usage): Situational
Purpose: To supply the full name of an individual or organizational entity
Element Summary:
Ref
Id
Element Name
NM101
98
Entity Identifier Code
Req
Type
Min/Max
Usage
M
ID
2/3
Required
Description: Code identifying an organizational entity, a physical location, property or an
individual
CodeList Summary (Total Codes: 1312, Included: 1)
Code Name
QB
NM102
1065
Purchase Service Provider
Entity Type Qualifier
M
ID
1/1
Required
Description: Code qualifying the type of entity
CodeList Summary (Total Codes: 14, Included: 2)
Code Name
1
2
Person
Non-Person Entity
Syntax Rules:
1. P0809 - If either NM108 or NM109 is present, then the other is required.
2. C1110 - If NM111 is present, then NM110 is required.
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
Notes:
1. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,
then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.
2. Used when it is necessary to send an additional payer-specific provider identification number for
non-destination (COB) payers.
3. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.
Example:
NM1*QB*2~
837P_CG.ecs
265
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 355
REF Other Payer Purchased
Max: 3
Detail - Optional
Service Provider
Identification
Loop:
2330F
Elements: 2
User Option (Usage): Required
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
1/30
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 8)
Code Name
1A
1B
1C
1D
EI
G2
LU
N5
REF02
127
Blue Cross Provider Number
Blue Shield Provider Number
Medicare Provider Number
Medicaid Provider Number
Employer's Identification Number
Provider Commercial Number
Location Number
Provider Plan Network Identification Number
Reference Identification
C
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Other Payer Purchased Service Provider Identifier
Other Payer Purchased Service Provider Identification
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. Non-destination (COB) payers’ provider identification number(s).
2. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.
Example:
REF*G2*8893U21~
837P_CG.ecs
266
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 325
Loop Other Payer Service Facility
Location
Repeat: 1
Optional
Loop:
2330G
Elements: N/A
User Option (Usage): Situational
Purpose: To supply the full name of an individual or organizational entity
Loop Summary:
Pos
Id
Segment Name
325
355
NM1
REF
Other Payer Service Facility Location
Other Payer Service Facility Location
Identification
Req
Max Use
O
O
1
3
Repeat
Usage
Situational
Required
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
Notes:
1. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,
then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.
2. Used when it is necessary to send an additional payer-specific provider identification number for
non-destination (COB) payers.
3. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.
Example:
NM1*TL*2~
837P_CG.ecs
267
For internal use only
12/1/2010
Health Care Claim: Professional - 837
NM1 Other Payer Service Facility
Location
Pos: 325
Max: 1
Detail - Optional
Loop:
2330G
Elements: 2
User Option (Usage): Situational
Purpose: To supply the full name of an individual or organizational entity
Element Summary:
Ref
Id
Element Name
NM101
98
Entity Identifier Code
Req
Type
Min/Max
Usage
M
ID
2/3
Required
Description: Code identifying an organizational entity, a physical location, property or an
individual
CodeList Summary (Total Codes: 1312, Included: 4)
Code Name
NM102
1065
77
Service Location
Use when other codes in this element do not apply.
FA
LI
TL
Facility
Independent Lab
Testing Laboratory
Entity Type Qualifier
M
ID
1/1
Required
Description: Code qualifying the type of entity
CodeList Summary (Total Codes: 14, Included: 1)
Code Name
2
Non-Person Entity
Syntax Rules:
1. P0809 - If either NM108 or NM109 is present, then the other is required.
2. C1110 - If NM111 is present, then NM110 is required.
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
Notes:
1. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,
then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.
2. Used when it is necessary to send an additional payer-specific provider identification number for
non-destination (COB) payers.
3. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.
Example:
NM1*TL*2~
837P_CG.ecs
268
For internal use only
12/1/2010
Health Care Claim: Professional - 837
REF Other Payer Service Facility
Location Identification
Pos: 355
Max: 3
Detail - Optional
Loop:
2330G
Elements: 2
User Option (Usage): Required
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
1/30
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 7)
Code Name
1A
1B
1C
1D
G2
LU
N5
REF02
127
Blue Cross Provider Number
Blue Shield Provider Number
Medicare Provider Number
Medicaid Provider Number
Provider Commercial Number
Location Number
Provider Plan Network Identification Number
Reference Identification
C
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Other Payer Service Facility Location Identifier
Alias: Other Payer Service Facility Location Identification
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. Non-destination (COB) payers’ provider identification number(s).
2. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.
Example:
REF*G2*LAB1234~
837P_CG.ecs
269
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 325
Loop Other Payer Supervising
Provider
Repeat: 1
Optional
Loop:
2330H
Elements: N/A
User Option (Usage): Situational
Purpose: To supply the full name of an individual or organizational entity
Loop Summary:
Pos
Id
Segment Name
325
355
NM1
REF
Other Payer Supervising Provider
Other Payer Supervising Provider
Identification
Req
Max Use
O
O
1
3
Repeat
Usage
Situational
Required
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
Notes:
1. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,
then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.
2. Used when it is necessary to send an additional payer-specific provider identification number for
non-destination (COB) payers.
3. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.
Example:
NM1*DQ*1~
837P_CG.ecs
270
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 325
NM1 Other Payer Supervising
Max: 1
Detail - Optional
Provider
Loop:
2330H
Elements: 2
User Option (Usage): Situational
Purpose: To supply the full name of an individual or organizational entity
Element Summary:
Ref
Id
Element Name
NM101
98
Entity Identifier Code
Req
Type
Min/Max
Usage
M
ID
2/3
Required
Description: Code identifying an organizational entity, a physical location, property or an
individual
CodeList Summary (Total Codes: 1312, Included: 1)
Code Name
DQ
NM102
1065
Supervising Physician
Entity Type Qualifier
M
ID
1/1
Required
Description: Code qualifying the type of entity
CodeList Summary (Total Codes: 14, Included: 1)
Code Name
1
Person
Syntax Rules:
1. P0809 - If either NM108 or NM109 is present, then the other is required.
2. C1110 - If NM111 is present, then NM110 is required.
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
Notes:
1. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,
then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.
2. Used when it is necessary to send an additional payer-specific provider identification number for
non-destination (COB) payers.
3. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.
Example:
NM1*DQ*1~
837P_CG.ecs
271
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 355
REF Other Payer Supervising
Max: 3
Detail - Optional
Provider Identification
Loop:
2330H
Elements: 2
User Option (Usage): Required
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
1/30
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 6)
Code Name
1B
1C
1D
EI
G2
N5
REF02
127
Blue Shield Provider Number
Medicare Provider Number
Medicaid Provider Number
Employer's Identification Number
Provider Commercial Number
Provider Plan Network Identification Number
Reference Identification
C
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Other Payer Supervising Provider Identifier
Alias: Other Payer Supervising Provider Identification
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. Non-destination (COB) payers’ provider identification number(s).
2. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.
Example:
REF*G2*53334~
837P_CG.ecs
272
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 365
Loop Service Line
Repeat: 50
Optional
Loop: 2400 Elements: N/A
User Option (Usage): Required
Purpose: To reference a line number in a transaction set
Loop Summary:
Pos
Id
Segment Name
365
370
400
420
425
430
435
445
450
450
450
455
455
455
455
455
455
455
LX
SV1
SV5
PWK
CR1
CR2
CR3
CR5
CRC
CRC
CRC
DTP
DTP
DTP
DTP
DTP
DTP
DTP
455
455
455
455
455
455
462
465
470
470
DTP
DTP
DTP
DTP
DTP
DTP
MEA
CN1
REF
REF
470
470
470
470
REF
REF
REF
REF
470
REF
470
470
470
REF
REF
REF
Service Line
Professional Service
Durable Medical Equipment Service
DMERC CMN Indicator
Ambulance Transport Information
Spinal Manipulation Service Information
Durable Medical Equipment Certification
Home Oxygen Therapy Information
Ambulance Certification
Hospice Employee Indicator
DMERC Condition Indicator
Date - Service Date
Date - Certification Revision Date
Date - Begin Therapy Date
Date - Last Certification Date
Date - Date Last Seen
Date - Test
Date - Oxygen Saturation/Arterial Blood
Gas Test
Date - Shipped
Date - Onset of Current Symptom/Illness
Date - Last X-ray
Date - Acute Manifestation
Date - Initial Treatment
Date - Similar Illness/Symptom Onset
Test Result
Contract Information
Repriced Line Item Reference Number
Adjusted Repriced Line Item Reference
Number
Prior Authorization or Referral Number
Line Item Control Number
Mammography Certification Number
Clinical Laboratory Improvement
Amendment (CLIA) Identification
Referring Clinical Laboratory Improvement
Amendment (CLIA) Facility Identification
Immunization Batch Number
Ambulatory Patient Group (APG)
Oxygen Flow Rate
837P_CG.ecs
273
Req
Max Use
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
1
1
1
1
1
5
1
1
3
1
2
1
1
1
1
1
2
3
Repeat
Required
Required
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Required
Situational
Situational
Situational
Situational
Situational
Situational
Usage
O
O
O
O
O
O
O
O
O
O
1
1
1
1
1
1
20
1
1
1
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
O
O
O
O
2
1
1
1
Situational
Situational
Situational
Situational
O
1
Situational
O
O
O
1
4
1
Situational
Situational
Situational
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos
Id
Segment Name
470
475
475
475
480
485
488
491
492
494
500
500
500
500
500
500
500
540
551
REF
AMT
AMT
AMT
K3
NTE
PS1
HSD
HCP
Universal Product Number (UPN)
Sales Tax Amount
Approved Amount
Postage Claimed Amount
File Information
Line Note
Purchased Service Information
Health Care Services Delivery
Line Pricing/Repricing Information
Loop 2410
Loop 2420A
Loop 2420B
Loop 2420C
Loop 2420D
Loop 2420E
Loop 2420F
Loop 2420G
Loop 2430
Loop 2440
Req
Max Use
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
1
1
1
1
10
1
1
1
1
Repeat
Usage
25
1
1
1
1
1
2
4
25
5
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Notes:
1. The Service Line LX segment begins with 1 and is incremented by one for each additional service line of a
claim. The LX functions as a line counter.
2. The datum in the LX is not usually returned in the 835 (Remittance Advice) transaction. LX01 may be used as
a line item control number by the payer in the 835 if a line item control number has not been submitted on the
service line. See that REF for more information. LX01 is used to indicate bundling/unbundling in SVC06. See
Section 1.4.3 for more information on bundling and unbundling.
3. Because this is a required segment, this is a required loop. See Appendix A for further details on ASC X12
syntax rules.
Example:
LX*1~
837P_CG.ecs
274
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 365
LX Service Line
Max: 1
Detail - Optional
Loop: 2400
Elements: 1
User Option (Usage): Required
Purpose: To reference a line number in a transaction set
Element Summary:
Ref
Id
Element Name
LX01
554
Assigned Number
Req
Type
Min/Max
Usage
M
N0
1/6
Required
Description: Number assigned for differentiation within a transaction set
Alias: Line Counter
NSF Reference: FA0-02.0, FB0-02.0, FB1-02.0, GA0-02.0, GC0-02.0, GX0-02.0, GX2-02.
0, HA0-02.0, FB2-02.0, GU0-02.0
The service line number incremented by 1 for each service line.
Notes:
1. The Service Line LX segment begins with 1 and is incremented by one for each additional service line of a
claim. The LX functions as a line counter.
2. The datum in the LX is not usually returned in the 835 (Remittance Advice) transaction. LX01 may be used as
a line item control number by the payer in the 835 if a line item control number has not been submitted on the
service line. See that REF for more information. LX01 is used to indicate bundling/unbundling in SVC06. See
Section 1.4.3 for more information on bundling and unbundling.
3. Because this is a required segment, this is a required loop. See Appendix A for further details on ASC X12
syntax rules.
Example:
LX*1~
837P_CG.ecs
275
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 370
SV1 Professional Service
Max: 1
Detail - Optional
Loop: 2400
Elements: 10
User Option (Usage): Required
Purpose: To specify the claim service detail for a Health Care professional
Element Summary:
Ref
Id
Element Name
SV101
C003
Composite Medical Procedure
Identifier
Req
Type
M
Comp
Min/Max
Usage
Required
Description: To identify a medical procedure by its standardized codes and applicable
modifiers
Alias: Procedure identifier
User Note 6:
Codes: HC, IV, N1, N2, N3, N4, ZZ
User Note 7:
BSC can accept N4 only in 'nonaddenda' submissions and HC in both '"non-addenda' and
'addenda' submissions. Codes: HC, N4
SV101-01
235
Product/Service ID Qualifier
M
ID
2/2
Required
Description: Code identifying the type/source of the descriptive number used in
Product/Service ID (234)
Industry: Product or Service ID Qualifier
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.
User Note 6:
Home infusion services and drug claims can be billed on the 837 professional electronic
claims transaction using the following guidelines:
. Report the appropriate J code in the service line of the claim (loop 2400 SV101-1)
. Report date of service in the service line (loop 2400 DTP03)
. Report name of drug in service line notes (loop 2400 NTE-2)
Refer to further notes under Loop 2410
CodeList Summary (Total Codes: 477, Included: 3)
Code Name
HC
Health Care Financing Administration Common Procedural Coding System
(HCPCS) Codes
Because the AMA’s CPT codes are also level 1 HCPCS codes, they are reported
under HC.
CODE SOURCE:
130: Health Care Financing Administration Common Procedural Coding System
IV
837P_CG.ecs
Home Infusion EDI Coalition (HIEC) Product/Service Code
This code set is not allowed for use under HIPAA at the time of this writing. The
qualifier can only be used:
1) If a new rule names HIEC as an allowable code set under HIPAA.
2) For Property & Casualty claims/encounters that are not covered under HIPAA.
276
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Code Name
CODE SOURCE:
513: Home Infusion EDI Coalition (HIEC) Product/Service Code List
ZZ
SV101-02
234
Mutually Defined
Jurisdictionally Defined Procedure and Supply Codes. (Used for Worker’s
Compensation claims). Contact your local (State) Jurisdiction for a list of these
codes.
Product/Service ID
M
AN
1/48
Required
Description: Identifying number for a product or service
Industry: Procedure Code
NSF Reference: FA0-09.0, FB0-15.0, GU0-07.0
User Note 6:
• Use J codes for home infusion/drugs.
• BSC can accept NDC Codes in this element for 'non-addenda' submissions and in Loop
2410 of 'addenda' submissions.
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
SV101-03
1339
Procedure Modifier
O
AN
2/2
Situational
Description: This identifies special circumstances related to the performance of the
service, as defined by trading partners
Alias: Procedure Modifier 1
NSF Reference: FA0-10.0, GU0-08.0
Use this modifier for the first procedure code modifier.
Required when a modifier clarifies/improves the reporting accuracy of the associated
procedure code.
User Note 6:
• With the exception of members in National Account and Medicare Risk groups, BSC can
take adjudicative action on only the first modifier received, SV202-3, for anesthesia
services. Claims including anesthesia services for members in National Account groups
require submission of both the HCPCS and CPT modifiers appropriate for the anesthesia
service provided. i.e. both SV202-3 and SV202-4 should be populated.
• SV202-3 is required on all ambulance services using the appropriate origin and
destination codes.
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
SV101-04
1339
Procedure Modifier
O
AN
2/2
Situational
Description: This identifies special circumstances related to the performance of the
service, as defined by trading partners
837P_CG.ecs
277
For internal use only
12/1/2010
Ref
Health Care Claim: Professional - 837
Id
Element Name
Alias: Procedure Modifier 2
Req
Type
Min/Max
Usage
NSF Reference: FA0-11.0
Use this modifier for the second procedure code modifier.
Required when a modifier clarifies/improves the reporting accuracy of the associated
procedure code.
User Note 6:
• With the exception of members in National Account and Medicare Risk groups, BSC can
take adjudicative action on only the first modifier received, SV202-3, for anesthesia
services. Claims including anesthesia services for members in National Account groups
require submission of both the HCPCS and CPT modifiers appropriate for the anesthesia
service provided. i.e. both SV202-3 and SV202-4 should be populated.
• SV202-3 is required on all ambulance services using the appropriate origin and
destination codes.
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
SV101-05
1339
Procedure Modifier
O
AN
2/2
Situational
Description: This identifies special circumstances related to the performance of the
service, as defined by trading partners
Alias: Procedure Modifier 3
NSF Reference: FA0-12.0
Use this modifier for the third procedure code modifier.
Required when a modifier clarifies/improves the reporting accuracy of the associated
procedure code.
User Note 6:
• With the exception of members in National Account and Medicare Risk groups, BSC can
take adjudicative action on only the first modifier received, SV202-3, for anesthesia
services. Claims including anesthesia services for members in National Account groups
require submission of both the HCPCS and CPT modifiers appropriate for the anesthesia
service provided. i.e. both SV202-3 and SV202-4 should be populated.
• SV202-3 is required on all ambulance services using the appropriate origin and
destination codes.
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
SV101-06
1339
Procedure Modifier
O
AN
2/2
Situational
Description: This identifies special circumstances related to the performance of the
service, as defined by trading partners
Alias: Procedure Modifier 4
NSF Reference: FA0-36.0
837P_CG.ecs
278
For internal use only
12/1/2010
Ref
Health Care Claim: Professional - 837
Id
Element Name
Req
Type
Min/Max
Usage
Use this modifier for the fourth procedure code modifier.
Required when a modifier clarifies/improves the reporting accuracy of the associated
procedure code.
User Note 6:
• With the exception of members in National Account and Medicare Risk groups, BSC can
take adjudicative action on only the first modifier received, SV202-3, for anesthesia
services. Claims including anesthesia services for members in National Account groups
require submission of both the HCPCS and CPT modifiers appropriate for the anesthesia
service provided. i.e. both SV202-3 and SV202-4 should be populated.
• SV202-3 is required on all ambulance services using the appropriate origin and
destination codes.
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
SV102
782
Monetary Amount
O
R
1/18
Required
2/2
Required
Description: Monetary amount
Industry: Line Item Charge Amount
Alias: Submitted charge amount
NSF Reference: FA0-13.0
For encounter transmissions, zero (0) may be a valid amount.
SV103
355
Unit or Basis for Measurement Code
C
ID
Description: Code specifying the units in which a value is being expressed, or manner in
which a measurement has been taken
NSF Reference: FA0-50.0
FA0-50.0 is only used in Medicare COB payer-to-payer situations.
CodeList Summary (Total Codes: 794, Included: 3)
Code Name
SV104
380
F2
International Unit
International Unit is used to indicate dosage amount. Dosage amount is only used
for drug claims when the dosage of the drug is variable within a single NDC
number (e.g., blood factors).
MJ
UN
Minutes
Unit
Quantity
C
R
1/15
Required
Description: Numeric value of quantity
Industry: Service Unit Count
Alias: Units or Minutes
NSF Reference: FA0-18.0, FA0-19.0, FB0-16.0
Note: If a decimal is needed to report units, include it in this element, e.g., “15.6".
SV105
837P_CG.ecs
1331
Facility Code Value
O
279
AN
1/2
Situational
For internal use only
12/1/2010
Ref
Health Care Claim: Professional - 837
Id
Element Name
Req
Type
Min/Max
Usage
Description: Code identifying the type of facility where services were performed; the first
and second positions of the Uniform Bill Type code or the Place of Service code from the
Electronic Media Claims National Standard Format
Industry: Place of Service Code
Alias: Place of Service Code
NSF Reference: FA0-07.0, GU0-05.0
Required if value is different than value carried in CLM05-1 in Loop ID-2300.
Use this element for codes identifying a place of service from code source 237. As a
courtesy, the codes are listed below, however, the code list is thought to be complete at the
time of publication of this implementation guideline. Since this list is subject to change, only
codes contained in the document available from code source 237 are to be supported in
this transaction and take precedence over any and all codes listed here.
11 Office
12 Home
21 Inpatient Hospital
22 Outpatient Hospital
23 Emergency Room - Hospital
24 Ambulatory Surgical Center
25 Birthing Center
26 Military Treatment Facility
31 Skilled Nursing Facility
32 Nursing Facility
33 Custodial Care Facility
34 Hospice
41 Ambulance - Land
42 Ambulance - Air or Water
51 Inpatient Psychiatric Facility
52 Psychiatric Facility Partial Hospitalization
53 Community Mental Health Center
54 Intermediate Care Facility/Mentally Retarded
55 Residential Substance Abuse Treatment Facility
56 Psychiatric Residential Treatment Center
50 Federally Qualified Health Center
60 Mass Immunization Center
61 Comprehensive Inpatient Rehabilitation Facility
62 Comprehensive Outpatient Rehabilitation Facility
65 End Stage Renal Disease Treatment Facility
71 State or Local Public Health Clinic
72 Rural Health Clinic
81 Independent Laboratory
99 Other Unlisted Facility
User Note 6:
AMBULANCE
Line Level Place of Service value.
ExternalCodeList
Name: 237
Description: Place of Service from Health Care Financing Administration Claim Form
SV107
C004
Composite Diagnosis Code Pointer
O
Comp
Situational
Description: To identify one or more diagnosis code pointers
Alias: Diagnosis Code Pointer
Required if HI segment in Loop ID-2300 is used.
SV107-01
837P_CG.ecs
1328
Diagnosis Code Pointer
M
280
N0
1/2
Required
For internal use only
12/1/2010
Ref
Health Care Claim: Professional - 837
Id
Element Name
Req
Type
Min/Max
Usage
Description: A pointer to the claim diagnosis code in the order of importance to this
service
NSF Reference: FA0-14.0
Use this pointer for the first diagnosis code pointer (primary diagnosis for this service line).
Use remaining diagnosis pointers in declining level of importance to service line.
Acceptable values are 1 through 8, inclusive.
SV107-02
1328
Diagnosis Code Pointer
O
N0
1/2
Situational
Description: A pointer to the claim diagnosis code in the order of importance to this
service
NSF Reference: FA0-15.0
Use this pointer for the second diagnosis code pointer.
Required if the service relates to that specific diagnosis and is needed to substantiate the
medical treatment. Acceptable values are 1 through 8, inclusive.
SV107-03
1328
Diagnosis Code Pointer
O
N0
1/2
Situational
Description: A pointer to the claim diagnosis code in the order of importance to this
service
NSF Reference: FA0-16.0
Use this pointer for the third diagnosis code pointer.
Required if the service relates to that specific diagnosis and is needed to substantiate the
medical treatment. Acceptable values are 1 through 8, inclusive.
SV107-04
1328
Diagnosis Code Pointer
O
N0
1/2
Situational
Description: A pointer to the claim diagnosis code in the order of importance to this
service
NSF Reference: FA0-17.0
Use this pointer for the fourth diagnosis code pointer.
Required if the service relates to that specific diagnosis and is needed to substantiate the
medical treatment. Acceptable values are 1 through 8, inclusive.
SV109
1073
Yes/No Condition or Response Code
O
ID
1/1
Situational
Description: Code indicating a Yes or No condition or response
Industry: Emergency Indicator
NSF Reference: FA0-20.0
Required when the service is known to be an emergency by the provider.
Emergency definition: The patient requires immediate medical intervention as a result of
severe, life threatening, or potentially disabling conditions.
CodeList Summary (Total Codes: 4, Included: 1)
Code Name
Y
SV111
1073
Yes
Yes/No Condition or Response Code
O
ID
1/1
Situational
Description: Code indicating a Yes or No condition or response
Industry: EPSDT Indicator
NSF Reference: FB0-22.0
Required if Medicaid services are the result of a screening referral.
CodeList Summary (Total Codes: 4, Included: 1)
837P_CG.ecs
281
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Code Name
Y
SV112
1073
Yes
Yes/No Condition or Response Code
O
ID
1/1
Situational
1/1
Situational
Description: Code indicating a Yes or No condition or response
Industry: Family Planning Indicator
NSF Reference: FB0-23.0
Required if applicable for Medicaid claims.
CodeList Summary (Total Codes: 4, Included: 1)
Code Name
Y
SV115
1327
Yes
Copay Status Code
O
ID
Description: Code indicating whether or not co-payment requirements were met on a line
by line basis
Industry: Co-Pay Status Code
Alias: Co-Pay Waiver
NSF Reference: FB0-21.0
Required if patient was exempt from co-pay.
CodeList Summary (Total Codes: 4, Included: 1)
Code Name
0
Copay exempt
Syntax Rules:
1. P0304 - If either SV103 or SV104 is present, then the other is required.
Semantics:
1.
2.
3.
4.
5.
6.
7.
8.
9.
SV102 is the submitted charge amount.
SV105 is the place of service.
SV108 is the independent lab charges.
SV109 is the emergency-related indicator; a "Y" value indicates service provided was emergency related; an
"N" value indicates service provided was not emergency related.
SV111 is early and periodic screen for diagnosis and treatment of children (EPSDT) involvement; a "Y" value
indicates EPSDT involvement; an "N" value indicates no EPSDT involvement.
SV112 is the family planning involvement indicator. A "Y" value indicates family planning services
involvement; an "N" value indicates no family planning services involvement.
SV117 is the health care manpower shortage area (HMSA) facility identification.
SV118 is the health care manpower shortage area (HMSA) zip code.
SV119 is a noncovered charge amount.
Comments:
1. If SV113 is equal to "L" or "N", then SV114 is required.
Example:
SV1*HC:99211:25*12.25*UN*1*11**1:2:3**N~
837P_CG.ecs
282
For internal use only
12/1/2010
Health Care Claim: Professional - 837
SV5 Durable Medical Equipment
Service
Pos: 400
Max: 1
Detail - Optional
Loop: 2400
Elements: 6
User Option (Usage): Situational
Purpose: To specify the claim service detail for durable medical equipment
Element Summary:
Ref
Id
Element Name
SV501
C003
Composite Medical Procedure
Identifier
Req
Type
M
Comp
Min/Max
Usage
Required
Description: To identify a medical procedure by its standardized codes and applicable
modifiers
SV501-01
235
Product/Service ID Qualifier
M
ID
2/2
Required
Description: Code identifying the type/source of the descriptive number used in
Product/Service ID (234)
Industry: Procedure Identifier
CodeList Summary (Total Codes: 477, Included: 1)
Code Name
HC
Health Care Financing Administration Common Procedural Coding System
(HCPCS) Codes
CODE SOURCE:
130: Health Care Financing Administration Common Procedural Coding System
SV501-02
234
Product/Service ID
M
AN
1/48
Required
Description: Identifying number for a product or service
Industry: Procedure Code
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
M
ID
2/2
Required
Description: Code specifying the units in which a value is being expressed, or manner in
which a measurement has been taken
CodeList Summary (Total Codes: 794, Included: 1)
Code Name
DA
SV503
380
Days
Quantity
M
R
1/15
Required
X
R
1/18
Situational
Description: Numeric value of quantity
Industry: Length of Medical Necessity
SV504
782
Monetary Amount
Description: Monetary amount
Industry: DME Rental Price
837P_CG.ecs
283
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Ref
Id
Element Name
SV505
782
Monetary Amount
Req
Type
Min/Max
Usage
X
R
1/18
Situational
O
ID
1/1
Situational
Description: Monetary amount
Industry: DME Purchase Price
SV506
594
Frequency Code
Description: Code indicating frequency or type of payment
Industry: Rental Unit Price Indicator
CodeList Summary (Total Codes: 16, Included: 3)
Code Name
1
4
6
Weekly
Monthly
Daily
Syntax Rules:
1. R0405 - At least one of SV504 or SV505 is required.
2. C0604 - If SV506 is present, then SV504 is required.
Semantics:
1.
2.
3.
4.
SV503
SV504
SV505
SV506
is the length of medical treatment required.
is the rental price.
is the purchase price.
is the frequency at which the rental equipment is billed.
Notes:
1. Required when reporting rental and purchase price information for durable medical equipment.
Example:
SV5*HC:A4631*DA*30*50*5000*4~
837P_CG.ecs
284
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 420
PWK DMERC CMN Indicator
Max: 1
Detail - Optional
Loop: 2400
Elements: 2
User Option (Usage): Situational
Purpose: To identify the type or transmission or both of paperwork or supporting information
Element Summary:
Ref
Id
Element Name
PWK01
755
Report Type Code
Req
Type
Min/Max
Usage
M
ID
2/2
Required
Description: Code indicating the title or contents of a document, report or supporting item
Industry: Attachment Report Type Code
Alias: DMERC Report Type Code
CodeList Summary (Total Codes: 522, Included: 1)
Code Name
CT
PWK02
756
Certification
Report Transmission Code
O
ID
1/2
Required
Description: Code defining timing, transmission method or format by which reports are to
be sent
Industry: Attachment Transmission Code
NSF Reference: EA0-40.0
CodeList Summary (Total Codes: 55, Included: 5)
Code Name
AB
AD
AF
AG
NS
Previously Submitted to Payer
Certification Included in this Claim
Narrative Segment included in this Claim
No Documentation is Required
Not Specified
NS = Paperwork is available on request at the provider’s site. This means that the
paperwork is not being sent with the claim at this time. Instead, it is available to the
payer (or appropriate entity) at their request.
Syntax Rules:
1. P0506 - If either PWK05 or PWK06 is present, then the other is required.
Comments:
1. PWK05 and PWK06 may be used to identify the addressee by a code number.
2. PWK07 may be used to indicate special information to be shown on the specified report.
3. PWK08 may be used to indicate action pertaining to a report.
Notes:
1. Required on Medicare claims when DMERC CMN is included in this claim.
Example:
PWK*CT*AB~
837P_CG.ecs
285
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 425
CR1 Ambulance Transport
Max: 1
Detail - Optional
Information
Loop: 2400
Elements: 8
User Option (Usage): Situational
Purpose: To supply information related to the ambulance service rendered to a patient
Element Summary:
Ref
Id
Element Name
CR101
355
Unit or Basis for Measurement Code
Req
Type
Min/Max
Usage
C
ID
2/2
Situational
Description: Code specifying the units in which a value is being expressed, or manner in
which a measurement has been taken
Required if CR102 is present.
CodeList Summary (Total Codes: 794, Included: 1)
Code Name
LB
CR102
81
Pound
Weight
C
R
1/10
Situational
Description: Numeric value of weight
Industry: Patient Weight
NSF Reference: GA0-05.0
Required if it is necessary to justify the medical necessity of the level of ambulance
services.
CR103
1316
Ambulance Transport Code
O
ID
1/1
Required
1/1
Required
Description: Code indicating the type of ambulance transport
Alias: Ambulance transport code
NSF Reference: GA0-07.0
All valid standard codes are used. (Total Codes: 4)
CR104
1317
Ambulance Transport Reason Code
O
ID
Description: Code indicating the reason for ambulance transport
Alias: Ambulance Transport Reason Code
NSF Reference: GA0-15.0
All valid standard codes are used. (Total Codes: 5)
CR105
355
Unit or Basis for Measurement Code
C
ID
2/2
Required
Description: Code specifying the units in which a value is being expressed, or manner in
which a measurement has been taken
CodeList Summary (Total Codes: 794, Included: 1)
Code Name
DH
CR106
380
Miles
Quantity
C
R
1/15
Required
Description: Numeric value of quantity
Industry: Transport Distance
NSF Reference: GA0-17.0, FA0-50.0
837P_CG.ecs
286
For internal use only
12/1/2010
Ref
Health Care Claim: Professional - 837
Id
Element Name
Req
Type
Min/Max
Usage
NSF crosswalk to FA0-50.0 is used only in Medicare payer-to-payer COB situations.
CR109
352
Description
O
AN
1/80
Situational
Description: A free-form description to clarify the related data elements and their content
Industry: Round Trip Purpose Description
Alias: Transport purpose description
NSF Reference: GA0-20.0
Required if CR103 (Ambulance Transport Code) = “X - Round Trip”; otherwise not used.
CR110
352
Description
O
AN
1/80
Situational
Description: A free-form description to clarify the related data elements and their content
Industry: Stretcher Purpose Description
NSF Reference: GA0-21.0
Required if needed to justify usage of stretcher.
Syntax Rules:
1. P0102 - If either CR101 or CR102 is present, then the other is required.
2. P0506 - If either CR105 or CR106 is present, then the other is required.
Semantics:
1.
2.
3.
4.
5.
6.
CR102 is the weight of the patient at time of transport.
CR106 is the distance traveled during transport.
CR107 is the address of origin.
CR108 is the address of destination.
CR109 is the purpose for the round trip ambulance service.
CR110 is the purpose for the usage of a stretcher during ambulance service.
Notes:
1. Required on all ambulance claims if the information is different than in the CR1 at the claim level (Loop
ID-2300).
Example:
CR1*LB*140*I*A*DH*12****UNCONSCIOUS~
User Note 6:
AMBULANCE
Line Level Ambulance Information (see page 248-Loop 2300 CR103, CR104, CR106, CR109, and CR110)
837P_CG.ecs
287
For internal use only
12/1/2010
Health Care Claim: Professional - 837
CR2 Spinal Manipulation Service
Information
Pos: 430
Max: 5
Detail - Optional
Loop: 2400
Elements: 4
User Option (Usage): Situational
Purpose: To supply information related to the chiropractic service rendered to a patient
Element Summary:
Ref
Id
Element Name
CR208
1342
Nature of Condition Code
Req
Type
Min/Max
Usage
O
ID
1/1
Required
1/80
Situational
Description: Code indicating the nature of a patient's condition
Industry: Patient Condition Code
Alias: Nature of Condition Code. Spinal Manipulation
NSF Reference: GC0-11.0
All valid standard codes are used. (Total Codes: 7)
CR210
352
Description
O
AN
Description: A free-form description to clarify the related data elements and their content
Industry: Patient Condition Description
Alias: Patient Condition Description, Chiropractic
NSF Reference: GC0-14.0
Used at discretion of submitter.
CR211
352
Description
O
AN
1/80
Situational
Description: A free-form description to clarify the related data elements and their content
Industry: Patient Condition Description
Alias: Patient Condition Description, Chiropractic
NSF Reference: GC0-14.0
Used at discretion of submitter.
CR212
1073
Yes/No Condition or Response Code
O
ID
1/1
Situational
Description: Code indicating a Yes or No condition or response
Industry: X-ray Availability Indicator
Alias: X-ray Availability Indicator, Chiropractic
NSF Reference: GC0-15.0
Required for service dates prior to January 1, 2000.
CodeList Summary (Total Codes: 4, Included: 2)
Code Name
N
Y
No
Yes
Syntax Rules:
1. P0102 - If either CR201 or CR202 is present, then the other is required.
2. C0403 - If CR204 is present, then CR203 is required.
3. P0506 - If either CR205 or CR206 is present, then the other is required.
837P_CG.ecs
288
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Semantics:
1.
2.
3.
4.
5.
CR201 is the number this treatment is in the series.
CR202 is the total number of treatments in the series.
CR206 is the time period involved in the treatment series.
CR207 is the number of treatments rendered in the month of service.
CR209 is complication indicator. A "Y" value indicates a complicated condition; an "N" value indicates an
uncomplicated condition.
6. CR210 is a description of the patient's condition.
7. CR211 is an additional description of the patient's condition.
8. CR212 is X-rays availability indicator. A "Y" value indicates X-rays are maintained and available for carrier
review; an "N" value indicates X-rays are not maintained and available for carrier review.
Comments:
1. When both CR203 and CR204 are present, CR203 is the beginning level of subluxation and CR204 is the
ending level of subluxation.
Notes:
1. Required on chiropractic claims involving spinal manipulation and known to impact payer’s adjudication
process.
Example:
CR2********M****Y~
837P_CG.ecs
289
For internal use only
12/1/2010
Health Care Claim: Professional - 837
CR3 Durable Medical Equipment
Certification
Pos: 435
Max: 1
Detail - Optional
Loop: 2400
Elements: 3
User Option (Usage): Situational
Purpose: To supply information regarding a physician's certification for durable medical equipment
Element Summary:
Ref
Id
Element Name
CR301
1322
Certification Type Code
Req
Type
Min/Max
Usage
O
ID
1/1
Required
ID
2/2
Required
Description: Code indicating the type of certification
NSF Reference: GU0-04.0
CodeList Summary (Total Codes: 14, Included: 3)
Code Name
I
R
S
CR302
355
Initial
Renewal
Revised
Unit or Basis for Measurement Code
C
Description: Code specifying the units in which a value is being expressed, or manner in
which a measurement has been taken
CodeList Summary (Total Codes: 794, Included: 1)
Code Name
MO
CR303
380
Months
Quantity
C
R
1/15
Required
Description: Numeric value of quantity
Industry: Durable Medical Equipment Duration
Alias: DME Duration
NSF Reference: GU0-21.0
Length of time DME equipment is needed.
Syntax Rules:
1. P0203 - If either CR302 or CR303 is present, then the other is required.
Semantics:
1. CR302 and CR303 specify the time period covered by this certification.
2. CR305 is the prognosis of the patient.
Notes:
1. Required if it is necessary to include supporting documentation in an electronic form for Medicare DMERC
claims for which the provider is required to obtain a certificate of medical necessity (CMN) from the physician.
Example:
CR3*I*MO*6~
837P_CG.ecs
290
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 445
CR5 Home Oxygen Therapy
Max: 1
Detail - Optional
Information
Loop: 2400
Elements: 8
User Option (Usage): Situational
Purpose: To supply information regarding certification of medical necessity for home oxygen therapy
Element Summary:
Ref
Id
Element Name
CR501
1322
Certification Type Code
Req
Type
Min/Max
Usage
O
ID
1/1
Required
R
1/15
Required
R
1/15
Situational
R
1/15
Situational
1/1
Required
Description: Code indicating the type of certification
Alias: Certification Type Code. Oxygen Therapy
NSF Reference: GX0-04.0
CodeList Summary (Total Codes: 14, Included: 3)
Code Name
I
R
S
CR502
380
Initial
Renewal
Revised
Quantity
O
Description: Numeric value of quantity
Industry: Treatment Period Count
Alias: Certification Period, Home Oxygen Therapy
NSF Reference: GX0-06.0
CR510
380
Quantity
O
Description: Numeric value of quantity
Industry: Arterial Blood Gas Quantity
Alias: Arterial Blood Gas
NSF Reference: GX0-22.0
Either CR510 or CR511 is required.
Required on claims which report arterial blood gas.
CR511
380
Quantity
O
Description: Numeric value of quantity
Industry: Oxygen Saturation Quantity
Alias: Oxygen Saturation
NSF Reference: GX0-23.0
Either CR510 or CR511 is required.
Required on claims which report oxygen saturation quantity.
CR512
1349
Oxygen Test Condition Code
O
ID
Description: Code indicating the conditions under which a patient was tested
Alias: Oxygen test condition code
NSF Reference: GX0-26.0
CodeList Summary (Total Codes: 7, Included: 3)
837P_CG.ecs
291
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Code Name
E
R
S
CR513
1350
Exercising
At rest on room air
Sleeping
Oxygen Test Findings Code
O
ID
1/1
Situational
Description: Code indicating the findings of oxygen tests performed on a patient
Alias: Oxygen test finding code
NSF Reference: GX0-27.0
Required if patient’s arterial PO2 is greater than 55 mmHg and less than 60 mmHg, or
oxygen saturation is greater than 88%. Use CR513, CR514, or CR515 as appropriate.
CodeList Summary (Total Codes: 3, Included: 1)
Code Name
1
CR514
1350
Dependent edema suggesting congestive heart failure
Oxygen Test Findings Code
O
ID
1/1
Situational
Description: Code indicating the findings of oxygen tests performed on a patient
Alias: Oxygen test finding code
NSF Reference: GX0-27.0
Required if patient’s arterial PO2 is greater than 55 mmHg and less than 60 mmHg, or
oxygen saturation is greater than 88%. Use CR513, CR514, or CR515 as appropriate.
CodeList Summary (Total Codes: 3, Included: 1)
Code Name
2
CR515
1350
"P" Pulmonale on Electrocardiogram (EKG)
Oxygen Test Findings Code
O
ID
1/1
Situational
Description: Code indicating the findings of oxygen tests performed on a patient
Alias: Oxygen test finding code
NSF Reference: GX0-27.0
Required if patient’s arterial PO2 is greater than 55 mmHg and less than 60 mmHg, or
oxygen saturation is greater than 88%. Use CR513, CR514, or CR515 as appropriate.
CodeList Summary (Total Codes: 3, Included: 1)
Code Name
3
Erythrocythemia with a hematocrit greater than 56 percent
Semantics:
1.
2.
3.
4.
5.
6.
7.
8.
9.
CR502 is the number of months covered by this certification.
CR505 is the reason for equipment.
CR506 is the oxygen flow rate in liters per minute.
CR507 is the number of times per day the patient must use oxygen.
CR508 is the number of hours per period of oxygen use.
CR509 is the special orders for the respiratory therapist.
CR510 is the arterial blood gas.
CR511 is the oxygen saturation.
CR516 is the oxygen flow rate for a portable oxygen system in liters per minute.
Notes:
837P_CG.ecs
292
For internal use only
12/1/2010
Health Care Claim: Professional - 837
1. Required on all initial, renewal, and revision home oxygen therapy claims.
Example:
CR5*I*6********56**R*1~
837P_CG.ecs
293
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 450
CRC Ambulance Certification
Max: 3
Detail - Optional
Loop: 2400
Elements: 7
User Option (Usage): Situational
Purpose: To supply information on conditions
Element Summary:
Ref
Id
Element Name
Req
Type
Min/Max
Usage
CRC01
1136
Code Category
M
ID
2/2
Required
Description: Specifies the situation or category to which the code applies
CodeList Summary (Total Codes: 341, Included: 1)
Code Name
07
CRC02
1073
Ambulance Certification
Yes/No Condition or Response Code
M
ID
1/1
Required
2/2
Required
Description: Code indicating a Yes or No condition or response
Industry: Certification Condition Indicator
Alias: Certification Condition Code, Ambulance Certification
CodeList Summary (Total Codes: 4, Included: 2)
Code Name
N
Y
CRC03
1321
No
Yes
Condition Indicator
M
ID
Description: Code indicating a condition
Industry: Condition Code
Alias: Condition Indicator
The codes for CRC03 also can be used for CRC04 through CRC07.
CodeList Summary (Total Codes: 1079, Included: 10)
Code Name
01
Patient was admitted to a hospital
NSF Reference:
GA0-06.0
02
Patient was bed confined before the ambulance service
NSF Reference:
03
Patient was bed confined after the ambulance service
NSF Reference:
GA0-08.0
GA0-09.0
04
Patient was moved by stretcher
NSF Reference:
05
Patient was unconscious or in shock
NSF Reference:
GA0-10.0
837P_CG.ecs
294
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Code Name
GA0-11.0
06
Patient was transported in an emergency situation
NSF Reference:
GA0-12.0
07
Patient had to be physically restrained
NSF Reference:
GA0-13.0
08
Patient had visible hemorrhaging
NSF Reference:
GA0-14.0
09
Ambulance service was medically necessary
NSF Reference:
GA0-16.0
60
Transportation Was To the Nearest Facility
NSF Reference:
GA0-24.0
CRC04
1321
Condition Indicator
O
ID
2/2
Situational
Description: Code indicating a condition
Industry: Condition Code
Alias: Condition Indicator
Required if additional condition codes are needed.
Use the codes listed in CRC03.
CodeList Summary (Total Codes: 1079, Included: 10)
Code Name
01
Patient was admitted to a hospital
NSF Reference:
02
Patient was bed confined before the ambulance service
NSF Reference:
GA0-06.0
GA0-08.0
03
Patient was bed confined after the ambulance service
NSF Reference:
04
Patient was moved by stretcher
NSF Reference:
GA0-09.0
GA0-10.0
05
Patient was unconscious or in shock
NSF Reference:
06
Patient was transported in an emergency situation
NSF Reference:
GA0-11.0
GA0-12.0
07
837P_CG.ecs
Patient had to be physically restrained
NSF Reference:
295
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Code Name
GA0-13.0
08
Patient had visible hemorrhaging
NSF Reference:
GA0-14.0
09
Ambulance service was medically necessary
NSF Reference:
GA0-16.0
60
Transportation Was To the Nearest Facility
NSF Reference:
GA0-24.0
CRC05
1321
Condition Indicator
O
ID
2/2
Situational
Description: Code indicating a condition
Industry: Condition Code
Alias: Condition Indicator
Required if additional condition codes are needed.
Use the codes listed in CRC03.
CodeList Summary (Total Codes: 1079, Included: 10)
Code Name
01
Patient was admitted to a hospital
NSF Reference:
02
Patient was bed confined before the ambulance service
NSF Reference:
GA0-06.0
GA0-08.0
03
Patient was bed confined after the ambulance service
NSF Reference:
04
Patient was moved by stretcher
NSF Reference:
GA0-09.0
GA0-10.0
05
Patient was unconscious or in shock
NSF Reference:
06
Patient was transported in an emergency situation
NSF Reference:
GA0-11.0
GA0-12.0
07
Patient had to be physically restrained
NSF Reference:
08
Patient had visible hemorrhaging
NSF Reference:
GA0-13.0
GA0-14.0
09
837P_CG.ecs
Ambulance service was medically necessary
NSF Reference:
296
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Code Name
GA0-16.0
60
Transportation Was To the Nearest Facility
NSF Reference:
GA0-24.0
CRC06
1321
Condition Indicator
O
ID
2/2
Situational
2/2
Situational
Description: Code indicating a condition
Industry: Condition Code
Alias: Condition Indicator
Required if additional condition codes are needed.
Use the codes listed in CRC03.
CodeList Summary (Total Codes: 1079, Included: 10)
Code Name
01
Patient was admitted to a hospital
NSF Reference:
02
Patient was bed confined before the ambulance service
NSF Reference:
GA0-06.0
GA0-08.0
03
Patient was bed confined after the ambulance service
NSF Reference:
04
Patient was moved by stretcher
NSF Reference:
GA0-09.0
GA0-10.0
05
Patient was unconscious or in shock
NSF Reference:
06
Patient was transported in an emergency situation
NSF Reference:
GA0-11.0
GA0-12.0
07
Patient had to be physically restrained
NSF Reference:
08
Patient had visible hemorrhaging
NSF Reference:
GA0-13.0
GA0-14.0
09
Ambulance service was medically necessary
NSF Reference:
60
Transportation Was To the Nearest Facility
NSF Reference:
GA0-16.0
GA0-24.0
CRC07
837P_CG.ecs
1321
Condition Indicator
O
297
ID
For internal use only
12/1/2010
Ref
Health Care Claim: Professional - 837
Id
Element Name
Req
Type
Min/Max
Usage
Description: Code indicating a condition
Industry: Condition Code
Alias: Condition Indicator
Required if additional condition codes are needed.
Use the codes listed in CRC03.
CodeList Summary (Total Codes: 1079, Included: 10)
Code Name
01
Patient was admitted to a hospital
NSF Reference:
02
Patient was bed confined before the ambulance service
NSF Reference:
GA0-06.0
GA0-08.0
03
Patient was bed confined after the ambulance service
NSF Reference:
GA0-09.0
04
Patient was moved by stretcher
NSF Reference:
GA0-10.0
05
Patient was unconscious or in shock
NSF Reference:
GA0-11.0
06
Patient was transported in an emergency situation
NSF Reference:
GA0-12.0
07
Patient had to be physically restrained
NSF Reference:
GA0-13.0
08
Patient had visible hemorrhaging
NSF Reference:
GA0-14.0
09
Ambulance service was medically necessary
NSF Reference:
GA0-16.0
60
Transportation Was To the Nearest Facility
NSF Reference:
GA0-24.0
Semantics:
1. CRC01 qualifies CRC03 through CRC07.
2. CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03
through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply.
Notes:
1. The maximum number of CRC segments which can occur per 2400 loop is 3. Submitters are free to mix and
837P_CG.ecs
298
For internal use only
12/1/2010
Health Care Claim: Professional - 837
match the three types of service line level CRC segments shown in this implementation guide to meet their
billing/reporting needs but no more than a total of 3 CRC segments per 2400 loop are allowed.
2. Required on all service lines which bill/report ambulance services if the information is different when
CRC01=07 in Loop ID-2300.
Example:
CRC*07*Y*08~
837P_CG.ecs
299
For internal use only
12/1/2010
Health Care Claim: Professional - 837
CRC Hospice Employee Indicator
Pos: 450
Max: 1
Detail - Optional
Loop: 2400
Elements: 3
User Option (Usage): Situational
Purpose: To supply information on conditions
Element Summary:
Ref
Id
Element Name
Req
Type
Min/Max
Usage
CRC01
1136
Code Category
M
ID
2/2
Required
Description: Specifies the situation or category to which the code applies
CodeList Summary (Total Codes: 341, Included: 1)
Code Name
70
CRC02
1073
Hospice
Yes/No Condition or Response Code
M
ID
1/1
Required
Description: Code indicating a Yes or No condition or response
Industry: Hospice Employed Provider Indicator
Alias: Hospice Employee Indicator
NSF Reference: FA0-40.0
A “Y” value indicates the provider is employed by the hospice. A “N” value indicates the
provider is not employed by the hospice.
CodeList Summary (Total Codes: 4, Included: 2)
Code Name
N
Y
CRC03
1321
No
Yes
Condition Indicator
M
ID
2/2
Required
Description: Code indicating a condition
CodeList Summary (Total Codes: 1079, Included: 1)
Code Name
65
Open
Use this code as a place holder (element is mandatory) when reporting whether
the provider is a hospice employee.
Semantics:
1. CRC01 qualifies CRC03 through CRC07.
2. CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03
through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply.
Notes:
1. The example shows the method used to indicate whether the rendering provider is an employee of the hospice.
2. The maximum number of CRC segments which can occur per 2400 loop is 3. Submitters are free to mix and
match the three types of service line level CRC segments shown in this implementation guide to meet their
billing/reporting needs but no more than a total of 3 CRC segments per 2400 loop are allowed.
3. Required on all Medicare claims involving physician services to hospice patients.
837P_CG.ecs
300
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Example:
CRC*70*Y*65~
837P_CG.ecs
301
For internal use only
12/1/2010
Health Care Claim: Professional - 837
CRC DMERC Condition Indicator
Pos: 450
Max: 2
Detail - Optional
Loop: 2400
Elements: 7
User Option (Usage): Situational
Purpose: To supply information on conditions
Element Summary:
Ref
Id
Element Name
Req
Type
Min/Max
Usage
CRC01
1136
Code Category
M
ID
2/2
Required
Description: Specifies the situation or category to which the code applies
CodeList Summary (Total Codes: 341, Included: 2)
Code Name
09
11
CRC02
1073
Durable Medical Equipment Certification
Oxygen Therapy Certification
Yes/No Condition or Response Code
M
ID
1/1
Required
2/2
Required
Description: Code indicating a Yes or No condition or response
Industry: Certification Condition Indicator
Alias: Certification Condition Code Applies Indicator
CodeList Summary (Total Codes: 4, Included: 2)
Code Name
N
Y
CRC03
1321
No
Yes
Condition Indicator
M
ID
Description: Code indicating a condition
Alias: Condition Indicator
Use “P1" (GX0-20.0) to answer the Medicare Oxygen CMN question: ”The test was
performed either with the patient in a chronic stable state as an outpatient or within two
days prior to discharge from an inpatient facility to home."
Code ZV was approved by ASC X12 in the version 004011 Data Dictionary but is included
in this guide to provide standard way to report DMERC claims within the HIPAA
implementation time frame. It is recommended that entities who have a need to submit or
receive DMERC claims customize their 004010 translator map to allow this exception code.
CodeList Summary (Total Codes: 1080, Included: 5)
Code Name
37
Oxygen delivery equipment is stationary
NSF Reference:
GX0-05.0
38
Certification signed by the physician is on file at the supplier's office
GX0-35.0
GU0-24.0
AL
Ambulation Limitations
NSF Reference:
GX0-05.0
P1
837P_CG.ecs
Patient was Discharged from the First Facility
302
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Code Name
NSF Reference:
GX0-20.0
ZV
Replacement Item
NSF Reference:
GU0-06.0
CRC04
1321
Condition Indicator
O
ID
2/2
Situational
Description: Code indicating a condition
Alias: Condition Indicator
Required if additional condition codes are needed.
Use the codes listed in CRC03.
CodeList Summary (Total Codes: 1080, Included: 5)
Code Name
37
Oxygen delivery equipment is stationary
NSF Reference:
GX0-05.0
38
Certification signed by the physician is on file at the supplier's office
NSF Reference:
GX0-35.0
GU0-24.0
AL
Ambulation Limitations
NSF Reference:
GX0-05.0
P1
Patient was Discharged from the First Facility
NSF Reference:
GX0-20.0
ZV
Replacement Item
NSF Reference:
GU0-06.0
CRC05
1321
Condition Indicator
O
ID
2/2
Situational
Description: Code indicating a condition
Alias: Condition Indicator
Required if additional condition codes are needed.
Use the codes listed in CRC03.
CodeList Summary (Total Codes: 1080, Included: 5)
Code Name
37
Oxygen delivery equipment is stationary
NSF Reference:
GX0-05.0
38
Certification signed by the physician is on file at the supplier's office
NSF Reference:
GX0-35.0
GU0-24.0
AL
837P_CG.ecs
Ambulation Limitations
303
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Code Name
NSF Reference:
GX0-05.0
P1
Patient was Discharged from the First Facility
NSF Reference:
GX0-20.0
ZV
Replacement Item
NSF Reference:
GU0-06.0
CRC06
1321
Condition Indicator
O
ID
2/2
Situational
Description: Code indicating a condition
Alias: Condition Indicator
Required if additional condition codes are needed.
Use the codes listed in CRC03.
CodeList Summary (Total Codes: 1080, Included: 5)
Code Name
37
Oxygen delivery equipment is stationary
NSF Reference:
38
Certification signed by the physician is on file at the supplier's office
NSF Reference:
GX0-05.0
GX0-35.0
GU0-24.0
AL
Ambulation Limitations
NSF Reference:
GX0-05.0
P1
Patient was Discharged from the First Facility
NSF Reference:
GX0-20.0
ZV
Replacement Item
NSF Reference:
GU0-06.0
CRC07
1321
Condition Indicator
O
ID
2/2
Situational
Description: Code indicating a condition
Alias: Condition Indicator
Required if additional condition codes are needed.
Use the codes listed in CRC03.
CodeList Summary (Total Codes: 1080, Included: 5)
Code Name
37
Oxygen delivery equipment is stationary
NSF Reference:
38
Certification signed by the physician is on file at the supplier's office
NSF Reference:
GX0-05.0
837P_CG.ecs
304
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Code Name
GX0-35.0
GU0-24.0
AL
Ambulation Limitations
NSF Reference:
GX0-05.0
P1
Patient was Discharged from the First Facility
NSF Reference:
ZV
Replacement Item
NSF Reference:
GX0-20.0
GU0-06.0
Semantics:
1. CRC01 qualifies CRC03 through CRC07.
2. CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03
through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply.
Notes:
1. Required on all oxygen therapy and DME claims that require a certificate of medical necessity (CMN).
2. The maximum number of CRC segments which can occur per 2400 loop is 3. Submitters are free to mix and
match the three types of service line level CRC segments shown in this implementation guide to meet their
billing/reporting needs but no more than a total of 3 CRC segments per 2400 loop are allowed.
3. The first example shows a case where an item billed was not a replacement item.
Example:
CRC*09*N*ZV~
CRC*11*Y*37*38*P1~
837P_CG.ecs
305
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 455
DTP Date - Service Date
Max: 1
Detail - Optional
Loop: 2400
Elements: 3
User Option (Usage): Required
Purpose: To specify any or all of a date, a time, or a time period
Element Summary:
Ref
Id
Element Name
DTP01
374
Date/Time Qualifier
Req
Type
Min/Max
Usage
M
ID
3/3
Required
Description: Code specifying type of date or time, or both date and time
Industry: Date Time Qualifier
Service line date of service.
CodeList Summary (Total Codes: 1112, Included: 1)
Code Name
472
DTP02
1250
Service
Use RD8 in DTP02 to indicate begin/end or from/to dates.
Date Time Period Format Qualifier
M
ID
2/3
Required
Description: Code indicating the date format, time format, or date and time format
CodeList Summary (Total Codes: 39, Included: 2)
Code Name
D8
RD8
DTP03
1251
Date Expressed in Format CCYYMMDD
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
Use RD8 if it is necessary to indicate begin/end dates. Date range indicates drug
duration for which the supply of drug be will 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 (e.g., 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.
Date Time Period
M
AN
1/35
Required
Description: Expression of a date, a time, or range of dates, times or dates and times
Industry: Service Date
NSF Reference: FA0-05.0, FA0-06.0
User Note 6:
DATE: Date, a time, range of dates
User Note 7:
Home Infusion and Drugs
Report date of service in the service line
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
837P_CG.ecs
306
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Notes:
1. The total number of DTP segments in the 2400 loop cannot exceed 15.
2. In cases where a drug is being billed on a service line, the Date of Service DTP may be used to indicate the
range of dates through which the drug will be used by the patient. Use RD8 for this purpose.
3. In cases where a drug is being billed on a service line, the Date of Service DTP is used to indicate the date the
prescription was written (or otherwise communicated by the prescriber if not written).
Example:
DTP*472*RD8*19970607-19970608~
837P_CG.ecs
307
For internal use only
12/1/2010
Health Care Claim: Professional - 837
DTP Date - Certification Revision
Date
Pos: 455
Max: 1
Detail - Optional
Loop: 2400
Elements: 3
User Option (Usage): Situational
Purpose: To specify any or all of a date, a time, or a time period
Element Summary:
Ref
Id
Element Name
DTP01
374
Date/Time Qualifier
Req
Type
Min/Max
Usage
M
ID
3/3
Required
Description: Code specifying type of date or time, or both date and time
Industry: Date Time Qualifier
CodeList Summary (Total Codes: 1112, Included: 1)
Code Name
607
DTP02
1250
Certification Revision
Date Time Period Format Qualifier
M
ID
2/3
Required
Description: Code indicating the date format, time format, or date and time format
CodeList Summary (Total Codes: 39, Included: 1)
Code Name
D8
DTP03
1251
Date Expressed in Format CCYYMMDD
Date Time Period
M
AN
1/35
Required
Description: Expression of a date, a time, or range of dates, times or dates and times
Industry: Certification Revision Date
NSF Reference: GU0-20.0, GX0-11.0
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
Notes:
1. Required if CR301 (DMERC Certification) = “R” or “S”.
2. The total number of DTP segments in the 2400 loop cannot exceed 15.
Example:
DTP*607*D8*19970519~
837P_CG.ecs
308
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 455
DTP Date - Begin Therapy Date
Max: 1
Detail - Optional
Loop: 2400
Elements: 3
User Option (Usage): Situational
Purpose: To specify any or all of a date, a time, or a time period
Element Summary:
Ref
Id
Element Name
DTP01
374
Date/Time Qualifier
Req
Type
Min/Max
Usage
M
ID
3/3
Required
Description: Code specifying type of date or time, or both date and time
Industry: Date Time Qualifier
CodeList Summary (Total Codes: 1112, Included: 1)
Code Name
463
DTP02
1250
Begin Therapy
Date Time Period Format Qualifier
M
ID
2/3
Required
Description: Code indicating the date format, time format, or date and time format
CodeList Summary (Total Codes: 39, Included: 1)
Code Name
D8
DTP03
1251
Date Expressed in Format CCYYMMDD
Date Time Period
M
AN
1/35
Required
Description: Expression of a date, a time, or range of dates, times or dates and times
Industry: Begin Therapy Date
NSF Reference: GU0-19.0, GX0-10.0
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
Notes:
1. Required if it is necessary to include supporting documentation in an electronic form for Medicare DMERC
claims for which the provider is required to obtain a certificate of medical necessity (CMN) from the physician.
2. The total number of DTP segments in the 2400 loop cannot exceed 15.
Example:
DTP*463*D8*19970519~
837P_CG.ecs
309
For internal use only
12/1/2010
Health Care Claim: Professional - 837
DTP Date - Last Certification Date
Pos: 455
Max: 1
Detail - Optional
Loop: 2400
Elements: 3
User Option (Usage): Situational
Purpose: To specify any or all of a date, a time, or a time period
Element Summary:
Ref
Id
Element Name
DTP01
374
Date/Time Qualifier
Req
Type
Min/Max
Usage
M
ID
3/3
Required
Description: Code specifying type of date or time, or both date and time
Industry: Date Time Qualifier
CodeList Summary (Total Codes: 1112, Included: 1)
Code Name
461
DTP02
1250
Last Certification
Date Time Period Format Qualifier
M
ID
2/3
Required
Description: Code indicating the date format, time format, or date and time format
CodeList Summary (Total Codes: 39, Included: 1)
Code Name
D8
DTP03
1251
Date Expressed in Format CCYYMMDD
Date Time Period
M
AN
1/35
Required
Description: Expression of a date, a time, or range of dates, times or dates and times
Industry: Last Certification Date
NSF Reference: GX0-11.0, GU0-22.0
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
Notes:
1. Required if it is necessary to include supporting documentation in an electronic form for Medicare DMERC
claims for which the provider is required to obtain a certificate of medical necessity (CMN) from the physician.
2. Required on oxygen therapy certificates of medical necessity (CMN). This is the date the ordering physician
signed the CMN.
3. The total number of DTP segments in the 2400 loop cannot exceed 15.
Example:
DTP*461*D8*19970519~
837P_CG.ecs
310
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 455
DTP Date - Date Last Seen
Max: 1
Detail - Optional
Loop: 2400
Elements: 3
User Option (Usage): Situational
Purpose: To specify any or all of a date, a time, or a time period
Element Summary:
Ref
Id
Element Name
DTP01
374
Date/Time Qualifier
Req
Type
Min/Max
Usage
M
ID
3/3
Required
Description: Code specifying type of date or time, or both date and time
CodeList Summary (Total Codes: 1112, Included: 1)
Code Name
304
DTP02
1250
Latest Visit or Consultation
Date Time Period Format Qualifier
M
ID
2/3
Required
Description: Code indicating the date format, time format, or date and time format
CodeList Summary (Total Codes: 39, Included: 1)
Code Name
D8
DTP03
1251
Date Expressed in Format CCYYMMDD
Date Time Period
M
AN
1/35
Required
Description: Expression of a date, a time, or range of dates, times or dates and times
Industry: Last Seen Date
NSF Reference: EA0-48.0
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
Notes:
1. 1. Required when a claim involves services from an independent physical therapist, occupational therapist, or
physician service involving routine foot care and is different than the date listed at the claim level and is known to
impact the payer’s adjudication process.
2. The total number of DTP segments in the 2400 loop cannot exceed 15.
Example:
DTP*304*D8*19970813~
837P_CG.ecs
311
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 455
DTP Date - Test
Max: 2
Detail - Optional
Loop: 2400
Elements: 3
User Option (Usage): Situational
Purpose: To specify any or all of a date, a time, or a time period
Element Summary:
Ref
Id
Element Name
DTP01
374
Date/Time Qualifier
Req
Type
Min/Max
Usage
M
ID
3/3
Required
Description: Code specifying type of date or time, or both date and time
Industry: Date Time Qualifier
CodeList Summary (Total Codes: 1112, Included: 2)
Code Name
738
739
DTP02
1250
Most Recent Hemoglobin or Hematocrit or Both
Most Recent Serum Creatine
Date Time Period Format Qualifier
M
ID
2/3
Required
Description: Code indicating the date format, time format, or date and time format
CodeList Summary (Total Codes: 39, Included: 1)
Code Name
D8
DTP03
1251
Date Expressed in Format CCYYMMDD
Date Time Period
M
AN
1/35
Required
Description: Expression of a date, a time, or range of dates, times or dates and times
Industry: Test Performed Date
NSF Reference: FA0-41.0, FA0-46.0
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
Notes:
1. Required on initial EPO claims service lines for dialysis patients where test results are being billed/reported.
2. The total number of DTP segments in the 2400 loop cannot exceed 15.
Example:
DTP*738*D8*19970615~
837P_CG.ecs
312
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 455
DTP Date - Oxygen
Max: 3
Detail - Optional
Saturation/Arterial Blood
Gas Test
Loop: 2400
Elements: 3
User Option (Usage): Situational
Purpose: To specify any or all of a date, a time, or a time period
Element Summary:
Ref
Id
Element Name
DTP01
374
Date/Time Qualifier
Req
Type
Min/Max
Usage
M
ID
3/3
Required
Description: Code specifying type of date or time, or both date and time
Industry: Date Time Qualifier
CodeList Summary (Total Codes: 1112, Included: 3)
Code Name
DTP02
1250
119
Test Performed
Use for any 4 liter/minute test date. Results for this test date are reported in
MEA03 using either the GRA or ZO qualifiers in MEA02.
480
Arterial Blood Gas Test
Do not use to report any 4 liter/minute test date. Results for the arterial blood gas
test are reported in CR510.
481
Oxygen Saturation Test
Do not use to report any 4 liter/minute test date. Results for the oxygen saturation
test are reported in CR511.
Date Time Period Format Qualifier
M
ID
2/3
Required
Description: Code indicating the date format, time format, or date and time format
CodeList Summary (Total Codes: 39, Included: 1)
Code Name
D8
DTP03
1251
Date Expressed in Format CCYYMMDD
Date Time Period
M
AN
1/35
Required
Description: Expression of a date, a time, or range of dates, times or dates and times
Industry: Oxygen Saturation Test Date
NSF Reference: GX0-19.0, GX0-24.0
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
Notes:
1. Required on initial oxygen therapy service line(s) involving certificate of medical necessity (CMN).
2. The total number of DTP segments in the 2400 loop cannot exceed 15.
Example:
DTP*480*D8*19970615~
837P_CG.ecs
313
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 455
DTP Date - Shipped
Max: 1
Detail - Optional
Loop: 2400
Elements: 3
User Option (Usage): Situational
Purpose: To specify any or all of a date, a time, or a time period
Element Summary:
Ref
Id
Element Name
DTP01
374
Date/Time Qualifier
Req
Type
Min/Max
Usage
M
ID
3/3
Required
Description: Code specifying type of date or time, or both date and time
Industry: Date Time Qualifier
CodeList Summary (Total Codes: 1112, Included: 1)
Code Name
011
DTP02
1250
Shipped
Date Time Period Format Qualifier
M
ID
2/3
Required
Description: Code indicating the date format, time format, or date and time format
CodeList Summary (Total Codes: 39, Included: 1)
Code Name
D8
DTP03
1251
Date Expressed in Format CCYYMMDD
Date Time Period
M
AN
1/35
Required
Description: Expression of a date, a time, or range of dates, times or dates and times
Industry: Shipped Date
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
Notes:
1. Required when billing/reporting shipped products.
2. The total number of DTP segments in the 2400 loop cannot exceed 15.
Example:
DTP*011*D8*19970526~
837P_CG.ecs
314
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 455
DTP Date - Onset of Current
Max: 1
Detail - Optional
Symptom/Illness
Loop: 2400
Elements: 3
User Option (Usage): Situational
Purpose: To specify any or all of a date, a time, or a time period
Element Summary:
Ref
Id
Element Name
DTP01
374
Date/Time Qualifier
Req
Type
Min/Max
Usage
M
ID
3/3
Required
Description: Code specifying type of date or time, or both date and time
Industry: Date Time Qualifier
CodeList Summary (Total Codes: 1112, Included: 1)
Code Name
431
DTP02
1250
Onset of Current Symptoms or Illness
Date Time Period Format Qualifier
M
ID
2/3
Required
Description: Code indicating the date format, time format, or date and time format
CodeList Summary (Total Codes: 39, Included: 1)
Code Name
D8
DTP03
1251
Date Expressed in Format CCYYMMDD
Date Time Period
M
AN
1/35
Required
Description: Expression of a date, a time, or range of dates, times or dates and times
Industry: Onset Date
NSF Reference: EA0-07.0, EA0-16.0
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
Notes:
1. Required if different from that entered at claim level (Loop ID-2300).
2. Required on claims involving services to a patient experiencing symptoms similar or identical to previously
reported symptoms.
3. The total number of DTP segments in the 2400 loop cannot exceed 15.
Example:
DTP*431*D8*19971112~
837P_CG.ecs
315
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 455
DTP Date - Last X-ray
Max: 1
Detail - Optional
Loop: 2400
Elements: 3
User Option (Usage): Situational
Purpose: To specify any or all of a date, a time, or a time period
Element Summary:
Ref
Id
Element Name
DTP01
374
Date/Time Qualifier
Req
Type
Min/Max
Usage
M
ID
3/3
Required
Description: Code specifying type of date or time, or both date and time
Industry: Date Time Qualifier
CodeList Summary (Total Codes: 1112, Included: 1)
Code Name
455
DTP02
1250
Last X-Ray
Date Time Period Format Qualifier
M
ID
2/3
Required
Description: Code indicating the date format, time format, or date and time format
CodeList Summary (Total Codes: 39, Included: 1)
Code Name
D8
DTP03
1251
Date Expressed in Format CCYYMMDD
Date Time Period
M
AN
1/35
Required
Description: Expression of a date, a time, or range of dates, times or dates and times
Industry: Last X-Ray Date
NSF Reference: GC0-06.0
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
Notes:
1. Required for spinal manipulation certifications if different than information at claim level (Loop ID-2300).
2. The total number of DTP segments in the 2400 loop cannot exceed 15.
Example:
DTP*455*D8*19970220~
837P_CG.ecs
316
For internal use only
12/1/2010
Health Care Claim: Professional - 837
DTP Date - Acute Manifestation
Pos: 455
Max: 1
Detail - Optional
Loop: 2400
Elements: 3
User Option (Usage): Situational
Purpose: To specify any or all of a date, a time, or a time period
Element Summary:
Ref
Id
Element Name
DTP01
374
Date/Time Qualifier
Req
Type
Min/Max
Usage
M
ID
3/3
Required
Description: Code specifying type of date or time, or both date and time
Industry: Date Time Qualifier
CodeList Summary (Total Codes: 1112, Included: 1)
Code Name
453
DTP02
1250
Acute Manifestation of a Chronic Condition
Date Time Period Format Qualifier
M
ID
2/3
Required
Description: Code indicating the date format, time format, or date and time format
CodeList Summary (Total Codes: 39, Included: 1)
Code Name
D8
DTP03
1251
Date Expressed in Format CCYYMMDD
Date Time Period
M
AN
1/35
Required
Description: Expression of a date, a time, or range of dates, times or dates and times
Industry: Acute Manifestation Date
NSF Reference: GC0-12.0
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
Notes:
1. Required for spinal manipulation certifications if different than information at claim level (Loop ID-2300).
2. The total number of DTP segments in the 2400 loop cannot exceed 15.
Example:
DTP*453*D8*19961230~
837P_CG.ecs
317
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 455
DTP Date - Initial Treatment
Max: 1
Detail - Optional
Loop: 2400
Elements: 3
User Option (Usage): Situational
Purpose: To specify any or all of a date, a time, or a time period
Element Summary:
Ref
Id
Element Name
DTP01
374
Date/Time Qualifier
Req
Type
Min/Max
Usage
M
ID
3/3
Required
Description: Code specifying type of date or time, or both date and time
Industry: Date Time Qualifier
CodeList Summary (Total Codes: 1112, Included: 1)
Code Name
454
DTP02
1250
Initial Treatment
Date Time Period Format Qualifier
M
ID
2/3
Required
Description: Code indicating the date format, time format, or date and time format
CodeList Summary (Total Codes: 39, Included: 1)
Code Name
D8
DTP03
1251
Date Expressed in Format CCYYMMDD
Date Time Period
M
AN
1/35
Required
Description: Expression of a date, a time, or range of dates, times or dates and times
Industry: Initial Treatment Date
NSF Reference: GC0-05.0
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
Notes:
1. Required on all claims involving spinal manipulation for Medicare Part B if different than information at the
claim level (Loop ID-2300).
2. The total number of DTP segments in the 2400 loop cannot exceed 15.
Example:
DTP*454*D8*19970112~
837P_CG.ecs
318
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 455
DTP Date - Similar
Max: 1
Detail - Optional
Illness/Symptom Onset
Loop: 2400
Elements: 3
User Option (Usage): Situational
Purpose: To specify any or all of a date, a time, or a time period
Element Summary:
Ref
Id
Element Name
DTP01
374
Date/Time Qualifier
Req
Type
Min/Max
Usage
M
ID
3/3
Required
Description: Code specifying type of date or time, or both date and time
Industry: Date Time Qualifier
CodeList Summary (Total Codes: 1112, Included: 1)
Code Name
438
DTP02
1250
Onset of Similar Symptoms or Illness
Date Time Period Format Qualifier
M
ID
2/3
Required
Description: Code indicating the date format, time format, or date and time format
CodeList Summary (Total Codes: 39, Included: 1)
Code Name
D8
DTP03
1251
Date Expressed in Format CCYYMMDD
Date Time Period
M
AN
1/35
Required
Description: Expression of a date, a time, or range of dates, times or dates and times
Industry: Similar Illness or Symptom Date
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
Notes:
1. Required if line value is different than value given at claim level (Loop ID-2300) and claim involves services to
a patient experiencing symptoms similar or identical to previously reported symptoms.
2. The total number of DTP segments in the 2400 loop cannot exceed 15.
Example:
DTP*438*D8*19970115~
837P_CG.ecs
319
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 462
MEA Test Result
Max: 20
Detail - Optional
Loop: 2400
Elements: 3
User Option (Usage): Situational
Purpose: To specify physical measurements or counts, including dimensions, tolerances, variances, and
weights(See Figures Appendix for example of use of C001)
Element Summary:
Ref
Id
Element Name
MEA01
737
Measurement Reference ID Code
Req
Type
Min/Max
Usage
O
ID
2/2
Required
Description: Code identifying the broad category to which a measurement applies
Industry: Measurement Reference Identification Code
Alias: Measurement identifier
CodeList Summary (Total Codes: 152, Included: 2)
Code Name
MEA02
738
OG
Original
Starting dosage
TR
Test Results
Measurement Qualifier
O
ID
1/3
Required
Description: Code identifying a specific product or process characteristic to which a
measurement applies
CodeList Summary (Total Codes: 920, Included: 7)
Code Name
HT
R1
R2
R3
R4
ZO
GRA
MEA03
739
Height
Hemoglobin
Hematocrit
Epoetin Starting Dosage
Creatin
Oxygen
Gas Test Rate
Measurement Value
C
R
1/20
Required
Description: The value of the measurement
Industry: Test Results
NSF Reference: FA0-42.0 - Hemoglobin, FA0-43.0 - Hematocrit, FA0-45.0 - Epoetin
Starting Dosage, FA0-47.0 - Creatin, GX0-17.0 - Arterial Blood Gas on 4 liters/minute,
GX0-18.0 - Oxygen Saturation on 4 liters/minute, GU0-16.0 - Patient Height
Syntax Rules:
1.
2.
3.
4.
5.
R03050608 - At least one of MEA03, MEA05, MEA06 or MEA08 is required.
C0504 - If MEA05 is present, then MEA04 is required.
C0604 - If MEA06 is present, then MEA04 is required.
L07030506 - If MEA07 is present, then at least one of MEA03, MEA05 or MEA06 is required.
E0803 - Only one of MEA08 or MEA03 may be present.
837P_CG.ecs
320
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Semantics:
1. MEA04 defines the unit of measure for MEA03, MEA05, and MEA06.
Comments:
1. When citing dimensional tolerances, any measurement requiring a sign (+ or -), or any measurement where a
positive (+) value cannot be assumed, use MEA05 as the negative (-) value and MEA06 as the positive (+)
value.
Notes:
1. Required on service lines for Dialysis for ESRD. Use R1, R2, R3, or R4 to qualify the Hemoglobin, Hematocrit,
Epoetin Starting Dosage and Creatinine test results.
2. Required on Oxygen Therapy service lines to report the Oxygen Saturation measurement from the Certificate
of Medical Necessity (CMN). Use ZO qualifier.
3. Required on Oxygen Therapy service lines to report the Arterial Blood Gas measurement from the Certificate
of Medical Necessity (CMN). Use GRA qualifier.
4. Required on DMERC service lines to report the Patient’s Height from the Certificate of Medical Necessity
(CMN). Use HT qualifier.
Example:
MEA*TR*R1*113.4~
837P_CG.ecs
321
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 465
CN1 Contract Information
Max: 1
Detail - Optional
Loop: 2400
Elements: 6
User Option (Usage): Situational
Purpose: To specify basic data about the contract or contract line item
Element Summary:
Ref
Id
Element Name
CN101
1166
Contract Type Code
Req
Type
Min/Max
Usage
M
ID
2/2
Required
Description: Code identifying a contract type
Alias: Contract type code
The developers of this implementation guide recommend always providing CN101 for
capitated encounters.
CodeList Summary (Total Codes: 50, Included: 7)
Code Name
01
02
03
04
05
06
09
CN102
782
Diagnosis Related Group (DRG)
Per Diem
Variable Per Diem
Flat
Capitated
Percent
Other
Monetary Amount
O
R
1/18
Situational
Description: Monetary amount
Industry: Contract Amount
Required if information is different than that given at claim level (Loop ID-2300).
CN103
332
Percent
O
R
1/6
Situational
Description: Percent expressed as a percent
Industry: Contract Percentage
Alias: Contract Allowance or Charge Percent
Required if information is different than that given at claim level (Loop ID-2300).
CN104
127
Reference Identification
O
AN
1/30
Situational
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Contract Code
Required if information is different than that given at claim level (Loop ID-2300).
CN105
338
Terms Discount Percent
O
R
1/6
Situational
Description: Terms discount percentage, expressed as a percent, available to the
purchaser if an invoice is paid on or before the Terms Discount Due Date
Industry: Terms Discount Percentage
Alias: Terms discount percent
Required if information is different than that given at claim level (Loop ID-2300).
837P_CG.ecs
322
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Ref
Id
Element Name
CN106
799
Version Identifier
Req
Type
Min/Max
Usage
O
AN
1/30
Situational
Description: Revision level of a particular format, program, technique or algorithm
Industry: Contract Version Identifier
Alias: Contract Version
Required if information is different than that given at claim level (Loop ID-2300).
Semantics:
1.
2.
3.
4.
CN102
CN103
CN104
CN106
is the contract amount.
is the allowance or charge percent.
is the contract code.
is an additional identifying number for the contract.
Notes:
1. Information contained at this level overwrites CN1 information at the claim level for this specific service line.
Example:
CN1*04*410.5~
837P_CG.ecs
323
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 470
REF Repriced Line Item
Max: 1
Detail - Optional
Reference Number
Loop: 2400
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
1/30
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 1)
Code Name
9B
REF02
127
Repriced Line Item Reference Number
Reference Identification
C
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Repriced Line Item Reference Number
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. This segment is intended to be used exclusively by repricing (pricing) organizations who have a need to
identify a certain line in their claim submission transmission to their payer organization.
Example:
REF*9B*444444~
837P_CG.ecs
324
For internal use only
12/1/2010
Health Care Claim: Professional - 837
REF Adjusted Repriced Line Item
Reference Number
Pos: 470
Max: 1
Detail - Optional
Loop: 2400
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
1/30
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 1)
Code Name
9D
REF02
127
Adjusted Repriced Line Item Reference Number
Reference Identification
C
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Adjusted Repriced Line Item Reference Number
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. This segment is intended to be used exclusively by repricing (pricing) organizations who have a need to
identify a certain line in their claim submission transmission to their payer organization.
Example:
REF*9D*444444~
837P_CG.ecs
325
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 470
REF Prior Authorization or
Max: 2
Detail - Optional
Referral Number
Loop: 2400
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
1/30
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 2)
Code Name
9F
G1
REF02
127
Referral Number
Prior Authorization Number
Reference Identification
C
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Prior Authorization or Referral Number
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
Required if service line involved a prior authorization number or referral number that is different than the number
reported at the claim level (Loop-ID 2300).
Example:
REF*9F*12345678~
User Note 6:
BSC cannot accept more that one prior authorization number per claim. This information is reported in Loop 2300.
837P_CG.ecs
326
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 470
REF Line Item Control Number
Max: 1
Detail - Optional
Loop: 2400
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
1/30
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 1)
Code Name
6R
REF02
127
Provider Control Number
Reference Identification
C
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Line Item Control Number
NSF Reference: FA0-04.0, FB0-04.0, FB1-04.0, FB2-04.0, FD0-04.0, FE0-04.0, HA0-04.0
User Note 6:
Provider Control Number: Please submit this to assist in posting 835s.
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. Required if it is necessary to send a line control or inventory number. Providers are STRONGLY encouraged to
routinely send a unique line item control number on all service lines, particularly if the provider automatically posts
their remittance advice. Submitting a unique line item control number gives providers the capability to
automatically post by service line. The line item control number should be unique within a patient control number
(CLM01). Payers are required to return this number in the remittance advice transaction (835) if the providers
sends it to them in the 837.
Example:
REF*6R*54321~
837P_CG.ecs
327
For internal use only
12/1/2010
Health Care Claim: Professional - 837
REF Mammography Certification
Number
Pos: 470
Max: 1
Detail - Optional
Loop: 2400
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
1/30
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 1)
Code Name
EW
REF02
127
Mammography Certification Number
Reference Identification
C
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Mammography Certification Number
NSF Reference: FA0-31.0
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. Required when mammography services are rendered by a certified mammography provider.
Example:
REF*EW*T554~
837P_CG.ecs
328
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 470
REF Clinical Laboratory
Max: 1
Detail - Optional
Improvement Amendment
(CLIA) Identification
Loop: 2400
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
1/30
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 1)
Code Name
X4
REF02
127
Clinical Laboratory Improvement Amendment Number
Reference Identification
C
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Clinical Laboratory Improvement Amendment Number
NSF Reference: FA0-34.0
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. Required for all CLIA certified facilities performing CLIA covered laboratory services and if number is different
than CLIA number reported at claim level (Loop ID-2300).
Example:
REF*X4*12D4567890~
837P_CG.ecs
329
For internal use only
12/1/2010
Health Care Claim: Professional - 837
REF Referring Clinical Laboratory
Improvement Amendment
(CLIA) Facility Identification
Pos: 470
Max: 1
Detail - Optional
Loop: 2400
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
1/30
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 1)
Code Name
F4
REF02
127
Facility Certification Number
Reference Identification
C
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Referring CLIA Number
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. Required for Medicare claims for any laboratory that referred tests to another laboratory covered by the CLIA
Act that is billed on this line.
Example:
REF*F4*34D1234567~
837P_CG.ecs
330
For internal use only
12/1/2010
Health Care Claim: Professional - 837
REF Immunization Batch Number
Pos: 470
Max: 1
Detail - Optional
Loop: 2400
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
1/30
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 1)
Code Name
BT
REF02
127
Batch Number
Reference Identification
C
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Immunization Batch Number
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. Use when required by state law for health data reporting.
Example:
REF*BT*DTP22333444~
837P_CG.ecs
331
For internal use only
12/1/2010
Health Care Claim: Professional - 837
REF Ambulatory Patient Group
(APG)
Pos: 470
Max: 4
Detail - Optional
Loop: 2400
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
1/30
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 1)
Code Name
1S
REF02
127
Ambulatory Patient Group (APG) Number
Reference Identification
C
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Ambulatory Patient Group Number
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. Used at discretion of submitter.
Example:
REF*1S*XXXXX~
837P_CG.ecs
332
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 470
REF Oxygen Flow Rate
Max: 1
Detail - Optional
Loop: 2400
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
1/30
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 1)
Code Name
TP
REF02
127
Test Specification Number
Oxygen Flow Rate
Reference Identification
C
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Oxygen Flow Rate
NSF Reference: GX0-14.0
Valid values are 1 - 999 liters per minute and X for less than 1 liter per minute.
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. Required on oxygen therapy certificate of medical necessity (CMN) claim where service line reports oxygen
flow rate.
Example:
REF*TP*002~
837P_CG.ecs
333
For internal use only
12/1/2010
Health Care Claim: Professional - 837
REF Universal Product Number
(UPN)
Pos: 470
Max: 1
Detail - Optional
Loop: 2400
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 2)
Code Name
REF02
127
OZ
Product Number
Code Source 41
Use to indicate Health Care Uniform Code Council System. See Appendix C, code
source 41.
VP
Vendor Product Number
Code Source 522
Use to indicate Health Industry Business Communications Council system. See
Appendix C, code source 522.
Reference Identification
C
AN
1/30
Required
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Universal Product Number
NSF Reference: FA0-62.0
ExternalCodeList
Name: 41
Description: Universal Product Code
ExternalCodeList
Name: 522
Description: Health Industry Labeler Identification Code
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. X12N has been informed by HCFA that this information will be required on Medicare claims in the near future.
It may also be required by some state Medicaids. This segment has been added to the 4010 implementation
guide to allow providers to meet the Medicare/Medicaid requirements when they are implemented. When
implemented by Medicare/Medicaid, the UPN is required on claim/encounters when an item/supply is being
billed/reported that has an associated UPN included in the Health Care Uniform Code Council system or the
Health Industry Business Communications Council system. See Appendix C for Code Source 41 and 522.
Example:
837P_CG.ecs
334
For internal use only
12/1/2010
Health Care Claim: Professional - 837
REF*OZ*5737904086~
837P_CG.ecs
335
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 475
AMT Sales Tax Amount
Max: 1
Detail - Optional
Loop: 2400
Elements: 2
User Option (Usage): Situational
Purpose: To indicate the total monetary amount
Element Summary:
Ref
Id
Element Name
AMT01
522
Amount Qualifier Code
Req
Type
Min/Max
Usage
M
ID
1/3
Required
R
1/18
Required
Description: Code to qualify amount
CodeList Summary (Total Codes: 1473, Included: 1)
Code Name
T
AMT02
782
Tax
Monetary Amount
M
Description: Monetary amount
Industry: Sales Tax Amount
Notes:
1. Required if sales tax applies to service line and submitter is required to report that information to the receiver.
Example:
AMT*T*45~
837P_CG.ecs
336
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 475
AMT Approved Amount
Max: 1
Detail - Optional
Loop: 2400
Elements: 2
User Option (Usage): Situational
Purpose: To indicate the total monetary amount
Element Summary:
Ref
Id
Element Name
AMT01
522
Amount Qualifier Code
Req
Type
Min/Max
Usage
M
ID
1/3
Required
R
1/18
Required
Description: Code to qualify amount
CodeList Summary (Total Codes: 1473, Included: 1)
Code Name
AAE
AMT02
782
Approved Amount
Monetary Amount
M
Description: Monetary amount
Industry: Approved Amount
NSF Reference: FA0-51.0
Notes:
1. Used primarily in payer-to-payer COB situations by the payer who is sending this claim to another payer.
Providers (in a provider-to-payer COB situation) do not usually complete this information but may do so if the
information is available.
2. The allowed amount equals the amount for the service line that was approved by the payer sending this 837 to
another payer.
Example:
AMT*AAE*125~
837P_CG.ecs
337
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 475
AMT Postage Claimed Amount
Max: 1
Detail - Optional
Loop: 2400
Elements: 2
User Option (Usage): Situational
Purpose: To indicate the total monetary amount
Element Summary:
Ref
Id
Element Name
AMT01
522
Amount Qualifier Code
Req
Type
Min/Max
Usage
M
ID
1/3
Required
R
1/18
Required
Description: Code to qualify amount
CodeList Summary (Total Codes: 1473, Included: 1)
Code Name
F4
AMT02
782
Postage Claimed
Monetary Amount
M
Description: Monetary amount
Industry: Postage Claimed Amount
Notes:
1. Required if service line charge (SV102) includes postage amount claimed in this service line.
Example:
AMT*F4*56.78~
837P_CG.ecs
338
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 480
K3 File Information
Max: 10
Detail - Optional
Loop: 2400
Elements: 1
User Option (Usage): Situational
Purpose: To transmit a fixed-format record or matrix contents
Element Summary:
Ref
Id
Element Name
K301
449
Fixed Format Information
Req
Type
Min/Max
Usage
M
AN
1/80
Required
Description: Data in fixed format agreed upon by sender and receiver
NSF Reference: HA0-05.0
Semantics:
1. K303 identifies the value of the index.
Comments:
1. The default for K302 is content.
Notes:
1. This segment may only be required if a state concludes it must use the K3 to meet an emergency legislative
requirement AND the administering state agency or other state organization has contacted the X12N workgroup,
requested a review of the K3 data requirement to ensure there is not an existing method within the
implementation guide to meet this requirement, and X12N determines that there is no method to meet the
requirement. Only then may the state require the temporary use of the K3 to meet the requirement. X12N will
submit the necessary data maintenance and refer the request to the appropriate
Example:
K3*STATE DATA REQUIREMENT~
837P_CG.ecs
339
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 485
NTE Line Note
Max: 1
Detail - Optional
Loop: 2400
Elements: 2
User Option (Usage): Situational
Purpose: To transmit information in a free-form format, if necessary, for comment or special instruction
Element Summary:
Ref
Id
Element Name
NTE01
363
Note Reference Code
Req
Type
Min/Max
Usage
O
ID
3/3
Required
Description: Code identifying the functional area or purpose for which the note applies
User Note 6:
Only “ADD” is acceptable for home infusion/drug claims.
User Note 7:
AMBULANCE
Used in conjunction with NTE02 to identify the purpose of the notes in NTE02.
Use ADD
CodeList Summary (Total Codes: 241, Included: 4)
Code Name
ADD
DCP
PMT
TPO
NTE02
352
Additional Information
Goals, Rehabilitation Potential, or Discharge Plans
Payment
Third Party Organization Notes
Description
M
AN
1/80
Required
Description: A free-form description to clarify the related data elements and their content
Industry: Line Note Text
NSF Reference: HA0-05.0
User Note 6:
Home Infusion and Drugs
Name of drug and any pertinent information. UP TO 80 BYTES.
User Note 7:
AMBULANCE
Free Format Comments field.
Comments:
1. The NTE segment permits free-form information/data which, under ANSI X12 standard implementations, is not
machine processable. The use of the NTE segment should therefore be avoided, if at all possible, in an
automated environment.
Notes:
1. Required if submitter used a"not otherwise classified" (NOC) procedure code on this service line (use ADD in
NTE01). Otherwise, use at providers discretion.
Example:
NTE*DCP*PATIENT GOAL TO BE OFF OXYGEN BY END OF MONTH~
837P_CG.ecs
340
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 488
PS1 Purchased Service
Max: 1
Detail - Optional
Information
Loop: 2400
Elements: 2
User Option (Usage): Situational
Purpose: To specify the information about services that are purchased
Element Summary:
Ref
Id
Element Name
PS101
127
Reference Identification
Req
Type
Min/Max
Usage
M
AN
1/30
Required
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Purchased Service Provider Identifier
NSF Reference: FB0-11.0
PS102
782
Monetary Amount
M
R
1/18
Required
Description: Monetary amount
Industry: Purchased Service Charge Amount
NSF Reference: FB0-05.0
Semantics:
1. PS101 is provider identification number.
2. PS102 is cost of the purchased service.
3. PS103 is the state where the service is purchased.
Notes:
1. Using the PS1 segment indicates that services were purchased from another source.
2. Required on service lines when the purchased service charge amount is necessary for processing.
3. Use this segment on vision claims when the acquisition cost of lenses is known to impact adjudication or
reimbursement.
Example:
PS1*PN222222*110~
837P_CG.ecs
341
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 491
HSD Health Care Services
Max: 1
Detail - Optional
Delivery
Loop: 2400
Elements: 8
User Option (Usage): Situational
Purpose: To specify the delivery pattern of health care services
Element Summary:
Ref
Id
Element Name
HSD01
673
Quantity Qualifier
Req
Type
Min/Max
Usage
C
ID
2/2
Situational
Description: Code specifying the type of quantity
Industry: Visits
Required if information is different than that given at claim level (Loop ID-2300).
CodeList Summary (Total Codes: 832, Included: 1)
Code Name
VS
HSD02
380
Visits
Quantity
C
R
1/15
Situational
Description: Numeric value of quantity
Industry: Number of Visits
HDS02 qualifies HSD01.
Required if information is different than that given at claim level (Loop ID-2300).
HSD03
355
Unit or Basis for Measurement Code
O
ID
2/2
Situational
Description: Code specifying the units in which a value is being expressed, or manner in
which a measurement has been taken
Industry: Frequency Period
Required if information is different than that given at claim level (Loop ID-2300).
CodeList Summary (Total Codes: 794, Included: 4)
Code Name
HSD04
1167
DA
MO
Days
Months
Month
Q1
WK
Quarter (Time)
Week
Sample Selection Modulus
O
R
1/6
Situational
Description: To specify the sampling frequency in terms of a modulus of the Unit of
Measure, e.g., every fifth bag, every 1.5 minutes
Industry: Frequency Count
Required if information is different than that given at claim level (Loop ID-2300).
HSD05
615
Time Period Qualifier
C
ID
1/2
Situational
Description: Code defining periods
Industry: Duration of Visits Units
Required if information is different than that given at claim level (Loop ID-2300).
837P_CG.ecs
342
For internal use only
12/1/2010
Ref
Health Care Claim: Professional - 837
Id
Element Name
Req
Type
Min/Max
Usage
N0
1/3
Situational
CodeList Summary (Total Codes: 36, Included: 3)
Code Name
7
34
35
HSD06
616
Day
Month
Week
Number of Periods
O
Description: Total number of periods
Industry: Duration of Visits, Number of Units
Required if information is different than that given at claim level (Loop ID-2300).
HSD07
678
Ship/Delivery or Calendar Pattern Code
O
ID
1/2
Situational
Description: Code which specifies the routine shipments, deliveries, or calendar pattern
Industry: Ship, Delivery or Calendar Pattern Code
Required if information is different than that given at claim level (Loop ID-2300).
CodeList Summary (Total Codes: 44, Included: 31)
Code Name
1
2
3
4
5
6
7
A
B
C
D
E
F
G
H
J
K
L
N
O
W
SA
SB
SC
SD
SG
SL
SP
SX
837P_CG.ecs
1st Week of the Month
2nd Week of the Month
3rd Week of the Month
4th Week of the Month
5th Week of the Month
1st & 3rd Weeks of the Month
2nd & 4th Weeks of the Month
Monday through Friday
Monday through Saturday
Monday through Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Monday through Thursday
As Directed
Daily Mon. through Fri.
Whenever Necessary
Sunday, Monday, Thursday, Friday, Saturday
Tuesday through Saturday
Sunday, Wednesday, Thursday, Friday, Saturday
Monday, Wednesday, Thursday, Friday, Saturday
Tuesday through Friday
Monday, Tuesday and Thursday
Monday, Tuesday and Friday
Wednesday and Thursday
343
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Code Name
SY
SZ
HSD08
679
Monday, Wednesday and Thursday
Tuesday, Thursday and Friday
Ship/Delivery Pattern Time Code
O
ID
1/1
Situational
Description: Code which specifies the time for routine shipments or deliveries
Industry: Delivery Pattern Time Code
Required if information is different than that given at claim level (Loop ID-2300).
CodeList Summary (Total Codes: 9, Included: 3)
Code Name
D
E
F
A.M.
P.M.
As Directed
Syntax Rules:
1. P0102 - If either HSD01 or HSD02 is present, then the other is required.
2. C0605 - If HSD06 is present, then HSD05 is required.
Notes:
1. The HSD segment is used to specify the delivery pattern of the health care services. This is how it is used:
HSD01 qualifies HSD02: If the value in HSD02=1 and the value in HSD01=VS (Visits), this means “one visit”.
Between HSD02 and HSD03 verbally insert a “per every.”
HSD03 qualifies HSD04: If the value in HSD04=3 and the value in HSD03=DA (Day), this means “three days.”
Between HSD04 and HSD05 verbally insert a “for.”
HSD05 qualifies HSD06: If the value in HSD06=21 and the value in HSD05=7 (Days), this means “21 days.”
The total message reads:
HSD*VS*1*DA*3*7*21~ = “One visit per every three days for 21 days.”
Another similar data string of HSD*VS*2*DA*4*7*20~ = Two visits per every four days for 20 days.
An alternate way to use HSD is to employ HSD07 and/or HSD08. A data string of HSD*VS*1*****SX*D~ means “1
visit on Wednesday and Thursday morning.”
2. Required on claims/encounters billing/reporting home health visits where further detail is necessary to clearly
substantiate medical treatment and if information is different than that given at claim level (Loop ID-2300).
Example:
HSD*VS*1*DA*1*7*10~ (This indicates ''1 visit every (per) 1 day (daily) for 10 days'')
HSD*VS*1*DA****W~ (This indicates ''1 visit per day whenever necessary'')
837P_CG.ecs
344
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 492
HCP Line Pricing/Repricing
Max: 1
Detail - Optional
Information
Loop: 2400
Elements: 14
User Option (Usage): Situational
Purpose: To specify pricing or repricing information about a health care claim or line item
Element Summary:
Ref
Id
Element Name
HCP01
1473
Pricing Methodology
Req
Type
Min/Max
Usage
C
ID
2/2
Required
Description: Code specifying pricing methodology at which the claim or line item has been
priced or repriced
Alias: Pricing/repricing methodology
Trading partners need to agree on the codes to use in this element. There do not appear to
be standard definitions for the code elements.
Used only by repricers as needed. This information is specific to the destination payer
reported in the 2010BB loop.
All valid standard codes are used. (Total Codes: 15)
HCP02
782
Monetary Amount
O
R
1/18
Required
Description: Monetary amount
Industry: Repriced Allowed Amount
Alias: Pricing/Repricing Allowed Amount
Used only by repricers as needed. This information is specific to the destination payer
reported in the 2010BB loop.
HCP03
782
Monetary Amount
O
R
1/18
Situational
Description: Monetary amount
Industry: Repriced Saving Amount
Alias: Pricing/Repricing Savings Amount
Used only by repricers as needed. This information is specific to the destination payer
reported in the 2010BB loop.
HCP04
127
Reference Identification
O
AN
1/30
Situational
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Repricing Organization Identifier
Alias: Pricing/Repricing Identification Number
Used only by repricers as needed. This information is specific to the destination payer
reported in the 2010BB loop.
HCP05
118
Rate
O
R
1/9
Situational
Description: Rate expressed in the standard monetary denomination for the currency
specified
Industry: Repricing Per Diem or Flat Rate Amount
Alias: Pricing/Repricing Rate
Used only by repricers as needed. This information is specific to the destination payer
reported in the 2010BB loop.
837P_CG.ecs
345
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Ref
Id
Element Name
HCP06
127
Reference Identification
Req
Type
Min/Max
Usage
O
AN
1/30
Situational
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Repriced Approved Ambulatory Patient Group Code
Alias: Approved APG code, Pricing
Used only by repricers as needed. This information is specific to the destination payer
reported in the 2010BB loop.
HCP07
782
Monetary Amount
O
R
1/18
Situational
Description: Monetary amount
Industry: Repriced Approved Ambulatory Patient Group Amount
Alias: Approved APG amount, Pricing
Used only by repricers as needed. This information is specific to the destination payer
reported in the 2010BB loop.
HCP09
235
Product/Service ID Qualifier
C
ID
2/2
Situational
Description: Code identifying the type/source of the descriptive number used in
Product/Service ID (234)
Industry: Product or Service ID Qualifier
Used only by repricers as needed. This information is specific to the destination payer
reported in the 2010BB loop.
CodeList Summary (Total Codes: 477, Included: 3)
Code Name
HC
Health Care Financing Administration Common Procedural Coding System
(HCPCS) Codes
Because the AMA’s CPT codes are also level 1 HCPCS codes, they are reported
under HC.
CODE SOURCE:
130: Health Care Financing Administration Common Procedural Coding System
IV
Home Infusion EDI Coalition (HIEC) Product/Service Code
CODE SOURCE:
513: Home Infusion EDI Coalition (HIEC) Product/Service Code List
ZZ
HCP10
234
Mutually Defined
Jurisdictionally Defined Procedure and Supply Codes. (Used for Worker’s
Compensation claims). Contact your local (State) Jurisdiction for a list of these
codes.
Product/Service ID
C
AN
1/48
Situational
Description: Identifying number for a product or service
Industry: Procedure Code
Alias: Pricing/Repricing Approved Procedure Code
Used only by repricers as needed. This information is specific to the destination payer
reported in the 2010BB loop.
ExternalCodeList
Name: 130
Description: Health Care Financing Administration Common Procedural Coding System
ExternalCodeList
837P_CG.ecs
346
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Name: 513
Description: Home Infusion EDI Coalition (HIEC) Product/Service Code List
HCP11
355
Unit or Basis for Measurement Code
C
ID
2/2
Situational
Description: Code specifying the units in which a value is being expressed, or manner in
which a measurement has been taken
Used only by repricers as needed. This information is specific to the destination payer
reported in the 2010BB loop.
CodeList Summary (Total Codes: 794, Included: 2)
Code Name
DA
UN
HCP12
380
Days
Unit
Quantity
C
R
1/15
Situational
Description: Numeric value of quantity
Industry: Repriced Approved Service Unit Count
Alias: Pricing/Repricing Approved Units or Inpatient Days
Used only by repricers as needed. This information is specific to the destination payer
reported in the 2010BB loop.
HCP13
901
Reject Reason Code
C
ID
2/2
Situational
Description: Code assigned by issuer to identify reason for rejection
Alias: Reject reason code
Used only by repricers as needed. This information is specific to the destination payer
reported in the 2010BB loop.
CodeList Summary (Total Codes: 181, Included: 6)
Code Name
T1
T2
T3
T4
T5
T6
HCP14
1526
Cannot Identify Provider as TPO (Third Party Organization) Participant
Cannot Identify Payer as TPO (Third Party Organization) Participant
Cannot Identify Insured as TPO (Third Party Organization) Participant
Payer Name or Identifier Missing
Certification Information Missing
Claim does not contain enough information for re-pricing
Policy Compliance Code
O
ID
1/2
Situational
Description: Code specifying policy compliance
Alias: Policy compliance code
Used only by repricers as needed. This information is specific to the destination payer
reported in the 2010BB loop.
All valid standard codes are used. (Total Codes: 5)
HCP15
1527
Exception Code
O
ID
1/2
Situational
Description: Code specifying the exception reason for consideration of out-of-network
health care services
Alias: Exception code
Used only by repricers as needed. This information is specific to the destination payer
reported in the 2010BB loop.
All valid standard codes are used. (Total Codes: 6)
837P_CG.ecs
347
For internal use only
12/1/2010
Ref
Health Care Claim: Professional - 837
Id
Element Name
Req
Type
Min/Max
Usage
Syntax Rules:
1. R0113 - At least one of HCP01 or HCP13 is required.
2. P0910 - If either HCP09 or HCP10 is present, then the other is required.
3. P1112 - If either HCP11 or HCP12 is present, then the other is required.
Semantics:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
HCP02 is the allowed amount.
HCP03 is the savings amount.
HCP04 is the repricing organization identification number.
HCP05 is the pricing rate associated with per diem or flat rate repricing.
HCP06 is the approved DRG code.
HCP07 is the approved DRG amount.
HCP08 is the approved revenue code.
HCP10 is the approved procedure code.
HCP12 is the approved service units or inpatient days.
HCP13 is the rejection message returned from the third party organization.
HCP15 is the exception reason generated by a third party organization.
Comments:
1. HCP06, HCP07, HCP08, HCP10, and HCP12 are fields that will contain different values from the original
submitted values.
Notes:
1. Used only by repricers as needed. This information is specific to the destination payer reported in the 2010BB
loop.
Example:
HCP*03*100*10*RPO12345~
837P_CG.ecs
348
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 494
Loop Drug Identification
Repeat: 25
Optional
Loop: 2410 Elements: N/A
User Option (Usage): Situational
Purpose: To specify basic item identification data
Loop Summary:
Pos
Id
Segment Name
494
495
496
LIN
CTP
REF
Drug Identification
Drug Pricing
Prescription Number
Req
Max Use
O
O
O
1
1
1
Repeat
Usage
Situational
Situational
Situational
Notes:
1. 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 eporting/adjudication processes. The NDC number is reported in
the LIN segment of Loop ID-2410.
2. Use Loop ID 2410 to specify billing/reporting for drugs provided that may be part of the service(s) described in
SV1.
Example:
LIN**N4*01234567891~
837P_CG.ecs
349
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 494
LIN Drug Identification
Max: 1
Detail - Optional
Loop: 2410
Elements: 2
User Option (Usage): Situational
Purpose: To specify basic item identification data
Element Summary:
Ref
Id
Element Name
LIN02
235
Product/Service ID Qualifier
Req
Type
Min/Max
Usage
M
ID
2/2
Required
Description: Code identifying the type/source of the descriptive number used in
Product/Service ID (234)
Industry: Product or Service ID Qualifier
User Note 6:
Code: N4 National drug format 5-4-2
User Note 7:
Home Infusion and Drugs
Use qualifier “N4” for NDC format 5-4-2 (Loop 2410 LIN02)
CodeList Summary (Total Codes: 477, Included: 1)
Code Name
N4
National Drug Code in 5-4-2 Format
CODE SOURCE:
240: National Drug Code by Format
LIN03
234
Product/Service ID
M
AN
1/48
Required
Description: Identifying number for a product or service
Industry: National Drug Code
Alias: National Drug Code
User Note 6:
Home Infusion and Drugs
Report the National Drug Code.
If the price of the NDC drug reported in LIN03 is different from the charges reported in the
SV102, create a CTP segment in Loop 2410.
ExternalCodeList
Name: 240
Description: National Drug Code by Format
Syntax Rules:
1.
2.
3.
4.
5.
6.
7.
8.
P0405 - If either LIN04 or LIN05
P0607 - If either LIN06 or LIN07
P0809 - If either LIN08 or LIN09
P1011 - If either LIN10 or LIN11
P1213 - If either LIN12 or LIN13
P1415 - If either LIN14 or LIN15
P1617 - If either LIN16 or LIN17
P1819 - If either LIN18 or LIN19
837P_CG.ecs
is present, then the other is required.
is present, then the other is required.
is present, then the other is required.
is present, then the other is required.
is present, then the other is required.
is present, then the other is required.
is present, then the other is required.
is present, then the other is required.
350
For internal use only
12/1/2010
9.
10.
11.
12.
13.
14.
P2021 - If either LIN20 or LIN21
P2223 - If either LIN22 or LIN23
P2425 - If either LIN24 or LIN25
P2627 - If either LIN26 or LIN27
P2829 - If either LIN28 or LIN29
P3031 - If either LIN30 or LIN31
Health Care Claim: Professional - 837
is present, then the other is required.
is present, then the other is required.
is present, then the other is required.
is present, then the other is required.
is present, then the other is required.
is present, then the other is required.
Semantics:
1. LIN01 is the line item identification
Comments:
1. See the Data Dictionary for a complete list of IDs.
2. LIN02 through LIN31 provide for fifteen different product/service IDs for each item. For example: Case, Color,
Drawing No., U.P.C. No., ISBN No., Model No., or SKU.
Notes:
1. 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 eporting/adjudication processes. The NDC number is reported in
the LIN segment of Loop ID-2410.
2. Use Loop ID 2410 to specify billing/reporting for drugs provided that may be part of the service(s) described in
SV1.
Example:
LIN**N4*01234567891~
User Note 6:
BSC can take adjudicative action on only the first of any Loop 2410 received.
837P_CG.ecs
351
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 495
CTP Drug Pricing
Max: 1
Detail - Optional
Loop: 2410
Elements: 3
User Option (Usage): Situational
Purpose: To specify pricing information
Element Summary:
Ref
Id
Element Name
CTP03
212
Unit Price
Req
Type
Min/Max
Usage
X
R
1/17
Required
1/15
Required
Description: Price per unit of product, service, commodity, etc.
Industry: Drug Unit Price
Alias: Drug Unit Price
User Note 6:
National Drug Code.
Required only if price is different from how it appears in SV102.
Price per unit of product, service, commodity, etc.
CTP04
380
Quantity
X
R
X
Comp
Description: Numeric value of quantity
Industry: National Drug Unit Count
Alias: National Drug Unit Count
User Note 6:
National drug unit count
Unit or basis of measurement
Include the appropriate qualifier
CTP05
C001
Composite Unit of Measure
Required
Description: To identify a composite unit of measure(See Figures Appendix for examples
of use)
Industry: Unit or Basis of Measurement
Alias: Unit or Basis of Measurement
CTP05-01
355
Unit or Basis for Measurement Code
M
ID
2/2
Required
Description: Code specifying the units in which a value is being expressed, or manner in
which a measurement has been taken
Alias: Code qualifier
User Note 6:
Include the appropriate qualifier:
F2-International unit
GR – gram
ML-milliter
UN-unit
CodeList Summary (Total Codes: 794, Included: 4)
837P_CG.ecs
352
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Code Name
F2
GR
ML
UN
International Unit
Gram
Milliliter
Unit
Syntax Rules:
1.
2.
3.
4.
5.
P0405 - If either CTP04 or CTP05 is present, then the other is required.
C0607 - If CTP06 is present, then CTP07 is required.
C0902 - If CTP09 is present, then CTP02 is required.
C1002 - If CTP10 is present, then CTP02 is required.
C1103 - If CTP11 is present, then CTP03 is required.
Semantics:
1. CTP07 is a multiplier factor to arrive at a final discounted price. A multiplier of .90 would be the factor if a 10%
discount is given.
2. CTP08 is the rebate amount.
Comments:
1. See Figures Appendix for an example detailing the use of CTP03 and CTP04.
2. See Figures Appendix for an example detailing the use of CTP03, CTP04 and CTP07.
Notes:
1. Required when it is necessary to provide a price specific to the NDC provided in LIN03 that is different than the
price reported in SV102.
Example:
CTP***1.15*2*UN~
837P_CG.ecs
353
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 496
REF Prescription Number
Max: 1
Detail - Optional
Loop: 2410
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
1/30
Required
Description: Code qualifying the Reference Identification
Alias: Code qualifier
CodeList Summary (Total Codes: 1503, Included: 1)
Code Name
XZ
REF02
127
Pharmacy Prescription Number
Reference Identification
X
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Prescription Number
Alias: Prescription Number
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. Required if dispensing of the drug has been done with an assigned Rx number.
2. In cases where a compound drug is being billed, the components of the compound will all have the same
prescription number. Payers receiving the claim can relate all the components by matching the prescription
number.
Example:
REF*XZ*123456~
837P_CG.ecs
354
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 500
Loop Rendering Provider Name
Repeat: 1
Optional
Loop:
2420A
Elements: N/A
User Option (Usage): Situational
Purpose: To supply the full name of an individual or organizational entity
Loop Summary:
Pos
Id
Segment Name
500
505
525
NM1
PRV
REF
Rendering Provider Name
Rendering Provider Specialty Information
Rendering Provider Secondary
Identification
Req
Max Use
O
O
O
1
1
5
Repeat
Usage
Situational
Situational
Situational
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
Notes:
1. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,
then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.
2. Required if the Rendering Provider NM1 information is different than that carried in the 2310B (claim) loop, or if
the Rendering provider information is carried at the Billing/Pay-to Provider loop level (2010AA/AB) and this
particular service line has a different Rendering Provider that what is given in the 2010AA/AB loop. The
identifying payer-specific numbers are those that belong to the destination payer identified in loop 2010BB.
3. 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 subsitute provider (locum
tenans) was used, that person should be entered here.
Example:
NM1*82*1*SMITH*JUNE*L***XX*87654321~
User Note 6:
Do not use if the information is the same as Loop 2310.
837P_CG.ecs
355
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 500
NM1 Rendering Provider Name
Max: 1
Detail - Optional
Loop:
2420A
Elements: 8
User Option (Usage): Situational
Purpose: To supply the full name of an individual or organizational entity
Element Summary:
Ref
Id
Element Name
NM101
98
Entity Identifier Code
Req
Type
Min/Max
Usage
M
ID
2/3
Required
Description: Code identifying an organizational entity, a physical location, property or an
individual
The entity identifier in NM101 applies to all segments in this iteration of Loop ID-2420.
CodeList Summary (Total Codes: 1312, Included: 1)
Code Name
82
NM102
1065
Rendering Provider
Entity Type Qualifier
M
ID
1/1
Required
AN
1/35
Required
Description: Code qualifying the type of entity
CodeList Summary (Total Codes: 14, Included: 2)
Code Name
1
2
NM103
1035
Person
Non-Person Entity
Name Last or Organization Name
O
Description: Individual last name or organizational name
Industry: Rendering Provider Last or Organization Name
Alias: Rendering Provider Last Name
NSF Reference: FB1-14.0
NM104
1036
Name First
O
AN
1/25
Situational
O
AN
1/25
Situational
Description: Individual first name
Industry: Rendering Provider First Name
NSF Reference: FB1-15.0
Required if NM102=1 (person).
NM105
1037
Name Middle
Description: Individual middle name or initial
Industry: Rendering Provider Middle Name
NSF Reference: FB1-16.0
Required if NM102=1 and the middle name/initial of the person is known.
NM107
1039
Name Suffix
O
AN
1/10
Situational
Description: Suffix to individual name
Industry: Rendering Provider Name Suffix
Alias: Rendering Provider Generation
837P_CG.ecs
356
For internal use only
12/1/2010
Ref
Health Care Claim: Professional - 837
Id
Element Name
Req
Type
Min/Max
Usage
C
ID
1/2
Required
Required if known.
NM108
66
Identification Code Qualifier
Description: Code designating the system/method of code structure used for Identification
Code (67)
NSF Reference: FA0-57.0
CodeList Summary (Total Codes: 215, Included: 3)
Code Name
NM109
67
24
34
Employer's Identification Number
Social Security Number
Social Security Number cannot be used for Medicare claims.
XX
Health Care Financing Administration National Provider Identifier
Identification Code
C
AN
2/80
Required
Description: Code identifying a party or other code
Industry: Rendering Provider Identifier
Alias: Rendering Provider Primary Identifier
NSF Reference: FA0-23.0, FA0-58.0
ExternalCodeList
Name: 537
Description: Health Care Financing Administration National Provider Identifier
Syntax Rules:
1. P0809 - If either NM108 or NM109 is present, then the other is required.
2. C1110 - If NM111 is present, then NM110 is required.
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
Notes:
1. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,
then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.
2. Required if the Rendering Provider NM1 information is different than that carried in the 2310B (claim) loop, or if
the Rendering provider information is carried at the Billing/Pay-to Provider loop level (2010AA/AB) and this
particular service line has a different Rendering Provider that what is given in the 2010AA/AB loop. The
identifying payer-specific numbers are those that belong to the destination payer identified in loop 2010BB.
3. 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 subsitute provider (locum
tenans) was used, that person should be entered here.
Example:
NM1*82*1*SMITH*JUNE*L***XX*87654321~
837P_CG.ecs
357
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 505
PRV Rendering Provider
Max: 1
Detail - Optional
Specialty Information
Loop:
2420A
Elements: 3
User Option (Usage): Situational
Purpose: To specify the identifying characteristics of a provider
Element Summary:
Ref
Id
Element Name
Req
Type
Min/Max
Usage
PRV01
1221
Provider Code
M
ID
1/3
Required
ID
2/3
Required
Description: Code identifying the type of provider
CodeList Summary (Total Codes: 26, Included: 1)
Code Name
PE
PRV02
128
Performing
Reference Identification Qualifier
M
Description: Code qualifying the Reference Identification
ZZ is used to indicate the “Health Care Provider Taxonomy” code list (provider specialty
code) which is available on the Washington Publishing Company web site:
http://www.wpc-edi.com. This taxonomy is maintained by the Blue Cross Blue Shield
Association and ASC X12N TG2 WG15.
CodeList Summary (Total Codes: 1503, Included: 1)
Code Name
ZZ
PRV03
127
Mutually Defined
Health Care Provider Taxonomy Code list
Reference Identification
M
AN
1/30
Required
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Provider Taxonomy Code
Alias: Provider Specialty Code
NSF Reference: FA0-37.0
ExternalCodeList
Name: HCPT
Description: Health Care Provider Taxonomy
Notes:
1. PRV02 qualifies PRV03.
2. Required when adjudication is known to be impacted by provider taxonomy code.
Example:
PRV*PE*ZZ*203BA050N~
837P_CG.ecs
358
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 525
REF Rendering Provider
Max: 5
Detail - Optional
Secondary Identification
Loop:
2420A
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
Description: Code qualifying the Reference Identification
User Note 6:
Use 0B for CA State license # Use 1B for BSC Provider ID
Do not use if the information is the same as Loop 2310
CodeList Summary (Total Codes: 1503, Included: 12)
Code Name
REF02
127
0B
1B
1C
1D
1G
1H
EI
G2
LU
N5
SY
State License Number
Blue Shield Provider Number
Medicare Provider Number
Medicaid Provider Number
Provider UPIN Number
CHAMPUS Identification Number
Employer's Identification Number
Provider Commercial Number
Location Number
Provider Plan Network Identification Number
Social Security Number
The social security number may not be used for Medicare.
X5
State Industrial Accident Provider Number
Reference Identification
C
AN
1/30
Required
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Rendering Provider Secondary Identifier
User Note 6:
Use only California State License Number or BSC Provider ID with the appropriate REF01
qualifier.
Do not use if the information is the same as Loop 2310.
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
837P_CG.ecs
359
For internal use only
12/1/2010
Health Care Claim: Professional - 837
1. Required when a secondary identification number is necessary to identify the entity. The primary identification
number should be carried in NM109 in this loop.
Example:
REF*1D*A12345~
User Note 6:
Do not use if the information is the same as 2310 Loop.
837P_CG.ecs
360
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Loop Purchased Service Provider
Name
Pos: 500
Repeat: 1
Optional
Loop:
2420B
Elements: N/A
User Option (Usage): Situational
Purpose: To supply the full name of an individual or organizational entity
Loop Summary:
Pos
Id
Segment Name
500
525
NM1
REF
Purchased Service Provider Name
Purchased Service Provider Secondary
Identification
Req
Max Use
O
O
1
5
Repeat
Usage
Situational
Situational
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
Notes:
1. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,
then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.
2. Required if purchased services are being billed/reported on this claim. Purchased services are situations where
(for example) a physician purchases a diagnostic exam from an outside entity. Purchased services do not include
substitute (locum tenens) provider situations. All payer-specific identifying numbers belong to the destination
payer identified in the 2010BB loop.
Example:
NM1*QB*2*XYZ HOLTER MONITOR INC*****34*444556666~
User Note 6:
Loop 2420B (Purchased Service Provider Name) is required when segment PS1 (Purchased Service Information)
is used in loop 2400 and SV101-02 does not start from 'V2'.
Example: (Do not use name in 2420B)
LX*1~
SV1*HC>83701>90*13.8*UN*1***1~
DTP*472*D8*20100923~
REF*6R*0007~
REF*X4*01D0641541~
PS1*00007816*13.8~
NM1*QB*2******XX*1999991111~
LX*2~
SV1*HC>84478>90*3.2*UN*1***1~
DTP*472*D8*20100923~
REF*6R*0008~
REF*X4*01D0641541~
PS1*00007816*3.2~
837P_CG.ecs
361
For internal use only
12/1/2010
Health Care Claim: Professional - 837
NM1*QB*2******XX*1999991111~
837P_CG.ecs
362
For internal use only
12/1/2010
Health Care Claim: Professional - 837
NM1 Purchased Service Provider
Name
Pos: 500
Max: 1
Detail - Optional
Loop:
2420B
Elements: 4
User Option (Usage): Situational
Purpose: To supply the full name of an individual or organizational entity
Element Summary:
Ref
Id
Element Name
NM101
98
Entity Identifier Code
Req
Type
Min/Max
Usage
M
ID
2/3
Required
Description: Code identifying an organizational entity, a physical location, property or an
individual
The entity identifier in NM101 applies to all segments in this iteration of Loop ID-2420.
CodeList Summary (Total Codes: 1312, Included: 1)
Code Name
QB
NM102
1065
Purchase Service Provider
Entity Type Qualifier
M
ID
1/1
Required
ID
1/2
Situational
Description: Code qualifying the type of entity
CodeList Summary (Total Codes: 14, Included: 2)
Code Name
1
2
NM108
66
Person
Non-Person Entity
Identification Code Qualifier
C
Description: Code designating the system/method of code structure used for Identification
Code (67)
Required if either Employer’s Identification/Social Security Number or National Provider
Identifier is known.
CodeList Summary (Total Codes: 215, Included: 3)
Code Name
24
34
XX
NM109
67
Employer's Identification Number
Social Security Number
Health Care Financing Administration National Provider Identifier
Identification Code
C
AN
2/80
Situational
Description: Code identifying a party or other code
Industry: Purchased Service Provider Identifier
Alias: Purchased Service Provider’s Primary Identification Number
NSF Reference: FB0-11.0
Required if either Employer’s Identification/Social Security Number or National Provider
Identifier is known.
ExternalCodeList
Name: 537
Description: Health Care Financing Administration National Provider Identifier
837P_CG.ecs
363
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Syntax Rules:
1. P0809 - If either NM108 or NM109 is present, then the other is required.
2. C1110 - If NM111 is present, then NM110 is required.
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
Notes:
1. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,
then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.
2. Required if purchased services are being billed/reported on this claim. Purchased services are situations where
(for example) a physician purchases a diagnostic exam from an outside entity. Purchased services do not include
substitute (locum tenens) provider situations. All payer-specific identifying numbers belong to the destination
payer identified in the 2010BB loop.
Example:
NM1*QB*2*XYZ HOLTER MONITOR INC*****34*444556666~
837P_CG.ecs
364
For internal use only
12/1/2010
Health Care Claim: Professional - 837
REF Purchased Service Provider
Secondary Identification
Pos: 525
Max: 5
Detail - Optional
Loop:
2420B
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 14)
Code Name
REF02
127
0B
1A
1B
1C
1D
1G
1H
EI
G2
LU
N5
SY
State License Number
Blue Cross Provider Number
Blue Shield Provider Number
Medicare Provider Number
Medicaid Provider Number
Provider UPIN Number
CHAMPUS Identification Number
Employer's Identification Number
Provider Commercial Number
Location Number
Provider Plan Network Identification Number
Social Security Number
The social security number may not be used for Medicare.
U3
X5
Unique Supplier Identification Number (USIN)
State Industrial Accident Provider Number
Reference Identification
C
AN
1/30
Required
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Purchased Service Provider Secondary Identifier
NSF Reference: FB0-11.0
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. Required when a secondary identification number is necessary to identify the entity. The primary identification
number should be carried in NM109 in this loop.
Example:
REF*1D*A12345~
837P_CG.ecs
365
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 500
Loop Service Facility Location
Repeat: 1
Optional
Loop:
2420C
Elements: N/A
User Option (Usage): Situational
Purpose: To supply the full name of an individual or organizational entity
Loop Summary:
Pos
Id
Segment Name
Req
Max Use
500
514
520
525
NM1
N3
N4
REF
Service Facility
Service Facility
Service Facility
Service Facility
Identification
O
O
O
O
1
1
1
5
Location
Location Address
Location City/State/ZIP
Location Secondary
Repeat
Usage
Situational
Required
Required
Situational
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
Notes:
1. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,
then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.
2. Required when the location of health care service for this service line is different than that carried in the
2010AA (Billing Provider), 2010AB (Pay-to Provider), or 2310D Service Facility Location loops. All payer-specific
identifying numbers belong to the destination payer identified in the 2010BB loop.
Example:
NM1*TL*2*A-OK MOBILE CLINIC*****24*11122333~
837P_CG.ecs
366
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 500
NM1 Service Facility Location
Max: 1
Detail - Optional
Loop:
2420C
Elements: 5
User Option (Usage): Situational
Purpose: To supply the full name of an individual or organizational entity
Element Summary:
Ref
Id
Element Name
NM101
98
Entity Identifier Code
Req
Type
Min/Max
Usage
M
ID
2/3
Required
Description: Code identifying an organizational entity, a physical location, property or an
individual
The entity identifier in NM101 applies to all segments in this iteration of Loop ID-2420.
CodeList Summary (Total Codes: 1312, Included: 4)
Code Name
NM102
1065
77
Service Location
Use when other codes in this element do not apply.
FA
LI
TL
Facility
Independent Lab
Testing Laboratory
Entity Type Qualifier
M
ID
1/1
Required
AN
1/35
Situational
Description: Code qualifying the type of entity
CodeList Summary (Total Codes: 14, Included: 1)
Code Name
2
NM103
1035
Non-Person Entity
Name Last or Organization Name
O
Description: Individual last name or organizational name
Industry: Laboratory or Facility Name
Alias: Service Facility Location Name
NSF Reference: GX0-25.0
Required except when service was rendered in the patient’s home.
NM108
66
Identification Code Qualifier
C
ID
1/2
Situational
Description: Code designating the system/method of code structure used for Identification
Code (67)
Required if either Employer’s Identification/Social Security Number (tax ID of service
location) or National Provider Identifier is known.
CodeList Summary (Total Codes: 215, Included: 3)
Code Name
837P_CG.ecs
24
34
Employer's Identification Number
Social Security Number
Do not use for Medicare claims.
XX
Health Care Financing Administration National Provider Identifier
367
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Ref
Id
Element Name
NM109
67
Identification Code
Req
Type
Min/Max
Usage
C
AN
2/80
Situational
Description: Code identifying a party or other code
Industry: Laboratory or Facility Primary Identifier
Alias: Service Facility Location Identification Number
Required if either Employer’s Identification/Social Security Number (tax ID of service
location) or National Provider Identifier is known.
ExternalCodeList
Name: 537
Description: Health Care Financing Administration National Provider Identifier
Syntax Rules:
1. P0809 - If either NM108 or NM109 is present, then the other is required.
2. C1110 - If NM111 is present, then NM110 is required.
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
Notes:
1. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,
then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.
2. Required when the location of health care service for this service line is different than that carried in the
2010AA (Billing Provider), 2010AB (Pay-to Provider), or 2310D Service Facility Location loops. All payer-specific
identifying numbers belong to the destination payer identified in the 2010BB loop.
Example:
NM1*TL*2*A-OK MOBILE CLINIC*****24*11122333~
837P_CG.ecs
368
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 514
N3 Service Facility Location
Max: 1
Detail - Optional
Address
Loop:
2420C
Elements: 2
User Option (Usage): Required
Purpose: To specify the location of the named party
Element Summary:
Ref
Id
Element Name
N301
166
Address Information
Req
Type
Min/Max
Usage
M
AN
1/55
Required
O
AN
1/55
Situational
Description: Address information
Industry: Laboratory or Facility Address Line
Alias: Service Facility Location Address 1
NSF Reference: GX2-04.0
N302
166
Address Information
Description: Address information
Industry: Laboratory or Facility Address Line
Alias: Service Facility Location Address 2
NSF Reference: GX2-05.0
Required if a second address line exists.
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 (e.g., “crossroad of State Road 34 and 45" or ”Exit near Mile marker 265 on Interstate 80".)
Example:
N3*2400 HEALTHY WAY~
837P_CG.ecs
369
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 520
N4 Service Facility Location
Max: 1
Detail - Optional
City/State/ZIP
Loop:
2420C
Elements: 4
User Option (Usage): Required
Purpose: To specify the geographic place of the named party
Element Summary:
Ref
Id
Element Name
N401
19
City Name
Req
Type
Min/Max
Usage
O
AN
2/30
Required
O
ID
2/2
Required
Description: Free-form text for city name
Industry: Laboratory or Facility City Name
Alias: Service Facility Location City
NSF Reference: GX2-06.0
N402
156
State or Province Code
Description: Code (Standard State/Province) as defined by appropriate government
agency
Industry: Laboratory or Facility State or Province Code
Alias: Service Facility Location State
CODE SOURCE: 22: States and Outlying Areas of the U.S.
NSF Reference: GX2-07.0
ExternalCodeList
Name: 22
Description: States and Outlying Areas of the U.S.
N403
116
Postal Code
O
ID
3/15
Required
Description: Code defining international postal zone code excluding punctuation and
blanks (zip code for United States)
Industry: Laboratory or Facility Postal Zone or ZIP Code
Alias: Service Facility Location ZIP Code
CODE SOURCE: 51: ZIP Code
NSF Reference: GX2-08.0
ExternalCodeList
Name: 51
Description: ZIP Code
N404
26
Country Code
O
ID
2/3
Situational
Description: Code identifying the country
Alias: Service Facility Location Country Code
CODE SOURCE: 5: Countries, Currencies and Funds
Required if the address is out of the U.S.
ExternalCodeList
Name: 5
Description: Countries, Currencies and Funds
837P_CG.ecs
370
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Syntax Rules:
1. C0605 - If N406 is present, then N405 is required.
Comments:
1. A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
2. N402 is required only if city name (N401) is in the U.S. or Canada.
Notes:
1. If service facility location is in an area where there are no street addresses, enter the name of the nearest town,
state and zip of where the service was rendered.
Example:
N4*HYANNIS*MA*02601~
837P_CG.ecs
371
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 525
REF Service Facility Location
Max: 5
Detail - Optional
Secondary Identification
Loop:
2420C
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
1/30
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 13)
Code Name
0B
1A
1B
1C
1D
1G
1H
G2
LU
N5
TJ
X4
X5
REF02
127
State License Number
Blue Cross Provider Number
Blue Shield Provider Number
Medicare Provider Number
Medicaid Provider Number
Provider UPIN Number
CHAMPUS Identification Number
Provider Commercial Number
Location Number
Provider Plan Network Identification Number
Federal Taxpayer's Identification Number
Clinical Laboratory Improvement Amendment Number
State Industrial Accident Provider Number
Reference Identification
C
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Service Facility Location Secondary Identifier
Alias: Service Facility Location Secondary Identification Number
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. Required when a secondary identification number is necessary to identify the entity. The primary identification
number should be carried in NM109 in this loop.
Example:
REF*1D*A12345~
837P_CG.ecs
372
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 500
Loop Supervising Provider Name
Repeat: 1
Optional
Loop:
2420D
Elements: N/A
User Option (Usage): Situational
Purpose: To supply the full name of an individual or organizational entity
Loop Summary:
Pos
Id
Segment Name
500
525
NM1
REF
Supervising Provider Name
Supervising Provider Secondary
Identification
Req
Max Use
O
O
1
5
Repeat
Usage
Situational
Situational
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
Notes:
1. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,
then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.
2. Required when rendering provider is supervised by a physician and the supervising physician is different than
that listed at the claim level for this service line. All paye-specific identifying numbers belong to the destination
payer identified in loop 2010BB.
Example:
NM1*DQ*1*KILLIAN*BART*B**II*24*222334444~
837P_CG.ecs
373
For internal use only
12/1/2010
Health Care Claim: Professional - 837
NM1 Supervising Provider Name
Pos: 500
Max: 1
Detail - Optional
Loop:
2420D
Elements: 8
User Option (Usage): Situational
Purpose: To supply the full name of an individual or organizational entity
Element Summary:
Ref
Id
Element Name
NM101
98
Entity Identifier Code
Req
Type
Min/Max
Usage
M
ID
2/3
Required
Description: Code identifying an organizational entity, a physical location, property or an
individual
CodeList Summary (Total Codes: 1312, Included: 1)
Code Name
DQ
NM102
1065
Supervising Physician
Entity Type Qualifier
M
ID
1/1
Required
AN
1/35
Required
Description: Code qualifying the type of entity
CodeList Summary (Total Codes: 14, Included: 1)
Code Name
1
NM103
1035
Person
Name Last or Organization Name
O
Description: Individual last name or organizational name
Industry: Supervising Provider Last Name
NSF Reference: FB1-18.0
NM104
1036
Name First
O
AN
1/25
Required
O
AN
1/25
Situational
Description: Individual first name
Industry: Supervising Provider First Name
NSF Reference: FB1-19.0
NM105
1037
Name Middle
Description: Individual middle name or initial
Industry: Supervising Provider Middle Name
NSF Reference: FB1-20.0
Required if NM102=1 and the middle name/initial of the person is known.
NM107
1039
Name Suffix
O
AN
1/10
Situational
C
ID
1/2
Situational
Description: Suffix to individual name
Industry: Supervising Provider Name Suffix
Alias: Supervising Provider Generation
Required if known.
NM108
66
Identification Code Qualifier
Description: Code designating the system/method of code structure used for Identification
837P_CG.ecs
374
For internal use only
12/1/2010
Ref
Health Care Claim: Professional - 837
Id
Element Name
Req
Type
Min/Max
Usage
Code (67)
Required if either Employer’s Identification/Social Security Number (Supervising provider’s
tax ID) or National Provider Identifier is known.
CodeList Summary (Total Codes: 215, Included: 3)
Code Name
NM109
67
24
34
Employer's Identification Number
Social Security Number
The social security number may not be used for Medicare.
XX
Health Care Financing Administration National Provider Identifier
Identification Code
C
AN
2/80
Situational
Description: Code identifying a party or other code
Industry: Supervising Provider Identifier
Alias: Supervising Provider’s Identification Number
NSF Reference: FB1-21.0
Required if either Employer’s Identification/Social Security Number (Supervising provider’s
tax ID) or National Provider Identifier is known.
ExternalCodeList
Name: 537
Description: Health Care Financing Administration National Provider Identifier
Syntax Rules:
1. P0809 - If either NM108 or NM109 is present, then the other is required.
2. C1110 - If NM111 is present, then NM110 is required.
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
Notes:
1. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,
then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.
2. Required when rendering provider is supervised by a physician and the supervising physician is different than
that listed at the claim level for this service line. All paye-specific identifying numbers belong to the destination
payer identified in loop 2010BB.
Example:
NM1*DQ*1*KILLIAN*BART*B**II*24*222334444~
837P_CG.ecs
375
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 525
REF Supervising Provider
Max: 5
Detail - Optional
Secondary Identification
Loop:
2420D
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 12)
Code Name
REF02
127
0B
1B
1C
1D
1G
1H
EI
G2
LU
N5
SY
State License Number
Blue Shield Provider Number
Medicare Provider Number
Medicaid Provider Number
Provider UPIN Number
CHAMPUS Identification Number
Employer's Identification Number
Provider Commercial Number
Location Number
Provider Plan Network Identification Number
Social Security Number
The social security number may not be used for Medicare.
X5
State Industrial Accident Provider Number
Reference Identification
C
AN
1/30
Required
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Supervising Provider Secondary Identifier
NSF Reference: FB1-21.0
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. Required when a secondary identification number is necessary to identify the entity. The primary identification
number should be carried in NM109 in this loop.
Example:
REF*1D*A12345~
837P_CG.ecs
376
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 500
Loop Ordering Provider Name
Repeat: 1
Optional
Loop:
2420E
Elements: N/A
User Option (Usage): Situational
Purpose: To supply the full name of an individual or organizational entity
Loop Summary:
Pos
Id
Segment Name
500
514
520
525
530
NM1
N3
N4
REF
PER
Ordering
Ordering
Ordering
Ordering
Ordering
Provider Name
Provider Address
Provider City/State/ZIP Code
Provider Secondary Identification
Provider Contact Information
Req
Max Use
O
O
O
O
O
1
1
1
5
1
Repeat
Usage
Situational
Situational
Situational
Situational
Situational
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
Notes:
1. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,
then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.
2. Required if a service or supply was ordered by a provider and that provider is a different entity than the
rendering provider for this service line. All payer-specific identifiers belong to the destination payer identified in
the 2010BB loop.
Example:
NM1*DK*1*RICHARDSON*TRENT****34*555667778~
837P_CG.ecs
377
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 500
NM1 Ordering Provider Name
Max: 1
Detail - Optional
Loop:
2420E
Elements: 8
User Option (Usage): Situational
Purpose: To supply the full name of an individual or organizational entity
Element Summary:
Ref
Id
Element Name
NM101
98
Entity Identifier Code
Req
Type
Min/Max
Usage
M
ID
2/3
Required
Description: Code identifying an organizational entity, a physical location, property or an
individual
The entity identifier in NM101 applies to all segments in this iteration of Loop ID-2420.
CodeList Summary (Total Codes: 1312, Included: 1)
Code Name
DK
NM102
1065
Ordering Physician
Entity Type Qualifier
M
ID
1/1
Required
AN
1/35
Required
Description: Code qualifying the type of entity
CodeList Summary (Total Codes: 14, Included: 1)
Code Name
1
NM103
1035
Person
Name Last or Organization Name
O
Description: Individual last name or organizational name
Industry: Ordering Provider Last Name
NSF Reference: FB1-06.0
NM104
1036
Name First
O
AN
1/25
Required
O
AN
1/25
Situational
Description: Individual first name
Industry: Ordering Provider First Name
NSF Reference: FB1-07.0
NM105
1037
Name Middle
Description: Individual middle name or initial
Industry: Ordering Provider Middle Name
NSF Reference: FB1-08.0
Required if NM102=1 and the middle name/initial of the person is known.
NM107
1039
Name Suffix
O
AN
1/10
Situational
C
ID
1/2
Situational
Description: Suffix to individual name
Industry: Ordering Provider Name Suffix
Alias: Ordering Provider Generation
Required if known.
NM108
837P_CG.ecs
66
Identification Code Qualifier
378
For internal use only
12/1/2010
Ref
Health Care Claim: Professional - 837
Id
Element Name
Req
Type
Min/Max
Usage
Description: Code designating the system/method of code structure used for Identification
Code (67)
Required if either Employer’s Identification/Social Security Number (Ordering provider’s tax
ID) or National Provider Identifier is known.
CodeList Summary (Total Codes: 215, Included: 3)
Code Name
NM109
67
24
34
Employer's Identification Number
Social Security Number
The social security number may not be used for Medicare.
XX
Health Care Financing Administration National Provider Identifier
Identification Code
C
AN
2/80
Situational
Description: Code identifying a party or other code
Industry: Ordering Provider Identifier
Alias: Ordering Provider Primary Identifier
NSF Reference: FB0-09.0, FB1-09.0, GX0-29.0
Required if either Employer’s Identification/Social Security Number (Ordering provider’s tax
ID) or National Provider Identifier is known.
ExternalCodeList
Name: 537
Description: Health Care Financing Administration National Provider Identifier
Syntax Rules:
1. P0809 - If either NM108 or NM109 is present, then the other is required.
2. C1110 - If NM111 is present, then NM110 is required.
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
Notes:
1. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,
then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.
2. Required if a service or supply was ordered by a provider and that provider is a different entity than the
rendering provider for this service line. All payer-specific identifiers belong to the destination payer identified in
the 2010BB loop.
Example:
NM1*DK*1*RICHARDSON*TRENT****34*555667778~
837P_CG.ecs
379
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 514
N3 Ordering Provider Address
Max: 1
Detail - Optional
Loop:
2420E
Elements: 2
User Option (Usage): Situational
Purpose: To specify the location of the named party
Element Summary:
Ref
Id
Element Name
N301
166
Address Information
Req
Type
Min/Max
Usage
M
AN
1/55
Required
O
AN
1/55
Situational
Description: Address information
Industry: Ordering Provider Address Line
Alias: Ordering Provider Address 1
NSF Reference: FB2-06.0
N302
166
Address Information
Description: Address information
Industry: Ordering Provider Address Line
Alias: Ordering Provider Address 2
NSF Reference: FB2-07.0
Required if a second address line exists.
Notes:
1. Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (Medicare
DMERC CMN) is used on service line for Medicare claims.
Example:
N3*2400 HEALTHY WAY~
837P_CG.ecs
380
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 520
N4 Ordering Provider
Max: 1
Detail - Optional
City/State/ZIP Code
Loop:
2420E
Elements: 4
User Option (Usage): Situational
Purpose: To specify the geographic place of the named party
Element Summary:
Ref
Id
Element Name
N401
19
City Name
Req
Type
Min/Max
Usage
O
AN
2/30
Required
O
ID
2/2
Required
Description: Free-form text for city name
Industry: Ordering Provider City Name
Alias: Ordering Provider City
NSF Reference: FB2-08.0
N402
156
State or Province Code
Description: Code (Standard State/Province) as defined by appropriate government
agency
Industry: Ordering Provider State Code
Alias: Ordering Provider State
CODE SOURCE: 22: States and Outlying Areas of the U.S.
NSF Reference: FB0-10.0, FB2-09.0
ExternalCodeList
Name: 22
Description: States and Outlying Areas of the U.S.
N403
116
Postal Code
O
ID
3/15
Required
Description: Code defining international postal zone code excluding punctuation and
blanks (zip code for United States)
Industry: Ordering Provider Postal Zone or ZIP Code
Alias: Ordering Provider Zip Code
CODE SOURCE: 51: ZIP Code
NSF Reference: FB2-10.0
ExternalCodeList
Name: 51
Description: ZIP Code
N404
26
Country Code
O
ID
2/3
Situational
Description: Code identifying the country
Alias: Ordering Provider Country Code
CODE SOURCE: 5: Countries, Currencies and Funds
Required if the address is out of the U.S.
ExternalCodeList
Name: 5
Description: Countries, Currencies and Funds
837P_CG.ecs
381
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Syntax Rules:
1. C0605 - If N406 is present, then N405 is required.
Comments:
1. A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
2. N402 is required only if city name (N401) is in the U.S. or Canada.
Notes:
1. Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (Medicare
DMERC CMN) is used on service line for Medicare claims.
Example:
N4*HYANNIS*MA*02601~
837P_CG.ecs
382
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 525
REF Ordering Provider
Max: 5
Detail - Optional
Secondary Identification
Loop:
2420E
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 12)
Code Name
REF02
127
0B
1B
1C
1D
1G
1H
EI
G2
LU
N5
SY
State License Number
Blue Shield Provider Number
Medicare Provider Number
Medicaid Provider Number
Provider UPIN Number
CHAMPUS Identification Number
Employer's Identification Number
Provider Commercial Number
Location Number
Provider Plan Network Identification Number
Social Security Number
The social security number may not be used for Medicare.
X5
State Industrial Accident Provider Number
Reference Identification
C
AN
1/30
Required
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Ordering Provider Secondary Identifier
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. Required when a secondary identification number is necessary to identify the entity. The primary identification
number should be carried in NM109 in this loop.
Example:
REF*1D*A12345~
837P_CG.ecs
383
For internal use only
12/1/2010
Health Care Claim: Professional - 837
PER Ordering Provider Contact
Information
Pos: 530
Max: 1
Detail - Optional
Loop:
2420E
Elements: 8
User Option (Usage): Situational
Purpose: To identify a person or office to whom administrative communications should be directed
Element Summary:
Ref
Id
Element Name
PER01
366
Contact Function Code
Req
Type
Min/Max
Usage
M
ID
2/2
Required
Description: Code identifying the major duty or responsibility of the person or group
named
CodeList Summary (Total Codes: 230, Included: 1)
Code Name
IC
PER02
93
Information Contact
Name
O
AN
1/60
Required
C
ID
2/2
Required
Description: Free-form name
Industry: Ordering Provider Contact Name
PER03
365
Communication Number Qualifier
Description: Code identifying the type of communication number
CodeList Summary (Total Codes: 40, Included: 3)
Code Name
EM
FX
TE
PER04
364
Electronic Mail
Facsimile
Telephone
Communication Number
C
AN
1/80
Required
Description: Complete communications number including country or area code when
applicable
NSF Reference: GX0-30.0, GU0-23.0
PER05
365
Communication Number Qualifier
C
ID
2/2
Situational
Description: Code identifying the type of communication number
Used at discretion of submitter.
CodeList Summary (Total Codes: 40, Included: 4)
Code Name
EM
EX
FX
TE
PER06
364
Electronic Mail
Telephone Extension
Facsimile
Telephone
Communication Number
C
AN
1/80
Situational
Description: Complete communications number including country or area code when
applicable
837P_CG.ecs
384
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Ref
Id
Element Name
Used at discretion of submitter.
PER07
365
Communication Number Qualifier
Req
Type
Min/Max
Usage
C
ID
2/2
Situational
Description: Code identifying the type of communication number
Used at discretion of submitter.
CodeList Summary (Total Codes: 40, Included: 4)
Code Name
EM
EX
FX
TE
PER08
364
Electronic Mail
Telephone Extension
Facsimile
Telephone
Communication Number
C
AN
1/80
Situational
Description: Complete communications number including country or area code when
applicable
Used at discretion of submitter.
Syntax Rules:
1. P0304 - If either PER03 or PER04 is present, then the other is required.
2. P0506 - If either PER05 or PER06 is present, then the other is required.
3. P0708 - If either PER07 or PER08 is present, then the other is required.
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 should 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 (e.g., (534) 224-2525 would be represented as
5342242525). The extension, when applicable, should be included in the communication number immediately
after the telephone number.
2. Required when services involving an oxygen therapy certificate of medical necessity (CMN) is being
billed/reported on this service line.
3. By definition of the standard, if PER03 is used, PER04 is required.
Example:
PER*IC*JOHN SMITH*TE*2015551212~
837P_CG.ecs
385
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 500
Loop Referring Provider Name
Repeat: 2
Optional
Loop:
2420F
Elements: N/A
User Option (Usage): Situational
Purpose: To supply the full name of an individual or organizational entity
Loop Summary:
Pos
Id
Segment Name
500
505
525
NM1
PRV
REF
Referring Provider Name
Referring Provider Specialty Information
Referring Provider Secondary Identification
Req
Max Use
O
O
O
1
1
5
Repeat
Usage
Situational
Situational
Situational
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
Notes:
1. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,
then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.
2. Required if this service line involves a referral and the referring provider is different than the rendering provider
and if the referring provider differs from that reported at the claim level (loop 2310A). All payer-specific identifying
numbers belong to the destination payer identified in the 2010BB loop.
3. When there is only one referral on the service line 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 service line. 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.
Example:
NM1*DN*1*WELBY*MARCUS*W**JR*34*444332222~
837P_CG.ecs
386
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 500
NM1 Referring Provider Name
Max: 1
Detail - Optional
Loop:
2420F
Elements: 8
User Option (Usage): Situational
Purpose: To supply the full name of an individual or organizational entity
Element Summary:
Ref
Id
Element Name
NM101
98
Entity Identifier Code
Req
Type
Min/Max
Usage
M
ID
2/3
Required
Description: Code identifying an organizational entity, a physical location, property or an
individual
CodeList Summary (Total Codes: 1312, Included: 2)
Code Name
NM102
1065
DN
Referring Provider
Use on the first iteration of this loop. Use if loop is used only once.
P3
Primary Care Provider
Use only if loop is used twice. Use only on second iteration of this loop.
Entity Type Qualifier
M
ID
1/1
Required
AN
1/35
Required
Description: Code qualifying the type of entity
CodeList Summary (Total Codes: 14, Included: 1)
Code Name
1
NM103
1035
Person
Name Last or Organization Name
O
Description: Individual last name or organizational name
Industry: Referring Provider Last Name
NSF Reference: FB1-10.0
NM104
1036
Name First
O
AN
1/25
Required
O
AN
1/25
Situational
Description: Individual first name
Industry: Referring Provider First Name
NSF Reference: FB1-11.0
NM105
1037
Name Middle
Description: Individual middle name or initial
Industry: Referring Provider Middle Name
NSF Reference: FB1-12.0
Required if NM102=1 and the middle name/initial of the person is known.
NM107
1039
Name Suffix
O
AN
1/10
Situational
Description: Suffix to individual name
Industry: Referring Provider Name Suffix
Alias: Referring Provider Generation
Required if known.
837P_CG.ecs
387
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Ref
Id
Element Name
NM108
66
Identification Code Qualifier
Req
Type
Min/Max
Usage
C
ID
1/2
Situational
Description: Code designating the system/method of code structure used for Identification
Code (67)
Required if either Employer’s Identification/Social Security Number (Referring Provider tax
ID) or National Provider Identifier is known.
CodeList Summary (Total Codes: 215, Included: 3)
Code Name
NM109
67
24
34
Employer's Identification Number
Social Security Number
The social security number may not be used for Medicare.
XX
Health Care Financing Administration National Provider Identifier
Identification Code
C
AN
2/80
Situational
Description: Code identifying a party or other code
Industry: Referring Provider Identifier
Alias: Referring Provider’s Identification Number
NSF Reference: FB1-13.0, FA0-24.0
Required if either Employer’s Identification/Social Security Number (Referring Provider tax
ID) or National Provider Identifier is known.
ExternalCodeList
Name: 537
Description: Health Care Financing Administration National Provider Identifier
Syntax Rules:
1. P0809 - If either NM108 or NM109 is present, then the other is required.
2. C1110 - If NM111 is present, then NM110 is required.
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
Notes:
1. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,
then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.
2. Required if this service line involves a referral and the referring provider is different than the rendering provider
and if the referring provider differs from that reported at the claim level (loop 2310A). All payer-specific identifying
numbers belong to the destination payer identified in the 2010BB loop.
3. When there is only one referral on the service line 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 service line. 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.
Example:
NM1*DN*1*WELBY*MARCUS*W**JR*34*444332222~
837P_CG.ecs
388
For internal use only
12/1/2010
Health Care Claim: Professional - 837
PRV Referring Provider Specialty
Information
Pos: 505
Max: 1
Detail - Optional
Loop:
2420F
Elements: 3
User Option (Usage): Situational
Purpose: To specify the identifying characteristics of a provider
Element Summary:
Ref
Id
Element Name
Req
Type
Min/Max
Usage
PRV01
1221
Provider Code
M
ID
1/3
Required
ID
2/3
Required
Description: Code identifying the type of provider
CodeList Summary (Total Codes: 26, Included: 1)
Code Name
RF
PRV02
128
Referring
Reference Identification Qualifier
M
Description: Code qualifying the Reference Identification
ZZ is used to indicate the “Health Care Provider Taxonomy” code list (provider specialty
code) which is available on the Washington Publishing Company web site:
http://www.wpc-edi.com. This taxonomy is maintained by the Blue Cross Blue Shield
Association and ASC X12N TG2 WG15.
CodeList Summary (Total Codes: 1503, Included: 1)
Code Name
ZZ
PRV03
127
Mutually Defined
Health Care Provider Taxonomy Code list
Reference Identification
M
AN
1/30
Required
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Provider Taxonomy Code
Alias: Provider Specialty Code
ExternalCodeList
Name: HCPT
Description: Health Care Provider Taxonomy
Notes:
1. Required if required under provider-payer contract.
2. PRV02 qualifies PRV03.
Example:
PRV*RF*ZZ*363LP0200N~
837P_CG.ecs
389
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 525
REF Referring Provider
Max: 5
Detail - Optional
Secondary Identification
Loop:
2420F
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 12)
Code Name
REF02
127
0B
1B
1C
1D
1G
1H
EI
G2
LU
N5
SY
State License Number
Blue Shield Provider Number
Medicare Provider Number
Medicaid Provider Number
Provider UPIN Number
CHAMPUS Identification Number
Employer's Identification Number
Provider Commercial Number
Location Number
Provider Plan Network Identification Number
Social Security Number
The social security number may not be used for Medicare.
X5
State Industrial Accident Provider Number
Reference Identification
C
AN
1/30
Required
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Referring Provider Secondary Identifier
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. Required when a secondary identification number is necessary to identify the entity. The primary identification
number should be carried in NM109 in this loop.
Example:
REF*1D*A12345~
837P_CG.ecs
390
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 500
Loop Other Payer Prior
Authorization or Referral Number
Repeat: 4
Optional
Loop:
2420G
Elements: N/A
User Option (Usage): Situational
Purpose: To supply the full name of an individual or organizational entity
Loop Summary:
Pos
Id
Segment Name
500
NM1
525
REF
Other Payer Prior Authorization or Referral
Number
Other Payer Prior Authorization or Referral
Number
Req
Max Use
Repeat
Usage
O
1
Situational
O
2
Required
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
Notes:
1. Required when it is necessary, in COB situations, to send a payer-specific line level referral number or prior
authorization number. The payer-specific numbers carried in the REF in this loop belong to the non-destination
(COB) payers.
2. The strategy in using this loop is to use NM109 to identify which payer the prior authorization/referral number
carried in the REF of this loop belongs to. For example, if there are 2 COB payers (non-destination payers) who
have additional referral numbers for this service line the data string for the 2420G loop would look like his:
NM1*PR*2******PI*PAYER #1 ID~ (This payer ID would be identified in an iteration of loop 2330B in it’s own 2320
loop) REF*9F*AAAAAAA~
NM1*PR*2******PI*PAYER#2 ID~ (This payer ID would also be identified in an interation of loop 2330B in it’s own
2320 loop) REF*9F*2BBBBBB~
3. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,
then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.
Example:
NM1*PR*2*UNION MUTUAL OF OREGON*****PI*223345~
837P_CG.ecs
391
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 500
NM1 Other Payer Prior
Max: 1
Detail - Optional
Authorization or Referral
Number
Loop:
2420G
Elements: 5
User Option (Usage): Situational
Purpose: To supply the full name of an individual or organizational entity
Element Summary:
Ref
Id
Element Name
NM101
98
Entity Identifier Code
Req
Type
Min/Max
Usage
M
ID
2/3
Required
Description: Code identifying an organizational entity, a physical location, property or an
individual
CodeList Summary (Total Codes: 1312, Included: 1)
Code Name
PR
NM102
1065
Payer
Entity Type Qualifier
M
ID
1/1
Required
AN
1/35
Required
1/2
Required
Description: Code qualifying the type of entity
CodeList Summary (Total Codes: 14, Included: 1)
Code Name
2
NM103
1035
Non-Person Entity
Name Last or Organization Name
O
Description: Individual last name or organizational name
Industry: Payer Name
NM108
66
Identification Code Qualifier
C
ID
Description: Code designating the system/method of code structure used for Identification
Code (67)
CodeList Summary (Total Codes: 215, Included: 2)
Code Name
PI
XV
Payor Identification
Health Care Financing Administration National Payer Identification Number
(PAYERID)
CODE SOURCE:
540: Health Care Financing Administration National PlanID
NM109
67
Identification Code
C
AN
2/80
Required
Description: Code identifying a party or other code
Industry: Other Payer Identification Number
Alias: Other Payer Identification
Must match corresponding Other Payer Identifier in NM109 in 2330B loop(s).
ExternalCodeList
Name: 540
837P_CG.ecs
392
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Description: Health Care Financing Administration National PlanID
Syntax Rules:
1. P0809 - If either NM108 or NM109 is present, then the other is required.
2. C1110 - If NM111 is present, then NM110 is required.
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
Notes:
1. Required when it is necessary, in COB situations, to send a payer-specific line level referral number or prior
authorization number. The payer-specific numbers carried in the REF in this loop belong to the non-destination
(COB) payers.
2. The strategy in using this loop is to use NM109 to identify which payer the prior authorization/referral number
carried in the REF of this loop belongs to. For example, if there are 2 COB payers (non-destination payers) who
have additional referral numbers for this service line the data string for the 2420G loop would look like his:
NM1*PR*2******PI*PAYER #1 ID~ (This payer ID would be identified in an iteration of loop 2330B in it’s own 2320
loop) REF*9F*AAAAAAA~
NM1*PR*2******PI*PAYER#2 ID~ (This payer ID would also be identified in an interation of loop 2330B in it’s own
2320 loop) REF*9F*2BBBBBB~
3. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,
then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.
Example:
NM1*PR*2*UNION MUTUAL OF OREGON*****PI*223345~
837P_CG.ecs
393
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 525
REF Other Payer Prior
Max: 2
Detail - Optional
Authorization or Referral
Number
Loop:
2420G
Elements: 2
User Option (Usage): Required
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
1/30
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 2)
Code Name
9F
G1
REF02
127
Referral Number
Prior Authorization Number
Reference Identification
C
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Other Payer Prior Authorization or Referral Number
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. Non-destination (COB) payers’ provider identification number(s).
Example:
REF*G1*AB333-Y5~
837P_CG.ecs
394
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Loop Line Adjudication Information
Pos: 540
Repeat: 25
Optional
Loop: 2430 Elements: N/A
User Option (Usage): Situational
Purpose: To convey service line adjudication information for coordination of benefits between the initial payers of a
health care claim and all subsequent payers
Loop Summary:
Pos
Id
Segment Name
540
545
550
SVD
CAS
DTP
Line Adjudication Information
Line Adjustment
Line Adjudication Date
Req
Max Use
O
O
O
1
99
1
Repeat
Usage
Situational
Situational
Required
Semantics:
1.
2.
3.
4.
SVD01 is the payer identification code.
SVD02 is the amount paid for this service line.
SVD04 is the revenue code.
SVD05 is the paid units of service.
Comments:
1. SVD03 represents the medical procedure code upon which adjudication of this service line was based. This
may be different than the submitted medical procedure code.
2. SVD06 is only used for bundling of service lines. It references the LX Assigned Number of the service line into
which this service line was bundled.
Notes:
1. To show unbundled lines: If, in the original claim, line 3 is unbundled into (for examples) 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. If a line item control number (REF01 = 6R) exists for the line, that number may be
used in SVD06 instead of the LX number when a line is unbundled.
2. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,
then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.
3. Required if claim has been previously adjudicated by payer identified in Loop 2330B and service line has
adjustments applied to it.
Example:
SVD*43*55*HC:84550**3~
837P_CG.ecs
395
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 540
SVD Line Adjudication
Max: 1
Detail - Optional
Information
Loop: 2430
Elements: 5
User Option (Usage): Situational
Purpose: To convey service line adjudication information for coordination of benefits between the initial payers of a
health care claim and all subsequent payers
Element Summary:
Ref
Id
Element Name
SVD01
67
Identification Code
Req
Type
Min/Max
Usage
M
AN
2/80
Required
Description: Code identifying a party or other code
Industry: Other Payer Primary Identifier
Alias: Other Payer identification code
This number should match NM109 in Loop ID-2330B identifying Other Payer.
SVD02
782
Monetary Amount
M
R
1/18
Required
Description: Monetary amount
Industry: Service Line Paid Amount
Alias: Paid Amount
NSF Reference: FA0-52.0
Zero “0" is an acceptable value for this element.
The FA0-52.0 NSF crosswalk is only used in payer-to-payer COB situations.
SVD03
C003
Composite Medical Procedure
Identifier
O
Comp
Required
Description: To identify a medical procedure by its standardized codes and applicable
modifiers
Alias: Procedure identifier
This element contains the procedure code that was used to pay this service line. It
crosswalks from SVC01 in the 835 transmission.
SVD03-01
235
Product/Service ID Qualifier
M
ID
2/2
Required
Description: Code identifying the type/source of the descriptive number used in
Product/Service ID (234)
Industry: Product or Service ID Qualifier
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.
CodeList Summary (Total Codes: 477, Included: 3)
Code Name
HC
Health Care Financing Administration Common Procedural Coding System
(HCPCS) Codes
Because the AMA’s CPT codes are also level 1 HCPCS codes, they are reported
under HC.
CODE SOURCE:
130: Health Care Financing Administration Common Procedural Coding System
837P_CG.ecs
396
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Code Name
IV
Home Infusion EDI Coalition (HIEC) Product/Service Code
This code set is not allowed for use under HIPAA at the time of this writing. The
qualifier can only be used: 1) If a new rule names HIEC as an allowable code set
under HIPAA. 2) For Property & Casualty claims/encounters that are not covered
under HIPAA.
CODE SOURCE:
513: Home Infusion EDI Coalition (HIEC) Product/Service Code List
ZZ
SVD03-02
234
Mutually Defined
Jurisdictionally Defined Procedure and Supply Codes. (Used for Worker’s
Compensation claims). Contact your local (State) Jurisdiction for a list of these
codes.
Product/Service ID
M
AN
1/48
Required
Description: Identifying number for a product or service
Industry: Procedure Code
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
SVD03-03
1339
Procedure Modifier
O
AN
2/2
Situational
Description: This identifies special circumstances related to the performance of the
service, as defined by trading partners
Alias: Procedure Modifier 1
Use this modifier for the first procedure code modifier.
Required when a modifier clarifies/improves the reporting accuracy of the associated
procedure code.
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
SVD03-04
1339
Procedure Modifier
O
AN
2/2
Situational
Description: This identifies special circumstances related to the performance of the
service, as defined by trading partners
Alias: Procedure Modifier 2
Use this modifier for the second procedure code modifier.
Required when a modifier clarifies/improves the reporting accuracy of the associated
procedure code.
ExternalCodeList
Name: 130
Description: Health Care Financing Administration Common Procedural Coding System
ExternalCodeList
837P_CG.ecs
397
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Name: 513
Description: Home Infusion EDI Coalition (HIEC) Product/Service Code List
SVD03-05
1339
Procedure Modifier
O
AN
2/2
Situational
Description: This identifies special circumstances related to the performance of the
service, as defined by trading partners
Alias: Procedure Modifier 3
Use this modifier for the third procedure code modifier.
Required when a modifier clarifies/improves the reporting accuracy of the associated
procedure code.
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
SVD03-06
1339
Procedure Modifier
O
AN
2/2
Situational
Description: This identifies special circumstances related to the performance of the
service, as defined by trading partners
Alias: Procedure Modifier 4
Use this modifier for the fourth procedure code modifier.
Required when a modifier clarifies/improves the reporting accuracy of the associated
procedure code.
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
SVD03-07
352
Description
O
AN
1/80
Situational
Description: A free-form description to clarify the related data elements and their content
Industry: Procedure Code Description
Required if SVC01-7 was returned in the 835 transaction.
SVD05
380
Quantity
O
R
1/15
Required
Description: Numeric value of quantity
Industry: Paid Service Unit Count
Alias: Paid units of service
Crosswalk from SVC05 in 835 or, if not present in 835, use original billed units.
SVD06
554
Assigned Number
O
N0
1/6
Situational
Description: Number assigned for differentiation within a transaction set
Industry: Bundled Line Number
Alias: Bundled Line Number
Use the LX from this transaction which points to the bundled line.
Required if payer bundled this service line.
837P_CG.ecs
398
For internal use only
12/1/2010
Ref
Health Care Claim: Professional - 837
Id
Element Name
Req
Type
Min/Max
Usage
Semantics:
1.
2.
3.
4.
SVD01 is the payer identification code.
SVD02 is the amount paid for this service line.
SVD04 is the revenue code.
SVD05 is the paid units of service.
Comments:
1. SVD03 represents the medical procedure code upon which adjudication of this service line was based. This
may be different than the submitted medical procedure code.
2. SVD06 is only used for bundling of service lines. It references the LX Assigned Number of the service line into
which this service line was bundled.
Notes:
1. To show unbundled lines: If, in the original claim, line 3 is unbundled into (for examples) 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. If a line item control number (REF01 = 6R) exists for the line, that number may be
used in SVD06 instead of the LX number when a line is unbundled.
2. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,
then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.
3. Required if claim has been previously adjudicated by payer identified in Loop 2330B and service line has
adjustments applied to it.
Example:
SVD*43*55*HC:84550**3~
837P_CG.ecs
399
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 545
CAS Line Adjustment
Max: 99
Detail - Optional
Loop: 2430
Elements: 19
User Option (Usage): Situational
Purpose: To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service
within the claim being paid
Element Summary:
Ref
Id
Element Name
CAS01
1033
Claim Adjustment Group Code
Req
Type
Min/Max
Usage
M
ID
1/2
Required
Description: Code identifying the general category of payment adjustment
Alias: Adjustment Group Code
CodeList Summary (Total Codes: 8, Included: 5)
Code Name
CO
CR
OA
PI
PR
CAS02
1034
Contractual Obligations
Correction and Reversals
Other adjustments
Payor Initiated Reductions
Patient Responsibility
Claim Adjustment Reason Code
M
ID
1/5
Required
Description: Code identifying the detailed reason the adjustment was made
Industry: Adjustment Reason Code
Alias: Adjustment Reason Code - Line Level
CODE SOURCE: 139: Claim Adjustment Reason Code
NSF Reference: FB3-05.0, FB3-07.0, FB3-09.0, FB3-11.0, FB3-13.0, FB3-15.0, FB3-17.0
Use the Claim Adjustment Reason Code list (See Appendix C).
ExternalCodeList
Name: 139
Description: Claim Adjustment Reason Code
CAS03
782
Monetary Amount
M
R
1/18
Required
Description: Monetary amount
Industry: Adjustment Amount
Alias: Adjusted Amount - Line Level
NSF Reference: FA0-27.0, FA0-28.0, FA0-35.0, FA0-48.0, FB0-06.0, FB0-07.0, FB0-08. 0,
FB3-06.0, FB3-08.0, FB3-10.0, FB3-12.0, FB3-14.0, FB3-16.0, FB3-18.0, FA0-53.0,
FA0-54.0
Use this amount for the adjustment amount.
CAS04
380
Quantity
O
R
1/15
Situational
Description: Numeric value of quantity
Industry: Adjustment Quantity
Alias: Adjusted Units - Line Level
Use this quantity for the units of service being adjusted.
Use as needed to show payer adjustment.
837P_CG.ecs
400
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Ref
Id
Element Name
CAS05
1034
Claim Adjustment Reason Code
Req
Type
Min/Max
Usage
C
ID
1/5
Situational
Description: Code identifying the detailed reason the adjustment was made
Industry: Adjustment Reason Code
Alias: Adjustment Reason Code - Line Level
CODE SOURCE: 139: Claim Adjustment Reason Code
NSF Reference: FB3-05.0, FB3-07.0, FB3-09.0, FB3-11.0, FB3-13.0, FB3-15.0, FB3-17.
0
Use as needed to show payer adjustment.
Use the Claim Adjustment Reason Code list (See Appendix C).
ExternalCodeList
Name: 139
Description: Claim Adjustment Reason Code
CAS06
782
Monetary Amount
C
R
1/18
Situational
Description: Monetary amount
Industry: Adjustment Amount
Alias: Adjusted Amount - Line Level
NSF Reference: FB3-06.0, FB3-08.0, FB3-10.0, FB3-12.0, FB3-14.0, FB3-16.0, FB3-18.0,
FA0-53.0, FA0-54.0
Use this amount for the adjustment amount.
Use as needed to show payer adjustment.
CAS07
380
Quantity
C
R
1/15
Situational
1/5
Situational
Description: Numeric value of quantity
Industry: Adjustment Quantity
Alias: Adjusted Units - Line Level
Use this quantity for the units of service being adjusted.
Use as needed to show payer adjustment.
CAS08
1034
Claim Adjustment Reason Code
C
ID
Description: Code identifying the detailed reason the adjustment was made
Industry: Adjustment Reason Code
Alias: Adjustment Reason Code - Line Level
CODE SOURCE: 139: Claim Adjustment Reason Code
NSF Reference: FB3-05.0, FB3-07.0, FB3-09.0, FB3-11.0, FB3-13.0, FB3-15.0, FB3-17.0
Use as needed to show payer adjustment.
Use the Claim Adjustment Reason Code list (See Appendix C).
ExternalCodeList
Name: 139
Description: Claim Adjustment Reason Code
CAS09
782
Monetary Amount
C
R
1/18
Situational
Description: Monetary amount
Industry: Adjustment Amount
837P_CG.ecs
401
For internal use only
12/1/2010
Ref
Health Care Claim: Professional - 837
Id
Element Name
Req
Type
Min/Max
Usage
Alias: Adjusted Amount - Line Level
NSF Reference: FB3-06.0, FB3-08.0, FB3-10.0, FB3-12.0, FB3-14.0, FB3-16.0, FB3-18.0,
FA0-53.0, FA0-54.0
Use this amount for the adjustment amount.
Use as needed to show payer adjustment.
CAS10
380
Quantity
C
R
1/15
Situational
1/5
Situational
Description: Numeric value of quantity
Industry: Adjustment Quantity
Alias: Adjusted Units - Line Level
Use this quantity for the units of service being adjusted.
Use as needed to show payer adjustment.
CAS11
1034
Claim Adjustment Reason Code
C
ID
Description: Code identifying the detailed reason the adjustment was made
Industry: Adjustment Reason Code
Alias: Adjustment Reason Code - Line Level
CODE SOURCE: 139: Claim Adjustment Reason Code
NSF Reference: FB3-05.0, FB3-07.0, FB3-09.0, FB3-11.0, FB3-13.0, FB3-15.0, FB3-17.0
Use as needed to show payer adjustment.
Use the Claim Adjustment Reason Code list (See Appendix C).
ExternalCodeList
Name: 139
Description: Claim Adjustment Reason Code
CAS12
782
Monetary Amount
C
R
1/18
Situational
Description: Monetary amount
Industry: Adjustment Amount
Alias: Adjusted Amount - Line Level
NSF Reference: FB3-06.0, FB3-08.0, FB3-10.0, FB3-12.0, FB3-14.0, FB3-16.0, FB3-18.0,
FA0-53.0, FA0-54.0
Use this amount for the adjustment amount.
Use as needed to show payer adjustment.
CAS13
380
Quantity
C
R
1/15
Situational
1/5
Situational
Description: Numeric value of quantity
Industry: Adjustment Quantity
Alias: Adjusted Units - Line Level
Use this quantity for the units of service being adjusted.
Use as needed to show payer adjustment.
CAS14
1034
Claim Adjustment Reason Code
C
ID
Description: Code identifying the detailed reason the adjustment was made
Industry: Adjustment Reason Code
Alias: Adjustment Reason Code - Line Level
CODE SOURCE: 139: Claim Adjustment Reason Code
NSF Reference: FB3-05.0, FB3-07.0, FB3-09.0, FB3-11.0, FB3-13.0, FB3-15.0, FB3-17.0
837P_CG.ecs
402
For internal use only
12/1/2010
Ref
Health Care Claim: Professional - 837
Id
Element Name
Req
Type
Min/Max
Usage
Use as needed to show payer adjustment.
Use the Claim Adjustment Reason Code list (See Appendix C).
ExternalCodeList
Name: 139
Description: Claim Adjustment Reason Code
CAS15
782
Monetary Amount
C
R
1/18
Situational
Description: Monetary amount
Industry: Adjustment Amount
Alias: Adjusted Amount - Line Level
NSF Reference: FB3-06.0, FB3-08.0, FB3-10.0, FB3-12.0, FB3-14.0, FB3-16.0, FB3-18.0,
FA0-53.0, FA0-54.0
Use this amount for the adjustment amount.
Use as needed to show payer adjustment.
CAS16
380
Quantity
C
R
1/15
Situational
1/5
Situational
Description: Numeric value of quantity
Industry: Adjustment Quantity
Alias: Adjusted Units - Line Level
Use this quantity for the units of service being adjusted.
Use as needed to show payer adjustment.
CAS17
1034
Claim Adjustment Reason Code
C
ID
Description: Code identifying the detailed reason the adjustment was made
Industry: Adjustment Reason Code
Alias: Adjustment Reason Code - Line Level
CODE SOURCE: 139: Claim Adjustment Reason Code
NSF Reference: FB3-05.0, FB3-07.0, FB3-09.0, FB3-11.0, FB3-13.0, FB3-15.0, FB3-17.0
Use as needed to show payer adjustment.
Use the Claim Adjustment Reason Code list (See Appendix C).
ExternalCodeList
Name: 139
Description: Claim Adjustment Reason Code
CAS18
782
Monetary Amount
C
R
1/18
Situational
Description: Monetary amount
Industry: Adjustment Amount
Alias: Adjusted Amount - Line Level
NSF Reference: FB3-06.0, FB3-08.0, FB3-10.0, FB3-12.0, FB3-14.0, FB3-16.0, FB3-18.0,
FA0-53.0, FA0-54.0
Use this amount for the adjustment amount.
Use as needed to show payer adjustment.
CAS19
380
Quantity
C
R
1/15
Situational
Description: Numeric value of quantity
Industry: Adjustment Quantity
Alias: Adjusted Units - Line Level
837P_CG.ecs
403
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Ref
Id
Element Name
Req
Type
Min/Max
Usage
Use this quantity for the units of service being adjusted.
Use as needed to show payer adjustment.
Syntax Rules:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
L050607 - If CAS05 is present, then at least one of CAS06 or CAS07 is required.
C0605 - If CAS06 is present, then CAS05 is required.
C0705 - If CAS07 is present, then CAS05 is required.
L080910 - If CAS08 is present, then at least one of CAS09 or CAS10 is required.
C0908 - If CAS09 is present, then CAS08 is required.
C1008 - If CAS10 is present, then CAS08 is required.
L111213 - If CAS11 is present, then at least one of CAS12 or CAS13 is required.
C1211 - If CAS12 is present, then CAS11 is required.
C1311 - If CAS13 is present, then CAS11 is required.
L141516 - If CAS14 is present, then at least one of CAS15 or CAS16 is required.
C1514 - If CAS15 is present, then CAS14 is required.
C1614 - If CAS16 is present, then CAS14 is required.
L171819 - If CAS17 is present, then at least one of CAS18 or CAS19 is required.
C1817 - If CAS18 is present, then CAS17 is required.
C1917 - If CAS19 is present, then CAS17 is required.
Semantics:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
CAS03
CAS04
CAS06
CAS07
CAS09
CAS10
CAS12
CAS13
CAS15
CAS16
CAS18
CAS19
is
is
is
is
is
is
is
is
is
is
is
is
the amount of adjustment.
the units of service being adjusted.
the amount of the adjustment.
the units of service being adjusted.
the amount of the adjustment.
the units of service being adjusted.
the amount of the adjustment.
the units of service being adjusted.
the amount of the adjustment.
the units of service being adjusted.
the amount of the adjustment.
the units of service being adjusted.
Comments:
1. Adjustment information is intended to help the provider balance the remittance information. Adjustment
amounts should fully explain the difference between submitted charges and the amount paid.
2. When the submitted charges are paid in full, the value for CAS03 should be zero.
Notes:
1. Required if the payer identified in Loop 2330B made line level adjustments which caused the amount paid to
differ from the amount originally charged.
2. Mapping CAS information into a flat file format may involve reading specific Claim Adjustment Reason Codes
and then mapping the subsequent Monetary Amount and/or Quantity elements to specific fields in the flat file.
3. There are some NSF COB elements which are covered through the use of the CAS segment. Please see the
claim level CAS segment for a note on handling those crosswalks at the claim level. Some of that information
may apply at the line level. Further information is given below which is more specific to line level issues. Balance
bill limiting charge (FA0-54.0). The adjustment for this information would be conveyed in a CAS amount element
if the provider billed for more than they were allowed to under contract.
4. The Claim Adjustment Reason codes are located on the Washington Publishing Company web site
837P_CG.ecs
404
For internal use only
12/1/2010
Health Care Claim: Professional - 837
http://www.wpc-edi.com.
Example:
CAS*PR*1*7.93~
CAS*OA*93*15.06~
837P_CG.ecs
405
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 550
DTP Line Adjudication Date
Max: 1
Detail - Optional
Loop: 2430
Elements: 3
User Option (Usage): Required
Purpose: To specify any or all of a date, a time, or a time period
Element Summary:
Ref
Id
Element Name
DTP01
374
Date/Time Qualifier
Req
Type
Min/Max
Usage
M
ID
3/3
Required
Description: Code specifying type of date or time, or both date and time
Industry: Date Time Qualifier
CodeList Summary (Total Codes: 1112, Included: 1)
Code Name
573
DTP02
1250
Date Claim Paid
Date Time Period Format Qualifier
M
ID
2/3
Required
Description: Code indicating the date format, time format, or date and time format
CodeList Summary (Total Codes: 39, Included: 1)
Code Name
D8
DTP03
1251
Date Expressed in Format CCYYMMDD
Date Time Period
M
AN
1/35
Required
Description: Expression of a date, a time, or range of dates, times or dates and times
Industry: Adjudication or Payment Date
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
Example:
DTP*573*D8*19970131~
837P_CG.ecs
406
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 551
Loop Form Identification Code
Repeat: 5
Optional
Loop: 2440 Elements: N/A
User Option (Usage): Situational
Purpose: Code to transmit standard industry codes
Loop Summary:
Pos
Id
Segment Name
551
552
LQ
FRM
Form Identification Code
Supporting Documentation
Req
Max Use
O
O
1
99
Repeat
Usage
Situational
Required
Notes:
1. Required if the provider is required to routinely include supporting documentation (a standardized paper form)
in electronic format. An example is for Medicare DMERC claims for which the provider is required to obtain a
certificate of medical necessity (CMN) from the physician. Medicare or other payers may require other supporting
documentation for other types of claims (e.g., home health). 266 4 2. The 2440 loop is designed to allow
providers to attach any type of standardized supplemental information to the claim when required to do so by the
payer. The LQ segment contains information to identify the form (LQ01) and the specific form number (LQ02). In
the example given below, LQ01=UT which identifies the form as a Medicare DMERC CMN form. LQ02=0102A
identifies which DMERC CMN form is being used. See Appendix K and the FRM segment for further notes on use
of this loop.
3. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,
then the LQ and FRM segments are “Required”.
4. Loop 2440 was approved by ASC X12 in the version 004011 Data Dictionary but is included in this guide to
provide standard way to report DMERC claims within the HIPAA implementation time frame. It is recommended
that entitles who have a need to submit or receive DMERC claims customize their 004010 translator map to allow
this loop.
Example:
LQ*UT*0102A~
837P_CG.ecs
407
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 551
LQ Form Identification Code
Max: 1
Detail - Optional
Loop: 2440
Elements: 2
User Option (Usage): Situational
Purpose: Code to transmit standard industry codes
Element Summary:
Ref
Id
Element Name
LQ01
1270
Code List Qualifier Code
Req
Type
Min/Max
Usage
O
ID
1/3
Required
Description: Code identifying a specific industry code list
Alias: Form Identification Code
CodeList Summary (Total Codes: 577, Included: 2)
Code Name
LQ02
1271
AS
Form Type Code
Use code AS to indicate that a Home Health form is being identified.
UT
Health Care Financing Administration (HCFA) Durable Medical Equipment Regional
Carrier (DMERC) Certificate of Medical Necessity (CMN) Forms
Industry Code
C
AN
1/30
Required
Description: Code indicating a code from a specific industry code list
Industry: Form Identifier
NSF Reference: GU0-25.0
Syntax Rules:
1. C0102 - If LQ01 is present, then LQ02 is required.
Notes:
1. Required if the provider is required to routinely include supporting documentation (a standardized paper form)
in electronic format. An example is for Medicare DMERC claims for which the provider is required to obtain a
certificate of medical necessity (CMN) from the physician. Medicare or other payers may require other supporting
documentation for other types of claims (e.g., home health). 266 4 2. The 2440 loop is designed to allow
providers to attach any type of standardized supplemental information to the claim when required to do so by the
payer. The LQ segment contains information to identify the form (LQ01) and the specific form number (LQ02). In
the example given below, LQ01=UT which identifies the form as a Medicare DMERC CMN form. LQ02=0102A
identifies which DMERC CMN form is being used. See Appendix K and the FRM segment for further notes on use
of this loop.
3. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,
then the LQ and FRM segments are “Required”.
4. Loop 2440 was approved by ASC X12 in the version 004011 Data Dictionary but is included in this guide to
provide standard way to report DMERC claims within the HIPAA implementation time frame. It is recommended
that entitles who have a need to submit or receive DMERC claims customize their 004010 translator map to allow
this loop.
Example:
LQ*UT*0102A~
837P_CG.ecs
408
For internal use only
12/1/2010
Health Care Claim: Professional - 837
FRM Supporting Documentation
Pos: 552
Max: 99
Detail - Optional
Loop: 2440
Elements: 5
User Option (Usage): Required
Purpose: To specify information in response to a codified questionnaire document
Element Summary:
Ref
Id
Element Name
FRM01
350
Assigned Identification
Req
Type
Min/Max
Usage
M
AN
1/20
Required
Description: Alphanumeric characters assigned for differentiation within a transaction set
Industry: Question Number/Letter
FRM02
1073
Yes/No Condition or Response Code
C
ID
1/1
Situational
Description: Code indicating a Yes or No condition or response
Industry: Question Response
NSF Reference: GU0-26.0, GU0-27.0, GU0-28.0, GU0-29.0, GU0-30.0, GU0-31.0,
GU0-32. 0, GU0-33.0, GU0-34.0, GU0-35.0, GU0-36.0, GU0-37.0, GU0-38.0, GU0-39.0,
GU0-40.0, GU0-43.0, GU0-44.0
FRM02, 03, 04, or 05 is required.
Used to answer question identified in FRM01 which utilizes a Yes/No response format.
CodeList Summary (Total Codes: 4, Included: 3)
Code Name
N
W
Y
FRM03
127
No
Not Applicable
Yes
Reference Identification
C
AN
1/30
Situational
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Question Response
NSF Reference: GU0-28.0, GU0-31.0, GU0-33.0, GU0-45.0, GU0-46.0, GU0-47.0,
GU0-48. 0, GU0-49.0, GU0-50.0, GU0-51.0, GU0-57.0, GU0-58.0, GU0-59.0, GU0-60.0,
GU0-61.0, GU0-62.0, GU0-63.0, GU0-64.0, GU0-65.0, GU0-66. 0, GU0-67.0, GU0-68.0
FRM02, 03, 04, or 05 is required.
Used to answer question identified in FRM01 which utilizes a text or uncodified response
format.
FRM04
373
Date
C
DT
8/8
Situational
Description: Date expressed as CCYYMMDD
Industry: Question Response
NSF Reference: GU0-53.0, GU0-54.0, GU0-55.0, GU0-56.0
FRM02, 03, 04, or 05 is required.
Used to answer question identified in FRM01 which utilizes a date response format.
FRM05
332
Percent
C
R
1/6
Situational
Description: Percent expressed as a percent
Industry: Question Response
NSF Reference: GU0-69.0, GU0-70.0, GU0-71.0
837P_CG.ecs
409
For internal use only
12/1/2010
Ref
Health Care Claim: Professional - 837
Id
Element Name
Req
Type
Min/Max
Usage
FRM02, 03, 04, or 05 is required.
Used to answer question identified in FRM01 which utilizes a percent response format.
Syntax Rules:
1. R02030405 - At least one of FRM02, FRM03, FRM04 or FRM05 is required.
Semantics:
1. FRM01 is the question number on a questionnaire or codified form.
2. FRM02, FRM03, FRM04 and FRM05 are responses which only have meaning in reference to the question
identified in FRM01.
Comments:
1. The FRM segment can only be used in the context of an identified questionnaire or list of questions. The
source of the questions can be identified by an associated segment or by transaction set notes in a particular
transaction.
Notes:
1. The LQ segment is used to identify the general (LQ01) and specific type (LQ02) for the form being reported in
the 2440. The FRM segment is used to answer specific questions on the form identified in the LQ. FRM01 is used
to indicate the question being answered. Answers can take one of 4 forms: FRM02 for Yes/No questions, FRM03
for text/uncodified answers, FRM04 for answers which use dates, and FRM05 for answers which are percents.
For each FRM01 (question) use a remaining FRM element, choosing the element which has the most appropriate
format. One FRM segment is used for each question/answer pair.
The example below shows how the FRM can be used to answer all the pertinent questions on DMERC form 0802
(LQ*UT*0802~). See Appendix K - Supporting Documentation Example, for a more detailed explaination of how to
use the 2440 Loop.
2. Loop 2440 was approved by ASC X12 in the version 004011 Data Dictionary but is included in this guide to
provide standard way to report DMERC claims within the HIPAA implementation time frame. It is recommended
that entitles who have a need to submit or receive DMERC claims customize their 004010 translator map to allow
this loop.
Example:
FRM*1A**J0234~
FRM*1B**500~
FRM*1C**4~
FRM*4*Y~
FRM*5A**5~
FRM*5B**3~
FRM*8*METHODIST HOSPITAL~
FRM*9*INDIANAPOLIS~
FRM*10**INDIANA~
FRM*11***19971101~
FRM*12*Y~
FRM*1*N~
837P_CG.ecs
410
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 001
Loop Patient Hierarchical Level
Repeat: >1
Optional
Loop:
2000C
Elements: N/A
User Option (Usage): Situational
Purpose: To identify dependencies among and the content of hierarchically related groups of data segments
Loop Summary:
Pos
Id
Segment Name
001
007
015
130
HL
PAT
Patient Hierarchical Level
Patient Information
Loop 2010CA
Loop 2300
Req
Max Use
O
O
O
O
1
1
Repeat
Usage
1
100
Situational
Required
Required
Required
Comments:
1. The HL segment is used to identify levels of detail information using a hierarchical structure, such as relating
line-item data to shipment data, and packaging data to line-item data.
2. The HL segment defines a top-down/left-right ordered structure.
3. HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction
set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which
case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each
subsequent HL segment within the transaction.
4. HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.
5. HL03 indicates the context of the series of segments following the current HL segment up to the next
occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent
segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
6. HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL
segment.
Notes:
1. This HL is required when the patient is a different person than the subscriber. There are no HLs subordinate to
the Patient HL.
2. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,
then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.
3. Receiving trading partners may have system limitations regarding the size of the transmission they can receive.
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. While the implementation guide sets no specific limit to
the number of Patient Hierarchical Level loops, there is an implied maximum of 5000.
Example:
HL*3*2*23*0~
837P_CG.ecs
411
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 001
HL Patient Hierarchical Level
Max: 1
Detail - Optional
Loop:
2000C
Elements: 4
User Option (Usage): Situational
Purpose: To identify dependencies among and the content of hierarchically related groups of data segments
Element Summary:
Ref
Id
Element Name
HL01
628
Hierarchical ID Number
Req
Type
Min/Max
Usage
M
AN
1/12
Required
Description: A unique number assigned by the sender to identify a particular data
segment in a hierarchical structure
HL02
734
Hierarchical Parent ID Number
O
AN
1/12
Required
Description: Identification number of the next higher hierarchical data segment that the
data segment being described is subordinate to
HL03
735
Hierarchical Level Code
M
ID
1/2
Required
Description: Code defining the characteristic of a level in a hierarchical structure
CodeList Summary (Total Codes: 170, Included: 1)
Code Name
23
HL04
736
Dependent
The code DEPENDENT is meant to convey that the information in this HL applies
to the patient when the subscriber and the patient are not the same person.
Hierarchical Child Code
O
ID
1/1
Required
Description: Code indicating if there are hierarchical child data segments subordinate to
the level being described
CodeList Summary (Total Codes: 2, Included: 1)
Code Name
0
No Subordinate HL Segment in This Hierarchical Structure.
Comments:
1. The HL segment is used to identify levels of detail information using a hierarchical structure, such as relating
line-item data to shipment data, and packaging data to line-item data.
2. The HL segment defines a top-down/left-right ordered structure.
3. HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction
set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which
case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each
subsequent HL segment within the transaction.
4. HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.
5. HL03 indicates the context of the series of segments following the current HL segment up to the next
occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent
segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
6. HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL
segment.
Notes:
1. This HL is required when the patient is a different person than the subscriber. There are no HLs subordinate to
837P_CG.ecs
412
For internal use only
12/1/2010
Health Care Claim: Professional - 837
the Patient HL.
2. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,
then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.
3. Receiving trading partners may have system limitations regarding the size of the transmission they can receive.
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. While the implementation guide sets no specific limit to
the number of Patient Hierarchical Level loops, there is an implied maximum of 5000.
Example:
HL*3*2*23*0~
837P_CG.ecs
413
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 007
PAT Patient Information
Max: 1
Detail - Optional
Loop:
2000C
Elements: 6
User Option (Usage): Required
Purpose: To supply patient information
Element Summary:
Ref
Id
Element Name
PAT01
1069
Individual Relationship Code
Req
Type
Min/Max
Usage
O
ID
2/2
Required
Description: Code indicating the relationship between two individuals or entities
Alias: Patients Relationship to Insured
NSF Reference: DA0-17.0
CodeList Summary (Total Codes: 153, Included: 25)
Code Name
01
04
05
07
09
10
15
17
19
20
21
22
23
24
29
32
33
34
36
39
40
41
43
53
G8
PAT05
1250
Spouse
Grandfather or Grandmother
Grandson or Granddaughter
Nephew or Niece
Adopted Child
Foster Child
Ward
Stepson or Stepdaughter
Child
Employee
Unknown
Handicapped Dependent
Sponsored Dependent
Dependent of a Minor Dependent
Significant Other
Mother
Father
Other Adult
Emancipated Minor
Organ Donor
Cadaver Donor
Injured Plaintiff
Child Where Insured Has No Financial Responsibility
Life Partner
Other Relationship
Date Time Period Format Qualifier
C
ID
2/3
Situational
Description: Code indicating the date format, time format, or date and time format
Required if patient is known to be deceased and the date of death is available to the
provider billing system.
CodeList Summary (Total Codes: 39, Included: 1)
837P_CG.ecs
414
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Code Name
D8
PAT06
1251
Date Expressed in Format CCYYMMDD
Date Time Period
C
AN
1/35
Situational
Description: Expression of a date, a time, or range of dates, times or dates and times
Industry: Patient Death Date
Alias: Date of Death
NSF Reference: CA0-21.0
Required if patient is known to be deceased and the date of death is available to the
provider billing system.
PAT07
355
Unit or Basis for Measurement Code
C
ID
2/2
Situational
Description: Code specifying the units in which a value is being expressed, or manner in
which a measurement has been taken
Required when PAT08 is used.
CodeList Summary (Total Codes: 794, Included: 1)
Code Name
01
PAT08
81
Actual Pounds
Weight
C
R
1/10
Situational
Description: Numeric value of weight
Industry: Patient Weight
NSF Reference: FA0-44.0, GU0-17.0
Required on:
1) claims/encounters involving EPO (epoetin) for patients on dialysis.
2) Medicare Durable Medical Equipment Regional Carriers certificate of medical necessity
(DMERC CMN) 02.03 and 10.02.
PAT09
1073
Yes/No Condition or Response Code
O
ID
1/1
Situational
Description: Code indicating a Yes or No condition or response
Industry: Pregnancy Indicator
Required when mandated by law. The determination of pregnancy should be completed in
compliance with applicable law. The “Y” code indicates that the patient is pregnant. If
PAT09 is not used it means the patient is not pregnant.
CodeList Summary (Total Codes: 4, Included: 1)
Code Name
Y
Yes
Syntax Rules:
1. P0506 - If either PAT05 or PAT06 is present, then the other is required.
2. P0708 - If either PAT07 or PAT08 is present, then the other is required.
Semantics:
1. PAT06 is the date of death.
2. PAT08 is the patient's weight.
3. PAT09 indicates whether the patient is pregnant or not pregnant. Code "Y" indicates the patient is pregnant;
code "N" indicates the patient is not pregnant.
Example:
837P_CG.ecs
415
For internal use only
12/1/2010
Health Care Claim: Professional - 837
PAT*01******01*145~
837P_CG.ecs
416
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 015
Loop Patient Name
Repeat: 1
Optional
Loop:
2010CA
Elements: N/A
User Option (Usage): Required
Purpose: To supply the full name of an individual or organizational entity
Loop Summary:
Pos
Id
Segment Name
015
025
030
032
035
035
NM1
N3
N4
DMG
REF
REF
Patient Name
Patient Address
Patient City/State/ZIP Code
Patient Demographic Information
Patient Secondary Identification
Property and Casualty Claim Number
Req
Max Use
O
O
O
O
O
O
1
1
1
1
5
1
Repeat
Usage
Required
Required
Required
Required
Situational
Situational
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
Example:
NM1*QC*1*DOE*SALLY*J***MI*SJD11111~
837P_CG.ecs
417
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 015
NM1 Patient Name
Max: 1
Detail - Optional
Loop:
2010CA
Elements: 8
User Option (Usage): Required
Purpose: To supply the full name of an individual or organizational entity
Element Summary:
Ref
Id
Element Name
NM101
98
Entity Identifier Code
Req
Type
Min/Max
Usage
M
ID
2/3
Required
Description: Code identifying an organizational entity, a physical location, property or an
individual
CodeList Summary (Total Codes: 1312, Included: 1)
Code Name
QC
NM102
1065
Patient
Entity Type Qualifier
M
ID
1/1
Required
AN
1/35
Required
Description: Code qualifying the type of entity
CodeList Summary (Total Codes: 14, Included: 1)
Code Name
1
NM103
1035
Person
Name Last or Organization Name
O
Description: Individual last name or organizational name
Industry: Patient Last Name
NSF Reference: CA0-04.0
NM104
1036
Name First
O
AN
1/25
Required
O
AN
1/25
Situational
Description: Individual first name
Industry: Patient First Name
NSF Reference: CA0-05.0
NM105
1037
Name Middle
Description: Individual middle name or initial
Industry: Patient Middle Name
Alias: Patient Middle Initial
NSF Reference: CA0-06.0
Required if NM102=1 and the middle name/initial of the person is known.
NM107
1039
Name Suffix
O
AN
1/10
Situational
Description: Suffix to individual name
Industry: Patient Name Suffix
Alias: Patient Generation
NSF Reference: CA0-07.0
Required if known.
837P_CG.ecs
418
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Ref
Id
Element Name
NM108
66
Identification Code Qualifier
Req
Type
Min/Max
Usage
C
ID
1/2
Situational
Description: Code designating the system/method of code structure used for Identification
Code (67)
Required if the patient identifier is different than the subscriber identifier.
CodeList Summary (Total Codes: 215, Included: 2)
Code Name
NM109
67
MI
Member Identification Number
The code MI is intended to be the subscriber’s identification number as assigned
by the payer. Payers use different terminology to convey the
same number. Therefore the 837 Professional Workgroup recommends using MI Member Identification Number to convey the following terms: Insured’s ID,
Subscriber’s ID, Health Insurance Claim Number (HIC), etc.
ZZ
Mutually Defined
The value ‘ZZ’, when used in this data element shall be defined as “HIPAA
Individual Identifier” once this identifier has been adopted. Under the Health
Insurance Portability and Accountability Act of 1996, the Secretary of the
Department of Health and Human Services must adopt a standard individual
identifier for use in this transaction.
Identification Code
C
AN
2/80
Situational
Description: Code identifying a party or other code
Industry: Patient Primary Identifier
Alias: Patient’s Primary Identification Number
NSF Reference: DA0-18.0
Required if the patient identifier is different than the subscriber identifier.
Syntax Rules:
1. P0809 - If either NM108 or NM109 is present, then the other is required.
2. C1110 - If NM111 is present, then NM110 is required.
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
Example:
NM1*QC*1*DOE*SALLY*J***MI*SJD11111~
837P_CG.ecs
419
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 025
N3 Patient Address
Max: 1
Detail - Optional
Loop:
2010CA
Elements: 2
User Option (Usage): Required
Purpose: To specify the location of the named party
Element Summary:
Ref
Id
Element Name
N301
166
Address Information
Req
Type
Min/Max
Usage
M
AN
1/55
Required
O
AN
1/55
Situational
Description: Address information
Industry: Patient Address Line
Alias: Patient Address 1
NSF Reference: CA0-11.0
N302
166
Address Information
Description: Address information
Industry: Patient Address Line
Alias: Patient Address 2
NSF Reference: CA0-12.0
Required if a second address line exists.
Example:
N3*RFD 10*100 COUNTRY LANE~
837P_CG.ecs
420
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 030
N4 Patient City/State/ZIP Code
Max: 1
Detail - Optional
Loop:
2010CA
Elements: 4
User Option (Usage): Required
Purpose: To specify the geographic place of the named party
Element Summary:
Ref
Id
Element Name
N401
19
City Name
Req
Type
Min/Max
Usage
O
AN
2/30
Required
O
ID
2/2
Required
Description: Free-form text for city name
Industry: Patient City Name
NSF Reference: CA0-13.0
N402
156
State or Province Code
Description: Code (Standard State/Province) as defined by appropriate government
agency
Industry: Patient State Code
CODE SOURCE: 22: States and Outlying Areas of the U.S.
NSF Reference: CA0-14.0
ExternalCodeList
Name: 22
Description: States and Outlying Areas of the U.S.
N403
116
Postal Code
O
ID
3/15
Required
Description: Code defining international postal zone code excluding punctuation and
blanks (zip code for United States)
Industry: Patient Postal Zone or ZIP Code
Alias: Patient Zip Code
CODE SOURCE: 51: ZIP Code
NSF Reference: CA0-15.0
ExternalCodeList
Name: 51
Description: ZIP Code
N404
26
Country Code
O
ID
2/3
Situational
Description: Code identifying the country
Alias: Patient Country Code
CODE SOURCE: 5: Countries, Currencies and Funds
Required if the address is out of the U.S.
ExternalCodeList
Name: 5
Description: Countries, Currencies and Funds
Syntax Rules:
1. C0605 - If N406 is present, then N405 is required.
837P_CG.ecs
421
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Comments:
1. A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
2. N402 is required only if city name (N401) is in the U.S. or Canada.
Example:
N4*CORNFIELD TOWNSHIP*IA*99999~
837P_CG.ecs
422
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 032
DMG Patient Demographic
Max: 1
Detail - Optional
Information
Loop:
2010CA
Elements: 3
User Option (Usage): Required
Purpose: To supply demographic information
Element Summary:
Ref
Id
Element Name
DMG01
1250
Date Time Period Format Qualifier
Req
Type
Min/Max
Usage
C
ID
2/3
Required
Description: Code indicating the date format, time format, or date and time format
CodeList Summary (Total Codes: 39, Included: 1)
Code Name
D8
DMG02
1251
Date Expressed in Format CCYYMMDD
Date Time Period
C
AN
1/35
Required
Description: Expression of a date, a time, or range of dates, times or dates and times
Industry: Patient Birth Date
Alias: Date of Birth
NSF Reference: CA0-08.0
DMG03
1068
Gender Code
O
ID
1/1
Required
Description: Code indicating the sex of the individual
Industry: Patient Gender Code
Alias: Gender - Patient
NSF Reference: CA0-09.0
CodeList Summary (Total Codes: 7, Included: 3)
Code Name
F
M
U
Female
Male
Unknown
Syntax Rules:
1. P0102 - If either DMG01 or DMG02 is present, then the other is required.
Semantics:
1. DMG02 is the date of birth.
2. DMG07 is the country of citizenship.
3. DMG09 is the age in years.
Example:
DMG*D8*19530101*F~
837P_CG.ecs
423
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 035
REF Patient Secondary
Max: 5
Detail - Optional
Identification
Loop:
2010CA
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 4)
Code Name
REF02
127
1W
Member Identification Number
If NM108 = M1 do not use this code.
23
Client Number
This code is intended to be used only in claims submitted to the Indian Health
Service/Contract Health Services (IHC/CHS) Fiscal Intermediary for the purpose
of reporting the Health Record Number.
IG
SY
Insurance Policy Number
Social Security Number
The social security number may not be used for Medicare.
Reference Identification
C
AN
1/30
Required
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Patient Secondary Identifier
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. Required if additional identification numbers are necessary to adjudicate the claim/encounter.
Example:
REF*SY*528779999~
837P_CG.ecs
424
For internal use only
12/1/2010
Health Care Claim: Professional - 837
REF Property and Casualty Claim
Number
Pos: 035
Max: 1
Detail - Optional
Loop:
2010CA
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
1/30
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 1)
Code Name
Y4
REF02
127
Agency Claim Number
Reference Identification
C
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Property Casualty Claim Number
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. In the case where the patient is the same person as the subscriber, the property and casualty claim number is
placed in Loop ID-2010BA. In the case where the patient is a different person than the subscriber, this number is
placed in Loop ID-2010CA. This number should be transmitted in only one place.
2. This is a property and casualty payer-assigned claim number. It is required on property and casualty claims.
Providers receive this number from the property and casualty payer during eligibility determinations or some other
communication with that payer. See Section 4.2, Property and Casualty, for additional information about property
and casualty claims.
3. Not required for HIPAA (The statutory definition of a health plan does not specifically include workers’
compensation programs, property and casualty programs, or disability insurance programs, and, consequently,
we are not requiring them to comply with the standards.) but may be required for other uses.
Example:
REF*Y4*4445555~
837P_CG.ecs
425
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 130
Loop Claim Information
Repeat: 100
Optional
Loop: 2300 Elements: N/A
User Option (Usage): Required
Purpose: To specify basic data about the claim
Loop Summary:
Pos
Id
Segment Name
130
135
135
135
135
135
135
135
135
135
CLM
DTP
DTP
DTP
DTP
DTP
DTP
DTP
DTP
DTP
135
135
135
135
135
135
135
DTP
DTP
DTP
DTP
DTP
DTP
DTP
155
160
175
175
175
180
180
PWK
CN1
AMT
AMT
AMT
REF
REF
180
180
180
180
REF
REF
REF
REF
180
180
180
180
REF
REF
REF
REF
180
180
REF
REF
Claim Information
Date - Initial Treatment
Date - Date Last Seen
Date - Onset of Current Illness/Symptom
Date - Acute Manifestation
Date - Similar Illness/Symptom Onset
Date - Accident
Date - Last Menstrual Period
Date - Last X-ray
Date - Hearing and Vision Prescription
Date
Date - Disability Begin
Date - Disability End
Date - Last Worked
Date - Authorized Return to Work
Date - Admission
Date - Discharge
Date - Assumed and Relinquished Care
Dates
Claim Supplemental Information
Contract Information
Credit/Debit Card Maximum Amount
Patient Amount Paid
Total Purchased Service Amount
Service Authorization Exception Code
Mandatory Medicare (Section 4081)
Crossover Indicator
Mammography Certification Number
Prior Authorization or Referral Number
Original Reference Number (ICN/DCN)
Clinical Laboratory Improvement
Amendment (CLIA) Number
Repriced Claim Number
Adjusted Repriced Claim Number
Investigational Device Exemption Number
Claim Identification Number for Clearing
Houses and Other Transmission
Intermediaries
Ambulatory Patient Group (APG)
Medical Record Number
837P_CG.ecs
426
Req
Max Use
O
O
O
O
O
O
O
O
O
O
1
1
1
1
5
10
10
1
1
1
Repeat
Required
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Usage
O
O
O
O
O
O
O
5
5
1
1
1
1
2
Situational
Situational
Situational
Situational
Situational
Situational
Situational
O
O
O
O
O
O
O
10
1
1
1
1
1
1
Situational
Situational
Situational
Situational
Situational
Situational
Situational
O
O
O
O
1
2
1
3
Situational
Situational
Situational
Situational
O
O
O
O
1
1
1
1
Situational
Situational
Situational
Situational
O
O
4
1
Situational
Situational
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos
Id
Segment Name
180
185
190
195
200
220
220
220
220
231
241
242
250
250
250
250
250
290
365
REF
K3
NTE
CR1
CR2
CRC
CRC
CRC
CRC
HI
HCP
Demonstration Project Identifier
File Information
Claim Note
Ambulance Transport Information
Spinal Manipulation Service Information
Ambulance Certification
Patient Condition Information: Vision
Homebound Indicator
EPSDT Referral
Health Care Diagnosis Code
Claim Pricing/Repricing Information
Loop 2305
Loop 2310A
Loop 2310B
Loop 2310C
Loop 2310D
Loop 2310E
Loop 2320
Loop 2400
Req
Max Use
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
1
10
1
1
1
3
3
1
1
1
1
Repeat
Usage
6
2
1
1
1
1
10
50
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Required
Semantics:
1. CLM02 is the total amount of all submitted charges of service segments for this claim.
2. CLM06 is provider signature on file indicator. A "Y" value indicates the provider signature is on file; an "N"
value indicates the provider signature is not on file.
3. CLM08 is assignment of benefits indicator. A "Y" value indicates insured or authorized person authorizes
benefits to be assigned to the provider; an "N" value indicates benefits have not been assigned to the
provider.
4. CLM13 is CHAMPUS nonavailability indicator. A "Y" value indicates a statement of non-availability is on file;
an "N" value indicates statement of nonavailability is not on file or not necessary.
5. CLM15 is charges itemized by service indicator. A "Y" value indicates charges are itemized by service; an "N"
value indicates charges are summarized by service.
6. CLM18 is explanation of benefit (EOB) indicator. A "Y" value indicates that a paper EOB is requested; an "N"
value indicates that no paper EOB is requested.
Notes:
1. Because this is a required segment, this is a required loop. See Appendix A for further details on ASC X12
syntax rules.
2. 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 ISA-IEA. Willing trading partners can agree to set limits higher.
3. 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 2010BD in the subscriber hierarchical level when the patient is the
subscriber, or it is placed at the patient/dependent hierarchical level when the patient is the dependent of the
subscriber as shown here. When the patient is the subscriber, loops 2000C and 2010CA are not sent. See
2.3.2.1, HL Segment, for details.
Example:
CLM*A37YH556*500***11::1*Y*A*Y*Y*C~
837P_CG.ecs
427
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 130
CLM Claim Information
Max: 1
Detail - Optional
Loop: 2300
Elements: 12
User Option (Usage): Required
Purpose: To specify basic data about the claim
Element Summary:
Ref
Id
Element Name
CLM01
1028
Claim Submitter's Identifier
Req
Type
Min/Max
Usage
M
AN
1/38
Required
Description: Identifier used to track a claim from creation by the health care provider
through payment
Industry: Patient Account Number
NSF Reference: CA0-03.0, CB0-03.0, DA0-03.0, DA1-03.0, DA2-03.0, EA0-03.0, EA103.0, EA2-03.0, FA0-03.0, FB0-03.0, FB1-03.0, FB2-03.0, FD0-03.0, FE0-03.0, GA0-03.0,
GC0-03.0, GX0-03.0, GX2-03.0, XA0-03.0, CA1-03. 0, GU0-03.0, HA0-03.0
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 completely unique
numbers for this field for each individual claim.
The maximum number of characters to be supported for this field is ’20’. A provider may
submit fewer characters depending upon their needs. However, the HIPAA maximum
requirement to be supported by any responding system is ’20’. Characters beyond 20 are
not required to be stored nor returned by any 837-receiving system.
CLM02
782
Monetary Amount
O
R
1/18
Required
Description: Monetary amount
Industry: Total Claim Charge Amount
Alias: Total Submitted Charges
NSF Reference: XA0-12.0
For encounter transmissions, zero (0) may be a valid amount.
CLM05
C023
Health Care Service Location
Information
O
Comp
Required
Description: To provide information that identifies the place of service or the type of bill
related to the location at which a health care service was rendered
Alias: Place of Service Code
NSF Reference: FA0-07.0
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
Description: Code identifying the type of facility where services were performed; the first
and second positions of the Uniform Bill Type code or the Place of Service code from the
Electronic Media Claims National Standard Format
Industry: Facility Type Code
Use this element for codes identifying a place of service from code source 237. As a
courtesy, the codes are listed below, however, the code list is thought to be complete at the
time of publication of this implementation guideline. Since this list is subject to change, only
codes contained in the document available from code source 237 are to be supported in
837P_CG.ecs
428
For internal use only
12/1/2010
Ref
Health Care Claim: Professional - 837
Id
Element Name
Req
Type
Min/Max
this transaction and take precedence over any and all codes listed here.
Usage
11 Office
12 Home
21 Inpatient Hospital
22 Outpatient Hospital
23 Emergency Room - Hospital
24 Ambulatory Surgical Center
25 Birthing Center
26 Military Treatment Facility
31 Skilled Nursing Facility
32 Nursing Facility
33 Custodial Care Facility
34 Hospice
41 Ambulance - Land
42 Ambulance - Air or Water
51 Inpatient Psychiatric Facility
52 Psychiatric Facility Partial Hospitalization
53 Community Mental Health Center
54 Intermediate Care Facility/Mentally Retarded
55 Residential Substance Abuse Treatment Facility
56 Psychiatric Residential Treatment Center
50 Federally Qualified Health Center
60 Mass Immunization Center
61 Comprehensive Inpatient Rehabilitation Facility
62 Comprehensive Outpatient Rehabilitation Facility
65 End Stage Renal Disease Treatment Facility
71 State or Local Public Health Clinic
72 Rural Health Clinic
81 Independent Laboratory
99 Other Unlisted Facility
ExternalCodeList
Name: 237
Description: Place of Service from Health Care Financing Administration Claim Form
CLM05-03
1325
Claim Frequency Type Code
O
ID
1/1
Required
Description: Code specifying the frequency of the claim; this is the third position of the
Uniform Billing Claim Form Bill Type
Industry: Claim Frequency Code
Alias: Claim Submission Reason Code
CODE SOURCE: 235: Claim Frequency Type Code
ExternalCodeList
Name: 235
Description: Claim Frequency Type Code
CLM06
1073
Yes/No Condition or Response Code
O
ID
1/1
Required
Description: Code indicating a Yes or No condition or response
Industry: Provider or Supplier Signature Indicator
Alias: Provider Signature on File
NSF Reference: EA0-37.0
CodeList Summary (Total Codes: 4, Included: 2)
837P_CG.ecs
429
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Code Name
N
Y
CLM07
1359
No
Yes
Provider Accept Assignment Code
O
ID
1/1
Required
Description: Code indicating whether the provider accepts assignment
Industry: Medicare Assignment Code
CLM07 indicates whether the provider accepts Medicare assignment.
The NSF mapping to FA0-59.0 occurs only in payer-to-payer COB situations.
All valid standard codes are used. (Total Codes: 4)
CLM08
1073
Yes/No Condition or Response Code
O
ID
1/1
Required
1/1
Required
Description: Code indicating a Yes or No condition or response
Industry: Benefits Assignment Certification Indicator
Alias: Assignment of Benefits Indicator
NSF Reference: DA0-15.0
CodeList Summary (Total Codes: 4, Included: 2)
Code Name
N
Y
CLM09
1363
No
Yes
Release of Information Code
O
ID
Description: Code indicating whether the provider has on file a signed statement by the
patient authorizing the release of medical data to other organizations
Alias: Release of Information Code
NSF Reference: EA0-13.0
All valid standard codes are used. (Total Codes: 6)
CLM10
1351
Patient Signature Source Code
O
ID
1/1
Situational
Description: Code indicating how the patient or subscriber authorization signatures were
obtained and how they are being retained by the provider
Alias: Patient Signature Source Code
NSF Reference: DA0-16.0
CLM10 is required except in cases where code ‘‘N’’ is used in CLM09.
All valid standard codes are used. (Total Codes: 5)
CLM11
C024
Related Causes Information
O
Comp
Situational
Description: To identify one or more related causes and associated state or country
information
Alias: Accident/Employment/Related Causes
CLM11-1, CLM11-2, or CLM11-3 are required when the condition being reported is
accident or employment related. If CLM11-1, CLM11-2, or CLM11-3 equals AP, then map
Yes to EA0-09.0. 2440 If DTP - Date of Accident (DTP01=439) is used, then CLM11 is
required.
CLM11-01
1362
Related-Causes Code
M
ID
2/3
Required
Description: Code identifying an accompanying cause of an illness, injury or an accident
Industry: Related Causes Code
NSF Reference: EA0-05.0 - Auto Accident or Other Accident, EA0-04.0 -Employment,
837P_CG.ecs
430
For internal use only
12/1/2010
Ref
Health Care Claim: Professional - 837
Id
Element Name
EA0-09.0 - Responsibility Indicator
Req
Type
Min/Max
Usage
ID
2/3
Situational
CodeList Summary (Total Codes: 6, Included: 4)
Code Name
AA
AP
EM
OA
CLM11-02
1362
Auto Accident
Another Party Responsible
Employment
Other Accident
Related-Causes Code
O
Description: Code identifying an accompanying cause of an illness, injury or an accident
Industry: Related Causes Code
NSF Reference: EA0-05.0 - Auto Accident or Other Accident, EA0-04.0 -Employment,
EA0-09.0 - Responsibility Indicator
Used if more than one code applies.
CodeList Summary (Total Codes: 6, Included: 4)
Code Name
AA
AP
EM
OA
CLM11-03
1362
Auto Accident
Another Party Responsible
Employment
Other Accident
Related-Causes Code
O
ID
2/3
Situational
Description: Code identifying an accompanying cause of an illness, injury or an accident
Industry: Related Causes Code
NSF Reference: EA0-05.0 - Auto Accident or Other Accident, EA0-04.0 -Employment,
EA0-09.0 - Responsibility Indicator
Used if more than one code applies.
CodeList Summary (Total Codes: 6, Included: 4)
Code Name
AA
AP
EM
OA
CLM11-04
156
Auto Accident
Another Party Responsible
Employment
Other Accident
State or Province Code
O
ID
2/2
Situational
Description: Code (Standard State/Province) as defined by appropriate government
agency
Industry: Auto Accident State or Province Code
CODE SOURCE: 22: States and Outlying Areas of the U.S.
NSF Reference: EA0-10.0
Required if CLM11-1, -2, or -3 = AA to identify the state in which the automobile accident
occurred. Use state postal code (CA = California, UT = Utah, etc).
ExternalCodeList
Name: 22
Description: States and Outlying Areas of the U.S.
837P_CG.ecs
431
For internal use only
12/1/2010
CLM11-05
Health Care Claim: Professional - 837
26
Country Code
O
ID
2/3
Situational
Description: Code identifying the country
CODE SOURCE: 5: Countries, Currencies and Funds
Required if the automobile accident occurred out of the United States to identify the
country in which the accident occurred.
ExternalCodeList
Name: 5
Description: Countries, Currencies and Funds
CLM12
1366
Special Program Code
O
ID
2/3
Situational
Description: Code indicating the Special Program under which the services rendered to
the patient were performed
Industry: Special Program Indicator
Alias: Special Program Code
NSF Reference: EA0-43.0
Required if the services were rendered under one of the following
circumstances/programs/projects.
CodeList Summary (Total Codes: 10, Included: 7)
Code Name
01
02
03
CLM16
1360
Early & Periodic Screening, Diagnosis, and Treatment (EPSDT) or Child Health
Assessment Program (CHAP)
Physically Handicapped Children's Program
Special Federal Funding
This code is used for Medicaid claims only.
05
Disability
This code is used for Medicaid claims only.
07
Induced Abortion - Danger to Life
This code is used for Medicaid claims only.
08
Induced Abortion - Rape or Incest
This code is used for Medicaid claims only.
09
Second Opinion or Surgery
This code is used for Medicaid claims only.
Provider Agreement Code
O
ID
1/1
Situational
Description: Code indicating the type of agreement under which the provider is submitting
this claim
Industry: Participation Agreement
Required if a non-participating (non-par) provider is submitting a participating (par)
claim/encounter. Sending the “P” code indicates that a non-par provider is sending a par
claim as allowed under certain plans.
CodeList Summary (Total Codes: 7, Included: 1)
Code Name
P
CLM20
1514
Participation Agreement
Delay Reason Code
O
ID
1/2
Situational
Description: Code indicating the reason why a request was delayed
837P_CG.ecs
432
For internal use only
12/1/2010
Ref
Health Care Claim: Professional - 837
Id
Element Name
Alias: Delay Reason Code
Req
Type
Min/Max
Usage
This element may be used if a particular claim is being transmitted in response to a request
for information (e.g., a 277), and the response has been delayed.
Required when claim is submitted late (past contracted date of filing limitations) and any of
the codes below apply.
CodeList Summary (Total Codes: 14, Included: 11)
Code Name
1
2
3
4
5
6
7
8
9
10
11
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
Semantics:
1. CLM02 is the total amount of all submitted charges of service segments for this claim.
2. CLM06 is provider signature on file indicator. A "Y" value indicates the provider signature is on file; an "N"
value indicates the provider signature is not on file.
3. CLM08 is assignment of benefits indicator. A "Y" value indicates insured or authorized person authorizes
benefits to be assigned to the provider; an "N" value indicates benefits have not been assigned to the
provider.
4. CLM13 is CHAMPUS nonavailability indicator. A "Y" value indicates a statement of non-availability is on file;
an "N" value indicates statement of nonavailability is not on file or not necessary.
5. CLM15 is charges itemized by service indicator. A "Y" value indicates charges are itemized by service; an "N"
value indicates charges are summarized by service.
6. CLM18 is explanation of benefit (EOB) indicator. A "Y" value indicates that a paper EOB is requested; an "N"
value indicates that no paper EOB is requested.
Notes:
1. Because this is a required segment, this is a required loop. See Appendix A for further details on ASC X12
syntax rules.
2. 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 ISA-IEA. Willing trading partners can agree to set limits higher.
3. 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 2010BD in the subscriber hierarchical level when the patient is the
subscriber, or it is placed at the patient/dependent hierarchical level when the patient is the dependent of the
subscriber as shown here. When the patient is the subscriber, loops 2000C and 2010CA are not sent. See
2.3.2.1, HL Segment, for details.
Example:
CLM*A37YH556*500***11::1*Y*A*Y*Y*C~
837P_CG.ecs
433
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 135
DTP Date - Initial Treatment
Max: 1
Detail - Optional
Loop: 2300
Elements: 3
User Option (Usage): Situational
Purpose: To specify any or all of a date, a time, or a time period
Element Summary:
Ref
Id
Element Name
DTP01
374
Date/Time Qualifier
Req
Type
Min/Max
Usage
M
ID
3/3
Required
Description: Code specifying type of date or time, or both date and time
Industry: Date Time Qualifier
CodeList Summary (Total Codes: 1112, Included: 1)
Code Name
454
DTP02
1250
Initial Treatment
Date Time Period Format Qualifier
M
ID
2/3
Required
Description: Code indicating the date format, time format, or date and time format
CodeList Summary (Total Codes: 39, Included: 1)
Code Name
D8
DTP03
1251
Date Expressed in Format CCYYMMDD
Date Time Period
M
AN
1/35
Required
Description: Expression of a date, a time, or range of dates, times or dates and times
Industry: Initial Treatment Date
NSF Reference: GC0-05.0
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
Notes:
1. Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in Loop
ID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300
for that service line only.
2. Required on all claims involving spinal manipulation for Medicare Part B.
Example:
DTP*454*D8*19970115~
837P_CG.ecs
434
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 135
DTP Date - Date Last Seen
Max: 1
Detail - Optional
Loop: 2300
Elements: 3
User Option (Usage): Situational
Purpose: To specify any or all of a date, a time, or a time period
Element Summary:
Ref
Id
Element Name
DTP01
374
Date/Time Qualifier
Req
Type
Min/Max
Usage
M
ID
3/3
Required
Description: Code specifying type of date or time, or both date and time
Industry: Date Time Qualifier
CodeList Summary (Total Codes: 1112, Included: 1)
Code Name
304
DTP02
1250
Latest Visit or Consultation
Date Time Period Format Qualifier
M
ID
2/3
Required
Description: Code indicating the date format, time format, or date and time format
CodeList Summary (Total Codes: 39, Included: 1)
Code Name
D8
DTP03
1251
Date Expressed in Format CCYYMMDD
Date Time Period
M
AN
1/35
Required
Description: Expression of a date, a time, or range of dates, times or dates and times
Industry: Last Seen Date
NSF Reference: EA0-48.0
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
Notes:
1. Required when claims involve services from an independent physical therapist, occupational therapist, or
physician services involving routine foot care and it is known to impact the payer’s adjudication process.
2. This is the date that the patient was seen by the attending/supervising physician for the qualifying medical
condition related to the services performed.
Example:
DTP*304*D8*19970115~
837P_CG.ecs
435
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 135
DTP Date - Onset of Current
Max: 1
Detail - Optional
Illness/Symptom
Loop: 2300
Elements: 3
User Option (Usage): Situational
Purpose: To specify any or all of a date, a time, or a time period
Element Summary:
Ref
Id
Element Name
DTP01
374
Date/Time Qualifier
Req
Type
Min/Max
Usage
M
ID
3/3
Required
Description: Code specifying type of date or time, or both date and time
Industry: Date Time Qualifier
CodeList Summary (Total Codes: 1112, Included: 1)
Code Name
431
DTP02
1250
Onset of Current Symptoms or Illness
Date Time Period Format Qualifier
M
ID
2/3
Required
Description: Code indicating the date format, time format, or date and time format
CodeList Summary (Total Codes: 39, Included: 1)
Code Name
D8
DTP03
1251
Date Expressed in Format CCYYMMDD
Date Time Period
M
AN
1/35
Required
Description: Expression of a date, a time, or range of dates, times or dates and times
Industry: Onset of Current Illness or Injury Date
NSF Reference: EA0-07.0
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
Notes:
1. Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in Loop
ID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300
for that service line only.
2. Required when information is available and if different than the date of service. If not used, claim/service date
is assumed to be the date of onset of illness/symptoms.
Example:
DTP*431*D8*19970115~
837P_CG.ecs
436
For internal use only
12/1/2010
Health Care Claim: Professional - 837
DTP Date - Acute Manifestation
Pos: 135
Max: 5
Detail - Optional
Loop: 2300
Elements: 3
User Option (Usage): Situational
Purpose: To specify any or all of a date, a time, or a time period
Element Summary:
Ref
Id
Element Name
DTP01
374
Date/Time Qualifier
Req
Type
Min/Max
Usage
M
ID
3/3
Required
Description: Code specifying type of date or time, or both date and time
Industry: Date Time Qualifier
CodeList Summary (Total Codes: 1112, Included: 1)
Code Name
453
DTP02
1250
Acute Manifestation of a Chronic Condition
Date Time Period Format Qualifier
M
ID
2/3
Required
Description: Code indicating the date format, time format, or date and time format
CodeList Summary (Total Codes: 39, Included: 1)
Code Name
D8
DTP03
1251
Date Expressed in Format CCYYMMDD
Date Time Period
M
AN
1/35
Required
Description: Expression of a date, a time, or range of dates, times or dates and times
Industry: Acute Manifestation Date
NSF Reference: GC0-12.0
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
Notes:
1. Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in Loop
ID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300
for that service line only.
2. Required when Loop 2300 CR208 = “A” or “M”, the claim involves spinal manipulation, and the payer is
Medicare.
Example:
DTP*453*D8*19970115~
837P_CG.ecs
437
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 135
DTP Date - Similar
Max: 10
Detail - Optional
Illness/Symptom Onset
Loop: 2300
Elements: 3
User Option (Usage): Situational
Purpose: To specify any or all of a date, a time, or a time period
Element Summary:
Ref
Id
Element Name
DTP01
374
Date/Time Qualifier
Req
Type
Min/Max
Usage
M
ID
3/3
Required
Description: Code specifying type of date or time, or both date and time
Industry: Date Time Qualifier
CodeList Summary (Total Codes: 1112, Included: 1)
Code Name
438
DTP02
1250
Onset of Similar Symptoms or Illness
Date Time Period Format Qualifier
M
ID
2/3
Required
Description: Code indicating the date format, time format, or date and time format
CodeList Summary (Total Codes: 39, Included: 1)
Code Name
D8
DTP03
1251
Date Expressed in Format CCYYMMDD
Date Time Period
M
AN
1/35
Required
Description: Expression of a date, a time, or range of dates, times or dates and times
Industry: Similar Illness or Symptom Date
NSF Reference: EA0-16.0
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
Notes:
1. Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in Loop
ID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300
for that service line only.
2. Required when claim involves services to a patient experiencing symptoms similar or identical to previously
reported symptoms.
Example:
DTP*438*D8*19970115~
837P_CG.ecs
438
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 135
DTP Date - Accident
Max: 10
Detail - Optional
Loop: 2300
Elements: 3
User Option (Usage): Situational
Purpose: To specify any or all of a date, a time, or a time period
Element Summary:
Ref
Id
Element Name
DTP01
374
Date/Time Qualifier
Req
Type
Min/Max
Usage
M
ID
3/3
Required
Description: Code specifying type of date or time, or both date and time
Industry: Date Time Qualifier
CodeList Summary (Total Codes: 1112, Included: 1)
Code Name
439
DTP02
1250
Accident
Date Time Period Format Qualifier
M
ID
2/3
Required
Description: Code indicating the date format, time format, or date and time format
CodeList Summary (Total Codes: 39, Included: 2)
Code Name
D8
DT
DTP03
1251
Date Expressed in Format CCYYMMDD
Date and Time Expressed in Format CCYYMMDDHHMM
Required if accident hour is known.
Date Time Period
M
AN
1/35
Required
Description: Expression of a date, a time, or range of dates, times or dates and times
Industry: Accident Date
NSF Reference: EA0-07.0 - Accident Date, EA0-11.0 Accident Hour (no minutes)
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
Notes:
1. Required if CLM11-1, CLM11-2, or CLM11-3 = AA, AB, AP or OA.
Example:
DTP*439*D8*19970114~
837P_CG.ecs
439
For internal use only
12/1/2010
Health Care Claim: Professional - 837
DTP Date - Last Menstrual Period
Pos: 135
Max: 1
Detail - Optional
Loop: 2300
Elements: 3
User Option (Usage): Situational
Purpose: To specify any or all of a date, a time, or a time period
Element Summary:
Ref
Id
Element Name
DTP01
374
Date/Time Qualifier
Req
Type
Min/Max
Usage
M
ID
3/3
Required
Description: Code specifying type of date or time, or both date and time
Industry: Date Time Qualifier
CodeList Summary (Total Codes: 1112, Included: 1)
Code Name
484
DTP02
1250
Last Menstrual Period
Date Time Period Format Qualifier
M
ID
2/3
Required
Description: Code indicating the date format, time format, or date and time format
CodeList Summary (Total Codes: 39, Included: 1)
Code Name
D8
DTP03
1251
Date Expressed in Format CCYYMMDD
Date Time Period
M
AN
1/35
Required
Description: Expression of a date, a time, or range of dates, times or dates and times
Industry: Last Menstrual Period Date
NSF Reference: EA0-07.0
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
Notes:
1. Required when claim involves pregnancy.
Example:
DTP*484*D8*19961113~
837P_CG.ecs
440
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 135
DTP Date - Last X-ray
Max: 1
Detail - Optional
Loop: 2300
Elements: 3
User Option (Usage): Situational
Purpose: To specify any or all of a date, a time, or a time period
Element Summary:
Ref
Id
Element Name
DTP01
374
Date/Time Qualifier
Req
Type
Min/Max
Usage
M
ID
3/3
Required
Description: Code specifying type of date or time, or both date and time
Industry: Date Time Qualifier
CodeList Summary (Total Codes: 1112, Included: 1)
Code Name
455
DTP02
1250
Last X-Ray
Date Time Period Format Qualifier
M
ID
2/3
Required
Description: Code indicating the date format, time format, or date and time format
CodeList Summary (Total Codes: 39, Included: 1)
Code Name
D8
DTP03
1251
Date Expressed in Format CCYYMMDD
Date Time Period
M
AN
1/35
Required
Description: Expression of a date, a time, or range of dates, times or dates and times
Industry: Last X-Ray Date
NSF Reference: GC0-06.0
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
Notes:
1. Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in Loop
ID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300
for that service line only.
2. Required when claim involves spinal manipulation if an x-ray was taken.
Example:
DTP*455*D8*19970114~
837P_CG.ecs
441
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 135
DTP Date - Hearing and Vision
Max: 1
Detail - Optional
Prescription Date
Loop: 2300
Elements: 3
User Option (Usage): Situational
Purpose: To specify any or all of a date, a time, or a time period
Element Summary:
Ref
Id
Element Name
DTP01
374
Date/Time Qualifier
Req
Type
Min/Max
Usage
M
ID
3/3
Required
Description: Code specifying type of date or time, or both date and time
Industry: Date Time Qualifier
CodeList Summary (Total Codes: 1112, Included: 1)
Code Name
471
DTP02
1250
Prescription
Date Time Period Format Qualifier
M
ID
2/3
Required
Description: Code indicating the date format, time format, or date and time format
CodeList Summary (Total Codes: 39, Included: 1)
Code Name
D8
DTP03
1251
Date Expressed in Format CCYYMMDD
Date Time Period
M
AN
1/35
Required
Description: Expression of a date, a time, or range of dates, times or dates and times
Industry: Prescription Date
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
Notes:
1. Required on claims where a prescription has been written for hearing devices or vision frames and lenses and
it is being billed on this claim.
Example:
DTP*471*D8*19970115~
837P_CG.ecs
442
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 135
DTP Date - Disability Begin
Max: 5
Detail - Optional
Loop: 2300
Elements: 3
User Option (Usage): Situational
Purpose: To specify any or all of a date, a time, or a time period
Element Summary:
Ref
Id
Element Name
DTP01
374
Date/Time Qualifier
Req
Type
Min/Max
Usage
M
ID
3/3
Required
Description: Code specifying type of date or time, or both date and time
Industry: Date Time Qualifier
CodeList Summary (Total Codes: 1112, Included: 1)
Code Name
360
DTP02
1250
Disability Begin
Date Time Period Format Qualifier
M
ID
2/3
Required
Description: Code indicating the date format, time format, or date and time format
CodeList Summary (Total Codes: 39, Included: 1)
Code Name
D8
DTP03
1251
Date Expressed in Format CCYYMMDD
Date Time Period
M
AN
1/35
Required
Description: Expression of a date, a time, or range of dates, times or dates and times
Industry: Disability From Date
NSF Reference: EA0-18.0
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
Notes:
1. Required on claims involving disability where, in the opinion of the provider, the patient was or will be unable to
perform the duties normally associated with his/her work.
2. Not required for HIPAA but may be required for other uses. (The statutory definition of a health plan does not
specifically include workers compensation programs, property and casualty programs, or disability insurance
programs.)
Example:
DTP*360*D8*19970114~
837P_CG.ecs
443
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 135
DTP Date - Disability End
Max: 5
Detail - Optional
Loop: 2300
Elements: 3
User Option (Usage): Situational
Purpose: To specify any or all of a date, a time, or a time period
Element Summary:
Ref
Id
Element Name
DTP01
374
Date/Time Qualifier
Req
Type
Min/Max
Usage
M
ID
3/3
Required
Description: Code specifying type of date or time, or both date and time
Industry: Date Time Qualifier
CodeList Summary (Total Codes: 1112, Included: 1)
Code Name
361
DTP02
1250
Disability End
Date Time Period Format Qualifier
M
ID
2/3
Required
Description: Code indicating the date format, time format, or date and time format
CodeList Summary (Total Codes: 39, Included: 1)
Code Name
D8
DTP03
1251
Date Expressed in Format CCYYMMDD
Date Time Period
M
AN
1/35
Required
Description: Expression of a date, a time, or range of dates, times or dates and times
Industry: Disability To Date
NSF Reference: EA0-19.0
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
Notes:
1. Required on claims/encounters involving disability where, in the opinion of the provider, the patient, after
having been absent from work for reasons related to the disability, was or will be able to perform the duties
normally associated with his/her work.
2. Not required for HIPAA but may be required for other uses. (The statutory definition of a health plan does not
specifically include workers compensation programs, property and casualty programs, or disability insurance
programs.)
Example:
DTP*361*D8*19970613~
837P_CG.ecs
444
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 135
DTP Date - Last Worked
Max: 1
Detail - Optional
Loop: 2300
Elements: 3
User Option (Usage): Situational
Purpose: To specify any or all of a date, a time, or a time period
Element Summary:
Ref
Id
Element Name
DTP01
374
Date/Time Qualifier
Req
Type
Min/Max
Usage
M
ID
3/3
Required
Description: Code specifying type of date or time, or both date and time
Industry: Date Time Qualifier
CodeList Summary (Total Codes: 1112, Included: 1)
Code Name
297
DTP02
1250
Date Last Worked
Date Time Period Format Qualifier
M
ID
2/3
Required
Description: Code indicating the date format, time format, or date and time format
CodeList Summary (Total Codes: 39, Included: 1)
Code Name
D8
DTP03
1251
Date Expressed in Format CCYYMMDD
Date Time Period
M
AN
1/35
Required
Description: Expression of a date, a time, or range of dates, times or dates and times
Industry: Last Worked Date
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
Notes:
1. Required on claims where this information is necessary for adjudication of the claim (e.g., workers
compensation claims involving absence from work).
Example:
DTP*297*D8*19970114~
837P_CG.ecs
445
For internal use only
12/1/2010
Health Care Claim: Professional - 837
DTP Date - Authorized Return to
Work
Pos: 135
Max: 1
Detail - Optional
Loop: 2300
Elements: 3
User Option (Usage): Situational
Purpose: To specify any or all of a date, a time, or a time period
Element Summary:
Ref
Id
Element Name
DTP01
374
Date/Time Qualifier
Req
Type
Min/Max
Usage
M
ID
3/3
Required
Description: Code specifying type of date or time, or both date and time
Industry: Date Time Qualifier
CodeList Summary (Total Codes: 1112, Included: 1)
Code Name
296
DTP02
1250
Return to Work
This is the date the provider has authorized the patient to return to work.
Date Time Period Format Qualifier
M
ID
2/3
Required
Description: Code indicating the date format, time format, or date and time format
CodeList Summary (Total Codes: 39, Included: 1)
Code Name
D8
DTP03
1251
Date Expressed in Format CCYYMMDD
Date Time Period
M
AN
1/35
Required
Description: Expression of a date, a time, or range of dates, times or dates and times
Industry: Work Return Date
NSF Reference: EA1-12.0
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
Notes:
1. Required on claims where this information is necessary for adjudication of the claim (e.g., workers
compensation claims involving absence from work).
Example:
DTP*296*D8*19970620~
837P_CG.ecs
446
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 135
DTP Date - Admission
Max: 1
Detail - Optional
Loop: 2300
Elements: 3
User Option (Usage): Situational
Purpose: To specify any or all of a date, a time, or a time period
Element Summary:
Ref
Id
Element Name
DTP01
374
Date/Time Qualifier
Req
Type
Min/Max
Usage
M
ID
3/3
Required
Description: Code specifying type of date or time, or both date and time
Industry: Date Time Qualifier
CodeList Summary (Total Codes: 1112, Included: 1)
Code Name
435
DTP02
1250
Admission
Date Time Period Format Qualifier
M
ID
2/3
Required
Description: Code indicating the date format, time format, or date and time format
CodeList Summary (Total Codes: 39, Included: 1)
Code Name
D8
DTP03
1251
Date Expressed in Format CCYYMMDD
Date Time Period
M
AN
1/35
Required
Description: Expression of a date, a time, or range of dates, times or dates and times
Industry: Related Hospitalization Admission Date
NSF Reference: GA0-23.0 (for ambulance claims only), EA0-28.0
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
Notes:
1. Required on all ambulance claims/encounters when the patient was known to be admitted to the hospital. Also
required on inpatient medical visits claims/encounters.
Example:
DTP*435*D8*19970114~
837P_CG.ecs
447
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 135
DTP Date - Discharge
Max: 1
Detail - Optional
Loop: 2300
Elements: 3
User Option (Usage): Situational
Purpose: To specify any or all of a date, a time, or a time period
Element Summary:
Ref
Id
Element Name
DTP01
374
Date/Time Qualifier
Req
Type
Min/Max
Usage
M
ID
3/3
Required
Description: Code specifying type of date or time, or both date and time
Industry: Date Time Qualifier
CodeList Summary (Total Codes: 1112, Included: 1)
Code Name
096
DTP02
1250
Discharge
Date Time Period Format Qualifier
M
ID
2/3
Required
Description: Code indicating the date format, time format, or date and time format
CodeList Summary (Total Codes: 39, Included: 1)
Code Name
D8
DTP03
1251
Date Expressed in Format CCYYMMDD
Date Time Period
M
AN
1/35
Required
Description: Expression of a date, a time, or range of dates, times or dates and times
Industry: Related Hospitalization Discharge Date
NSF Reference: GA0-22.0 (for Ambulance Claims only), EA0-29.0
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
Notes:
1. Required for inpatient claims when the patient was discharged from the facility and the discharge date is
known.
Example:
DTP*096*D8*19970115~
837P_CG.ecs
448
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 135
DTP Date - Assumed and
Max: 2
Detail - Optional
Relinquished Care Dates
Loop: 2300
Elements: 3
User Option (Usage): Situational
Purpose: To specify any or all of a date, a time, or a time period
Element Summary:
Ref
Id
Element Name
DTP01
374
Date/Time Qualifier
Req
Type
Min/Max
Usage
M
ID
3/3
Required
Description: Code specifying type of date or time, or both date and time
Industry: Date Time Qualifier
CodeList Summary (Total Codes: 1112, Included: 2)
Code Name
DTP02
1250
090
Report Start
Assumed Care Date - Use code 090 to indicate the date the provider filing this
claim assumed care from another provider during post-operative care.
091
Report End
Relinquished Care Date - Use code 091 to indicate the date the provider filing this
claim relinquished post-operative care to another provider.
Date Time Period Format Qualifier
M
ID
2/3
Required
Description: Code indicating the date format, time format, or date and time format
CodeList Summary (Total Codes: 39, Included: 1)
Code Name
D8
DTP03
1251
Date Expressed in Format CCYYMMDD
Date Time Period
M
AN
1/35
Required
Description: Expression of a date, a time, or range of dates, times or dates and times
Industry: Assumed or Relinquished Care Date
NSF Reference: EA1-25.0 - Provider Assumed Care Date, HA0-05.0 - Provider
Relinquished Care Date
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
Notes:
1. Required on Medicare claims to indicate “assumed care date” and “relinquished care date” for situations where
providers share post-operative care (global surgery claims). Assumed Care Date is the date care was assumed
by another provider during post-operative care. Relinquished Care Date is the date the provider filing this claim
ceased post-operative care. See Medicare guidelines for further explanation of these dates.
2. Example: Surgeon “A” relinquished post-operative care to Physician “B” five days after surgery. When Surgeon
“A” submits a claim/encounter “A” will use code “091 - Report End” to indicate the day the surgeon relinquished
care of this patient to Physician “B”. When Physician “B” submits a claim/encounter “B” will use code “090 Report Start” to indicate the date they assumed care of this patient from Surgeon “A”.
Example:
DTP*090*D8*19970214~
837P_CG.ecs
449
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 155
PWK Claim Supplemental
Max: 10
Detail - Optional
Information
Loop: 2300
Elements: 4
User Option (Usage): Situational
Purpose: To identify the type or transmission or both of paperwork or supporting information
Element Summary:
Ref
Id
Element Name
PWK01
755
Report Type Code
Req
Type
Min/Max
Usage
M
ID
2/2
Required
Description: Code indicating the title or contents of a document, report or supporting item
Industry: Attachment Report Type Code
NSF Reference: EA0-41.0
CodeList Summary (Total Codes: 522, Included: 20)
Code Name
PWK02
756
77
Support Data for Verification
REFERRAL. Use this code to indicate a completed referral form.
AS
B2
B3
B4
CT
DA
DG
DS
EB
MT
NN
OB
OZ
PN
PO
PZ
RB
RR
RT
Admission Summary
Prescription
Physician Order
Referral Form
Certification
Dental Models
Diagnostic Report
Discharge Summary
Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payor)
Models
Nursing Notes
Operative Note
Support Data for Claim
Physical Therapy Notes
Prosthetics or Orthotic Certification
Physical Therapy Certification
Radiology Films
Radiology Reports
Report of Tests and Analysis Report
Report Transmission Code
O
ID
1/2
Required
Description: Code defining timing, transmission method or format by which reports are to
be sent
Industry: Attachment Transmission Code
NSF Reference: EA0-40.0
CodeList Summary (Total Codes: 51, Included: 5)
Code Name
AA
837P_CG.ecs
Available on Request at Provider Site
This means that the paperwork is not being sent with the claim at this time.
450
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Code Name
Instead, it is available to the payer (or appropriate entity) at their request.
PWK05
66
BM
EL
By Mail
Electronically Only
Use to indicate that attachment is being transmitted in a separate X12 functional
group.
EM
FX
E-Mail
By Fax
Identification Code Qualifier
C
ID
1/2
Situational
Description: Code designating the system/method of code structure used for Identification
Code (67)
Required if PWK02 = “BM”, “EL”, “EM” or “FX”.
CodeList Summary (Total Codes: 215, Included: 1)
Code Name
AC
PWK06
67
Attachment Control Number
Identification Code
C
AN
2/80
Situational
Description: Code identifying a party or other code
Industry: Attachment Control Number
Required if PWK02 = “BM”, “EL”, “EM” or “FX”.
Syntax Rules:
1. P0506 - If either PWK05 or PWK06 is present, then the other is required.
Comments:
1. PWK05 and PWK06 may be used to identify the addressee by a code number.
2. PWK07 may be used to indicate special information to be shown on the specified report.
3. PWK08 may be used to indicate action pertaining to a report.
Notes:
1. The PWK segment is required if there is paper documentation supporting this claim. The PWK segment should
not be used if the information related to the claim is being sent within the 837 ST-SE envelope.
2. The PWK segment is required to identify attachments that are sent electronically (PWK02 = EL) but are
transmitted in another functional group (e.g., 275) rather than by paper. PWK06 is used to identify the attached
electronic documentation. The number in PWK06 would be carried in the TRN of the electronic attachment.
3. The PWK segment can be used to identify paperwork that is being held at the provider’s office and is available
upon request by the payer (or appropriate entity), but that is not being sent with the claim. Use code AA in
PWK02 to convey this specific use of the PWK segment. See code note under PWK02, code AA.
Example:
PWK*OB*BM***AC*DMN0012~
837P_CG.ecs
451
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 160
CN1 Contract Information
Max: 1
Detail - Optional
Loop: 2300
Elements: 6
User Option (Usage): Situational
Purpose: To specify basic data about the contract or contract line item
Element Summary:
Ref
Id
Element Name
CN101
1166
Contract Type Code
Req
Type
Min/Max
Usage
M
ID
2/2
Required
R
1/18
Situational
Description: Code identifying a contract type
Alias: Contract Type Code
CodeList Summary (Total Codes: 50, Included: 6)
Code Name
02
03
04
05
06
09
CN102
782
Per Diem
Variable Per Diem
Flat
Capitated
Percent
Other
Monetary Amount
O
Description: Monetary amount
Industry: Contract Amount
Required if the provider is required by contract to supply this information on the claim.
CN103
332
Percent
O
R
1/6
Situational
Description: Percent expressed as a percent
Industry: Contract Percentage
Alias: Contract Percent
Allowance or charge percent
Required if the provider is required by contract to supply this information on the claim.
CN104
127
Reference Identification
O
AN
1/30
Situational
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Contract Code
Required if the provider is required by contract to supply this information on the claim.
CN105
338
Terms Discount Percent
O
R
1/6
Situational
Description: Terms discount percentage, expressed as a percent, available to the
purchaser if an invoice is paid on or before the Terms Discount Due Date
Industry: Terms Discount Percentage
Alias: Terms Discount Percent
Required if the provider is required by contract to supply this information on the claim.
CN106
799
Version Identifier
O
AN
1/30
Situational
Description: Revision level of a particular format, program, technique or algorithm
837P_CG.ecs
452
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Ref
Id
Element Name
Industry: Contract Version Identifier
Req
Type
Min/Max
Usage
Required if the provider is required by contract to supply this information on the claim.
Semantics:
1.
2.
3.
4.
CN102
CN103
CN104
CN106
is the contract amount.
is the allowance or charge percent.
is the contract code.
is an additional identifying number for the contract.
Notes:
1. The developers of this implementation guide recommend that for non-capitated situations, contract information
be maintained in the receiver’s files and not be transmitted with each claim whenever possible. It is
recommended that submitters always include CN1 for encounters that include only capitated services.
2. Required if the provider is contractually obligated to provide contract information on this claim.
Example:
CN1*02*550~
837P_CG.ecs
453
For internal use only
12/1/2010
Health Care Claim: Professional - 837
AMT Credit/Debit Card Maximum
Amount
Pos: 175
Max: 1
Detail - Optional
Loop: 2300
Elements: 2
User Option (Usage): Situational
Purpose: To indicate the total monetary amount
Element Summary:
Ref
Id
Element Name
AMT01
522
Amount Qualifier Code
Req
Type
Min/Max
Usage
M
ID
1/3
Required
R
1/18
Required
Description: Code to qualify amount
CodeList Summary (Total Codes: 1473, Included: 1)
Code Name
MA
AMT02
782
Maximum Amount
Monetary Amount
M
Description: Monetary amount
Industry: Credit or Debit Card Maximum Amount
Notes:
1. Use this segment only for claims that contain credit/debit card information. This segment indicates the
maximum amount that can be credited to the account indicated in 2010BD - CREDIT/DEBIT CARD HOLDER
NAME.
2. The information carried under this segment must never be sent to the payer. This information is only for use
between a provider and a service organization offering patient collection services. In this case, it is the
responsibility of the collection service organization to remove this segment before forwarding the claim to the
payer.
Example:
AMT*MA*200~
837P_CG.ecs
454
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 175
AMT Patient Amount Paid
Max: 1
Detail - Optional
Loop: 2300
Elements: 2
User Option (Usage): Situational
Purpose: To indicate the total monetary amount
Element Summary:
Ref
Id
Element Name
AMT01
522
Amount Qualifier Code
Req
Type
Min/Max
Usage
M
ID
1/3
Required
R
1/18
Required
Description: Code to qualify amount
CodeList Summary (Total Codes: 1473, Included: 1)
Code Name
F5
AMT02
782
Patient Amount Paid
Monetary Amount
M
Description: Monetary amount
Industry: Patient Amount Paid
NSF Reference: XA0-19.0
Notes:
1. Required when patient has made payment specifically toward this claim.
2. Patient Amount Paid refers to the sum of all amounts paid on the claim by the patient or his/her
representative(s).
Example:
AMT*F5*152.45~
837P_CG.ecs
455
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 175
AMT Total Purchased Service
Max: 1
Detail - Optional
Amount
Loop: 2300
Elements: 2
User Option (Usage): Situational
Purpose: To indicate the total monetary amount
Element Summary:
Ref
Id
Element Name
AMT01
522
Amount Qualifier Code
Req
Type
Min/Max
Usage
M
ID
1/3
Required
Description: Code to qualify amount
CodeList Summary (Total Codes: 1473, Included: 1)
Code Name
NE
AMT02
782
Net Billed
Use this code to indicate Total Purchased Service Charges.
Monetary Amount
M
R
1/18
Required
Description: Monetary amount
Industry: Total Purchased Service Amount
NSF Reference: EA0-31.0
Notes:
1. Required if there are purchased service components to this claim.
2. Use this segment on vision claims when the acquisition cost of lenses is known to impact adjudication or
reimbursement.
3. Required on service lines when the purchased service charge amount is necessary for processing.
Example:
AMT*NE*57.35~
837P_CG.ecs
456
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 180
REF Service Authorization
Max: 1
Detail - Optional
Exception Code
Loop: 2300
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
1/30
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 1)
Code Name
4N
REF02
127
Special Payment Reference Number
Reference Identification
C
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Service Authorization Exception Code
CodeList Summary (Total Codes: 7, Included: 7)
Code Name
1
2
3
4
5
6
7
Immediate/Urgent Care
Services Rendered in a Retroactive Period
Emergency Care
Client as Temporary Medicaid
Request from County for Second Opinion to Recipient can Work
Request for Override Pending
Special Handling
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. Required when providers are required by state law (e.g., New York State Medicaid) to obtain authorization for
specific services but, for the reasons listed in REF02, performed the service without obtaining the service
authorization. Check with your state Medicaid to see if this applies in your state.
Example:
REF*4N*1~
837P_CG.ecs
457
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 180
REF Mandatory Medicare
Max: 1
Detail - Optional
(Section 4081) Crossover
Indicator
Loop: 2300
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
1/30
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 1)
Code Name
F5
REF02
127
Medicare Version Code
Reference Identification
C
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Medicare Section 4081 Indicator
NSF Reference: DA0-30.0
CodeList Summary (Total Codes: 2, Included: 2)
Code Name
N
Y
Regular crossover (NSF Value 2)
4081 (NSF Value 1)
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. Required for Medicare COB crossover claims when Beneficiary Assignment for mandatory Medicare (Section
4081) claim applies. This segment is only completed by Medicare; providers do not use this segment.
2. If this segment is not used that means this situation does not apply.
Example:
REF*F5*N~
837P_CG.ecs
458
For internal use only
12/1/2010
Health Care Claim: Professional - 837
REF Mammography Certification
Number
Pos: 180
Max: 1
Detail - Optional
Loop: 2300
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
1/30
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 1)
Code Name
EW
REF02
127
Mammography Certification Number
Reference Identification
C
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Mammography Certification Number
NSF Reference: FA0-31.0
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. Required when mammography services are rendered by a certified mammography provider.
Example:
REF*EW*T554~
837P_CG.ecs
459
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 180
REF Prior Authorization or
Max: 2
Detail - Optional
Referral Number
Loop: 2300
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
1/30
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 2)
Code Name
9F
G1
REF02
127
Referral Number
Prior Authorization Number
Reference Identification
C
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Prior Authorization or Referral Number
NSF Reference: DA0-14.0
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
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.
2. Required where services on this claim were preauthorized or where a referral is involved. Generally,
preauthorization/referral numbers are those numbers assigned by the payer/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 referral or prior
authorization number carried in this REF is specific to the destination payer reported in the 2010BB loop. If other
payers have similar numbers for this claim, report that information in the 2330 loop REF which holds that payer’s
information.
Example:
REF*G1*13579~
User Note 6:
For Professional EDI claims report Prior Authorization Number in REF02 segment in Loop 2300. Use the “G1”
qualifier in the REF01 segment of Loop 2300.
REF01 = G1
REF02 = Authorization Number
837P_CG.ecs
460
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Sample: REF*G1*12456789ABCD
Report the entity that approved the authorization (BSC, IPA, NIA), authorization date, date range service approved
and approved days/units in NTE02 Loop 2300. For Professional claims use Claim Note and for Institutional claims
use Billing Note. In both Professional and Institutional claims, use “ADD” as the value in NTE01.
Sample: NTE*ADD* BSC 20050719 20050719 20050722 4 DAYS
• first field is either BSC, IPA, or NIA
• second field is the date the auth was given (use ccyymmdd format)
• third field is the date range approved (use ccyymmdd ccyymmdd format)
• fourth field is either the amount of days approved or units
837P_CG.ecs
461
For internal use only
12/1/2010
Health Care Claim: Professional - 837
REF Original Reference Number
(ICN/DCN)
Pos: 180
Max: 1
Detail - Optional
Loop: 2300
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
1/30
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 1)
Code Name
F8
REF02
127
Original Reference Number
Reference Identification
C
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Claim Original Reference Number
Alias: Claim Original Reference Number (ICN/DCN)
NSF Reference: EA0-47.0
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. Required when CLM05-3 (Claim Submission Reason Code) = “6", ”7", or “8" and the payer has assigned a
payer number to the claim. The resubmission number is assigned to a previously submitted claim/encounter by
the destination payer or receiver.
2. This segment can be used for the payer assigned Original Document Control Number/Internal Control Number
(DCN/ICN) assigned to this claim by the payer identified in the 2010BB loop of this claim. This number would be
received from a payer in a case where the payer had received the original claim and, for whatever reason, had (1)
asked the provider to resubmit the claim and (2) had given the provider the payer’s claim identification number. In
this case the payer is expecting the provider to give them back their (the payer’s) claim number so that the payer
can match it in their adjudication system. By matching this number in the adjudication system, the payer knows
this is not a duplicate claim. This information is specific to the destination payer reported in the 2010BB loop. If
other payers have a similar number, report that information in the 2330 loop which holds that payer’s information.
Example:
REF*F8*R555588~
User Note 6:
Corrected claims can be sent electronically to Blue Shield of California, however, please wait for the original claim
to finalize before sending a corrected claim to avoid denial as a duplicate.
Once the initial has finalized in our system, re-bill the corrected claim with the appropriate adjustment bill type. You
will also need to include the following EDI segments on your adjusted claim:
837P_CG.ecs
462
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Send "F8" in REF01 (Loop 2300)
Send "14 digit number BSC ICN of incorrect original claim in REF02 (Loop 2300).
Sample: REF*F8*12345678912345~
Note: 12345678912345 should be replaced with the original claim’s Blue Shield of California internal control
number (ICN).
You can obtain the Blue Shield of California internal control number (ICN) using the claim status option on
Provider Connection or from the explanation of benefits (EOB) or electronic remittance advice (ERA).
837P_CG.ecs
463
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 180
REF Clinical Laboratory
Max: 3
Detail - Optional
Improvement Amendment
(CLIA) Number
Loop: 2300
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
1/30
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 1)
Code Name
X4
REF02
127
Clinical Laboratory Improvement Amendment Number
Reference Identification
C
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Clinical Laboratory Improvement Amendment Number
NSF Reference: FA0-34.0
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. Required on Medicare and Medicaid claims for any laboratory performing tests covered by the CLIA Act.
2. If a CLIA number is indicated at the line level (Loop ID-2400) in addition to the claim level (Loop ID-2300), that
would indicate an exception to the CLIA number at the claim level for that individual line.
3. In cases where this claim contains both in-house and outsourced laboratory services: For laboratory services
preformed by the billing or rendering provider the CLIA number is reported here; for laboratory services which
were outsourced, report that CLIA number at the 2400 loop.
Example:
REF*X4*12D4567890~
837P_CG.ecs
464
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 180
REF Repriced Claim Number
Max: 1
Detail - Optional
Loop: 2300
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
1/30
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 1)
Code Name
9A
REF02
127
Repriced Claim Reference Number
Reference Identification
C
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Repriced Claim Reference Number
NSF Reference: FE0-06.0 (TPO Reference Number)
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. Used only by repricers as needed. This information is specific to the destination payer reported in the 2010BB
loop.
Example:
REF*9A*RJ55555~
837P_CG.ecs
465
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 180
REF Adjusted Repriced Claim
Max: 1
Detail - Optional
Number
Loop: 2300
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
1/30
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 1)
Code Name
9C
REF02
127
Adjusted Repriced Claim Reference Number
Reference Identification
C
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Adjusted Repriced Claim Reference Number
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. Used only by repricers as needed. This information is specific to the destination payer reported in the 2010BB
loop.
Example:
REF*9C*RP44444444~
837P_CG.ecs
466
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 180
REF Investigational Device
Max: 1
Detail - Optional
Exemption Number
Loop: 2300
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
1/30
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 1)
Code Name
LX
REF02
127
Qualified Products List
Reference Identification
C
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Investigational Device Exemption Identifier
NSF Reference: EA0-54.0
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. Required when claim involves an FDA assigned investigational device exemption (IDE) number. Only one IDE
per claim is to be reported.
Example:
REF*LX*TG334~
837P_CG.ecs
467
For internal use only
12/1/2010
Health Care Claim: Professional - 837
REF Claim Identification Number
for Clearing Houses and
Other Transmission
Intermediaries
Pos: 180
Max: 1
Detail - Optional
Loop: 2300
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
1/30
Required
Description: Code qualifying the Reference Identification
Number assigned by clearinghouse/van/etc.
CodeList Summary (Total Codes: 1503, Included: 1)
Code Name
D9
REF02
127
Claim Number
Reference Identification
C
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Clearinghouse Trace Number
The value carried in this element is limited to a maximum of 20 positions.
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. Used only by transmission intermediaries (Automated Clearing Houses, and others) who need to attach their
own unique claim number.
2. Although this REF is supplied for transmission intermediaries to attach their own unique claim number to a
claim/encounter, 837- recipients are not required under HIPAA to return this number in any HIPAA transaction.
Trading partners may voluntarily agree to this interaction if they wish.
Example:
REF*D9*TJ98UU321~
837P_CG.ecs
468
For internal use only
12/1/2010
Health Care Claim: Professional - 837
REF Ambulatory Patient Group
(APG)
Pos: 180
Max: 4
Detail - Optional
Loop: 2300
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
1/30
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 1)
Code Name
1S
REF02
127
Ambulatory Patient Group (APG) Number
Reference Identification
C
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Ambulatory Patient Group Number
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. Required if the contractual reimbursement arrangement between provider and payer is based on APG and
their contractual arrangement requires that the provider send APG information to the payer on each claim.
Example:
REF*1S*XXXXX~
837P_CG.ecs
469
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 180
REF Medical Record Number
Max: 1
Detail - Optional
Loop: 2300
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
1/30
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 1)
Code Name
EA
REF02
127
Medical Record Identification Number
Reference Identification
C
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Medical Record Number
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. Used at discretion of submitter.
Example:
REF*EA*44444TH56~
837P_CG.ecs
470
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 180
REF Demonstration Project
Max: 1
Detail - Optional
Identifier
Loop: 2300
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
1/30
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 1)
Code Name
P4
REF02
127
Project Code
Reference Identification
C
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Demonstration Project Identifier
NSF Reference: EA0-43.0
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. Required on claims/encounters where a demonstration project is being billed/reported. This information is
specific to the destination payer reported in the 2010BB loop. If other payers have a similar number, report that
information in the 2330 loop which holds that payer’s information.
Example:
REF*P4*THJ1222~
837P_CG.ecs
471
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 185
K3 File Information
Max: 10
Detail - Optional
Loop: 2300
Elements: 1
User Option (Usage): Situational
Purpose: To transmit a fixed-format record or matrix contents
Element Summary:
Ref
Id
Element Name
K301
449
Fixed Format Information
Req
Type
Min/Max
Usage
M
AN
1/80
Required
Description: Data in fixed format agreed upon by sender and receiver
NSF Reference: HA0-05.0
Semantics:
1. K303 identifies the value of the index.
Comments:
1. The default for K302 is content.
Notes:
1. At the time of publication K3 segments have no specific use. However, they have been included in this
implementation guide to be used as an emergency kludge (fix-it) in the case of an unexpected data requirement
by a state regulatory authority. This data element can only be required if the specific use is a result of a state law
or a regulation issued by a state agency after the publication of this implementation guide, and only if the
appropriate national body (X12N, HCPCS, NUBC, NUCC, etc) cannot offer an alternative solution within the
current structure of the implementation guide.
2. This segment may only be required if a state concludes it must use the K3 to meet an emergency legislative
requirement AND the administering state agency or other state organization has contacted the X12N workgroup,
requested a review of the K3 data requirement to ensure there is not an existing method within the
implementation guide to meet this requirement, and X12N determines that there is no method to meet the
requirement. Only then may the state require the temporary use of the K3 to meet the requirement. X12N will
submit the necessary data maintenance and refer the request to the appropriate data content committee.
Example:
K3*STATE DATA REQUIREMENT~
837P_CG.ecs
472
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 190
NTE Claim Note
Max: 1
Detail - Optional
Loop: 2300
Elements: 2
User Option (Usage): Situational
Purpose: To transmit information in a free-form format, if necessary, for comment or special instruction
Element Summary:
Ref
Id
Element Name
NTE01
363
Note Reference Code
Req
Type
Min/Max
Usage
O
ID
3/3
Required
Description: Code identifying the functional area or purpose for which the note applies
CodeList Summary (Total Codes: 241, Included: 6)
Code Name
ADD
CER
DCP
DGN
PMT
TPO
NTE02
352
Additional Information
Certification Narrative
Goals, Rehabilitation Potential, or Discharge Plans
Diagnosis Description
Payment
Third Party Organization Notes
Description
M
AN
1/80
Required
Description: A free-form description to clarify the related data elements and their content
Industry: Claim Note Text
NSF Reference: HA0-05.0
Comments:
1. The NTE segment permits free-form information/data which, under ANSI X12 standard implementations, is not
machine processable. The use of the NTE segment should therefore be avoided, if at all possible, in an
automated environment.
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. The developers of this implementation guide
discourage using narrative information within the 837. Trading partners who require narrative information with
claims are encouraged to codify that information within the ASC X12 environment.
2. Required when: (1) State regulations mandate information not identified elsewhere within the claim set; or (2) 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.
Example:
NTE*ADD*SURGERY WAS UNUSUALLY LONG BECAUSE [FILL INREASON*~
837P_CG.ecs
473
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 195
CR1 Ambulance Transport
Max: 1
Detail - Optional
Information
Loop: 2300
Elements: 8
User Option (Usage): Situational
Purpose: To supply information related to the ambulance service rendered to a patient
Element Summary:
Ref
Id
Element Name
CR101
355
Unit or Basis for Measurement Code
Req
Type
Min/Max
Usage
C
ID
2/2
Situational
Description: Code specifying the units in which a value is being expressed, or manner in
which a measurement has been taken
Required if needed to justify extra ambulance services.
CodeList Summary (Total Codes: 794, Included: 1)
Code Name
LB
CR102
81
Pound
Weight
C
R
1/10
Situational
1/1
Required
1/1
Required
Description: Numeric value of weight
Industry: Patient Weight
NSF Reference: GA0-05.0
Required if needed to justify extra ambulance services.
CR103
1316
Ambulance Transport Code
O
ID
Description: Code indicating the type of ambulance transport
Alias: Ambulance Transport Code
NSF Reference: GA0-07.0
All valid standard codes are used. (Total Codes: 4)
CR104
1317
Ambulance Transport Reason Code
O
ID
Description: Code indicating the reason for ambulance transport
Alias: Ambulance Transport Reason Code
NSF Reference: GA0-15.0
CodeList Summary (Total Codes: 5, Included: 5)
Code Name
A
Patient was transported to nearest facility for care of symptoms, complaints, or both
Can be used to indicate that the patient was transferred to a residential facility.
B
C
D
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
E
CR105
355
Unit or Basis for Measurement Code
C
ID
2/2
Required
Description: Code specifying the units in which a value is being expressed, or manner in
which a measurement has been taken
837P_CG.ecs
474
For internal use only
12/1/2010
Health Care Claim: Professional - 837
CodeList Summary (Total Codes: 794, Included: 1)
Code Name
DH
CR106
380
Miles
Quantity
C
R
1/15
Required
Description: Numeric value of quantity
Industry: Transport Distance
NSF Reference: GA0-17.0, FA0-50.0
NSF crosswalk to FA0-50.0 is used only in Medicare payer-to-payer COB situations.
CR109
352
Description
O
AN
1/80
Situational
Description: A free-form description to clarify the related data elements and their content
Industry: Round Trip Purpose Description
NSF Reference: GA0-20.0
Required if CR103 (Ambulance Transport Code) = “X - Round Trip”; otherwise not used.
CR110
352
Description
O
AN
1/80
Situational
Description: A free-form description to clarify the related data elements and their content
Industry: Stretcher Purpose Description
NSF Reference: GA0-21.0
Required if needed to justify usage of stretcher.
Syntax Rules:
1. P0102 - If either CR101 or CR102 is present, then the other is required.
2. P0506 - If either CR105 or CR106 is present, then the other is required.
Semantics:
1.
2.
3.
4.
5.
6.
CR102 is the weight of the patient at time of transport.
CR106 is the distance traveled during transport.
CR107 is the address of origin.
CR108 is the address of destination.
CR109 is the purpose for the round trip ambulance service.
CR110 is the purpose for the usage of a stretcher during ambulance service.
Notes:
1. The CR1 segment in Loop ID-2300 applies to the entire claim unless an exception is reported in the CR1
segment in Loop ID-2400.
2. Required on all claims involving ambulance services.
Example:
CR1*LB*140*I*A*DH*12****UNCONSCIOUS~
837P_CG.ecs
475
For internal use only
12/1/2010
Health Care Claim: Professional - 837
CR2 Spinal Manipulation Service
Information
Pos: 200
Max: 1
Detail - Optional
Loop: 2300
Elements: 4
User Option (Usage): Situational
Purpose: To supply information related to the chiropractic service rendered to a patient
Element Summary:
Ref
Id
Element Name
CR208
1342
Nature of Condition Code
Req
Type
Min/Max
Usage
O
ID
1/1
Required
1/80
Situational
Description: Code indicating the nature of a patient's condition
Industry: Patient Condition Code
Alias: Nature of Condition Code. Spinal Manipulation
NSF Reference: GC0-11.0
All valid standard codes are used. (Total Codes: 7)
CR210
352
Description
O
AN
Description: A free-form description to clarify the related data elements and their content
Industry: Patient Condition Description
NSF Reference: GC0-14.0
Used at discretion of submitter.
CR211
352
Description
O
AN
1/80
Situational
Description: A free-form description to clarify the related data elements and their content
Industry: Patient Condition Description
Alias: Patient Condition Description. Spinal Manipulation
NSF Reference: GC0-14.0
Used at discretion of submitter.
CR212
1073
Yes/No Condition or Response Code
O
ID
1/1
Situational
Description: Code indicating a Yes or No condition or response
Industry: X-ray Availability Indicator
Alias: X-ray Availability Indicator. Spinal Manipulation
NSF Reference: GC0-15.0
Required for service dates prior to January 1, 2000.
CodeList Summary (Total Codes: 4, Included: 2)
Code Name
N
Y
No
Yes
Syntax Rules:
1. P0102 - If either CR201 or CR202 is present, then the other is required.
2. C0403 - If CR204 is present, then CR203 is required.
3. P0506 - If either CR205 or CR206 is present, then the other is required.
Semantics:
837P_CG.ecs
476
For internal use only
12/1/2010
Health Care Claim: Professional - 837
1.
2.
3.
4.
5.
CR201 is the number this treatment is in the series.
CR202 is the total number of treatments in the series.
CR206 is the time period involved in the treatment series.
CR207 is the number of treatments rendered in the month of service.
CR209 is complication indicator. A "Y" value indicates a complicated condition; an "N" value indicates an
uncomplicated condition.
6. CR210 is a description of the patient's condition.
7. CR211 is an additional description of the patient's condition.
8. CR212 is X-rays availability indicator. A "Y" value indicates X-rays are maintained and available for carrier
review; an "N" value indicates X-rays are not maintained and available for carrier review.
Comments:
1. When both CR203 and CR204 are present, CR203 is the beginning level of subluxation and CR204 is the
ending level of subluxation.
Notes:
1. The CR2 segment in Loop ID-2300 applies to the entire claim unless overridden by the presence of a CR2
segment in Loop ID-2400.
2. Required on chiropractic claims involving spinal manipulation and known to impact payer’s adjudication
process.
Example:
CR2********M****Y~
837P_CG.ecs
477
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 220
CRC Ambulance Certification
Max: 3
Detail - Optional
Loop: 2300
Elements: 7
User Option (Usage): Situational
Purpose: To supply information on conditions
Element Summary:
Ref
Id
Element Name
Req
Type
Min/Max
Usage
CRC01
1136
Code Category
M
ID
2/2
Required
Description: Specifies the situation or category to which the code applies
CodeList Summary (Total Codes: 341, Included: 1)
Code Name
07
CRC02
1073
Ambulance Certification
Yes/No Condition or Response Code
M
ID
1/1
Required
2/2
Required
Description: Code indicating a Yes or No condition or response
Industry: Certification Condition Indicator
Alias: Certification Condition Code Applies Indicator
CodeList Summary (Total Codes: 4, Included: 2)
Code Name
N
Y
CRC03
1321
No
Yes
Condition Indicator
M
ID
Description: Code indicating a condition
Industry: Condition Code
Alias: Condition Indicator
The codes for CRC03 also can be used for CRC04 through CRC07.
CodeList Summary (Total Codes: 1079, Included: 10)
Code Name
01
Patient was admitted to a hospital
NSF Reference:
GA0-06.0
02
Patient was bed confined before the ambulance service
NSF Reference:
03
Patient was bed confined after the ambulance service
NSF Reference:
GA0-08.0
GA0-09.0
04
Patient was moved by stretcher
NSF Reference:
05
Patient was unconscious or in shock
NSF Reference:
GA0-10.0
837P_CG.ecs
478
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Code Name
GA0-11.0
06
Patient was transported in an emergency situation
NSF Reference:
GA0-12.0
07
Patient had to be physically restrained
NSF Reference:
GA0-13.0
08
Patient had visible hemorrhaging
NSF Reference:
GA0-14.0
09
Ambulance service was medically necessary
NSF Reference:
GA0-16.0
60
Transportation Was To the Nearest Facility
NSF Reference:
GA0-24.0
CRC04
1321
Condition Indicator
O
ID
2/2
Situational
Description: Code indicating a condition
Industry: Condition Code
Alias: Condition Indicator
Required if additional condition codes are needed.
Use the codes listed in CRC03.
CodeList Summary (Total Codes: 1079, Included: 10)
Code Name
01
Patient was admitted to a hospital
NSF Reference:
02
Patient was bed confined before the ambulance service
NSF Reference:
GA0-06.0
GA0-08.0
03
Patient was bed confined after the ambulance service
NSF Reference:
04
Patient was moved by stretcher
NSF Reference:
GA0-09.0
GA0-10.0
05
Patient was unconscious or in shock
NSF Reference:
06
Patient was transported in an emergency situation
NSF Reference:
GA0-11.0
GA0-12.0
07
837P_CG.ecs
Patient had to be physically restrained
NSF Reference:
479
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Code Name
GA0-13.0
08
Patient had visible hemorrhaging
NSF Reference:
GA0-14.0
09
Ambulance service was medically necessary
NSF Reference:
GA0-16.0
60
Transportation Was To the Nearest Facility
NSF Reference:
GA0-24.0
CRC05
1321
Condition Indicator
O
ID
2/2
Situational
Description: Code indicating a condition
Industry: Condition Code
Alias: Condition Indicator
Required if additional condition codes are needed.
Use the codes listed in CRC03.
CodeList Summary (Total Codes: 1079, Included: 10)
Code Name
01
Patient was admitted to a hospital
NSF Reference:
02
Patient was bed confined before the ambulance service
NSF Reference:
GA0-06.0
GA0-08.0
03
Patient was bed confined after the ambulance service
NSF Reference:
04
Patient was moved by stretcher
NSF Reference:
GA0-09.0
GA0-10.0
05
Patient was unconscious or in shock
NSF Reference:
06
Patient was transported in an emergency situation
NSF Reference:
GA0-11.0
GA0-12.0
07
Patient had to be physically restrained
NSF Reference:
08
Patient had visible hemorrhaging
NSF Reference:
GA0-13.0
GA0-14.0
09
837P_CG.ecs
Ambulance service was medically necessary
NSF Reference:
480
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Code Name
GA0-16.0
60
Transportation Was To the Nearest Facility
NSF Reference:
GA0-24.0
CRC06
1321
Condition Indicator
O
ID
2/2
Situational
2/2
Situational
Description: Code indicating a condition
Industry: Condition Code
Alias: Condition Indicator
Required if additional condition codes are needed.
Use the codes listed in CRC03.
CodeList Summary (Total Codes: 1079, Included: 10)
Code Name
01
Patient was admitted to a hospital
NSF Reference:
02
Patient was bed confined before the ambulance service
NSF Reference:
GA0-06.0
GA0-08.0
03
Patient was bed confined after the ambulance service
NSF Reference:
04
Patient was moved by stretcher
NSF Reference:
GA0-09.0
GA0-10.0
05
Patient was unconscious or in shock
NSF Reference:
06
Patient was transported in an emergency situation
NSF Reference:
GA0-11.0
GA0-12.0
07
Patient had to be physically restrained
NSF Reference:
08
Patient had visible hemorrhaging
NSF Reference:
GA0-13.0
GA0-14.0
09
Ambulance service was medically necessary
NSF Reference:
60
Transportation Was To the Nearest Facility
NSF Reference:
GA0-16.0
GA0-24.0
CRC07
837P_CG.ecs
1321
Condition Indicator
O
481
ID
For internal use only
12/1/2010
Ref
Health Care Claim: Professional - 837
Id
Element Name
Req
Type
Min/Max
Usage
Description: Code indicating a condition
Industry: Condition Code
Alias: Condition Indicator
Required if additional condition codes are needed.
Use the codes listed in CRC03.
CodeList Summary (Total Codes: 1079, Included: 10)
Code Name
01
Patient was admitted to a hospital
NSF Reference:
02
Patient was bed confined before the ambulance service
NSF Reference:
GA0-06.0
GA0-08.0
03
Patient was bed confined after the ambulance service
NSF Reference:
GA0-09.0
04
Patient was moved by stretcher
NSF Reference:
GA0-10.0
05
Patient was unconscious or in shock
NSF Reference:
GA0-11.0
06
Patient was transported in an emergency situation
NSF Reference:
GA0-12.0
07
Patient had to be physically restrained
NSF Reference:
GA0-13.0
08
Patient had visible hemorrhaging
NSF Reference:
GA0-14.0
09
Ambulance service was medically necessary
NSF Reference:
GA0-16.0
60
Transportation Was To the Nearest Facility
NSF Reference:
GA0-24.0
Semantics:
1. CRC01 qualifies CRC03 through CRC07.
2. CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03
through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply.
Notes:
1. The CRC segment in Loop ID-2300 applies to the entire claim unless overridden by a CRC segment at the
837P_CG.ecs
482
For internal use only
12/1/2010
Health Care Claim: Professional - 837
service line level in Loop ID-2400 with the same value in CRC01.
2. Required on ambulance claims/encounters, i.e. when CR1 segment is used.
Example:
CRC*07*Y*01~
837P_CG.ecs
483
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 220
CRC Patient Condition
Max: 3
Detail - Optional
Information: Vision
Loop: 2300
Elements: 7
User Option (Usage): Situational
Purpose: To supply information on conditions
Element Summary:
Ref
Id
Element Name
Req
Type
Min/Max
Usage
CRC01
1136
Code Category
M
ID
2/2
Required
Description: Specifies the situation or category to which the code applies
CodeList Summary (Total Codes: 341, Included: 3)
Code Name
E1
E2
E3
CRC02
1073
Spectacle Lenses
Contact Lenses
Spectacle Frames
Yes/No Condition or Response Code
M
ID
1/1
Required
2/2
Required
Description: Code indicating a Yes or No condition or response
Industry: Certification Condition Indicator
Alias: Certification Condition Code Applies Indicator
CodeList Summary (Total Codes: 4, Included: 2)
Code Name
N
Y
CRC03
1321
No
Yes
Condition Indicator
M
ID
Description: Code indicating a condition
Industry: Condition Code
Alias: Condition Indicator
CodeList Summary (Total Codes: 1079, Included: 5)
Code Name
L1
L2
L3
L4
L5
CRC04
1321
General Standard of 20 Degree or .5 Diopter Sphere or Cylinder Change Met
Replacement Due to Loss or Theft
Replacement Due to Breakage or Damage
Replacement Due to Patient Preference
Replacement Due to Medical Reason
Condition Indicator
O
ID
2/2
Situational
Description: Code indicating a condition
Industry: Condition Code
Use codes listed in CRC03.
Required if additional condition codes are needed.
CodeList Summary (Total Codes: 1079, Included: 5)
837P_CG.ecs
484
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Code Name
L1
L2
L3
L4
L5
CRC05
1321
General Standard of 20 Degree or .5 Diopter Sphere or Cylinder Change Met
Replacement Due to Loss or Theft
Replacement Due to Breakage or Damage
Replacement Due to Patient Preference
Replacement Due to Medical Reason
Condition Indicator
O
ID
2/2
Situational
Description: Code indicating a condition
Industry: Condition Code
Use codes listed in CRC03.
Required if additional condition codes are needed.
CodeList Summary (Total Codes: 1079, Included: 5)
Code Name
L1
L2
L3
L4
L5
CRC06
1321
General Standard of 20 Degree or .5 Diopter Sphere or Cylinder Change Met
Replacement Due to Loss or Theft
Replacement Due to Breakage or Damage
Replacement Due to Patient Preference
Replacement Due to Medical Reason
Condition Indicator
O
ID
2/2
Situational
Description: Code indicating a condition
Industry: Condition Code
Use codes listed in CRC03.
Required if additional condition codes are needed.
CodeList Summary (Total Codes: 1079, Included: 5)
Code Name
L1
L2
L3
L4
L5
CRC07
1321
General Standard of 20 Degree or .5 Diopter Sphere or Cylinder Change Met
Replacement Due to Loss or Theft
Replacement Due to Breakage or Damage
Replacement Due to Patient Preference
Replacement Due to Medical Reason
Condition Indicator
O
ID
2/2
Situational
Description: Code indicating a condition
Industry: Condition Code
Use codes listed in CRC03.
Required if additional condition codes are needed.
CodeList Summary (Total Codes: 1079, Included: 5)
Code Name
L1
L2
L3
L4
L5
General Standard of 20 Degree or .5 Diopter Sphere or Cylinder Change Met
Replacement Due to Loss or Theft
Replacement Due to Breakage or Damage
Replacement Due to Patient Preference
Replacement Due to Medical Reason
Semantics:
837P_CG.ecs
485
For internal use only
12/1/2010
Health Care Claim: Professional - 837
1. CRC01 qualifies CRC03 through CRC07.
2. CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03
through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply.
Notes:
1. Required on vision claims/encounters involving replacement lenses or frames when this information is known
to impact reimbursement.
Example:
CRC*E1*Y*L1~
837P_CG.ecs
486
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 220
CRC Homebound Indicator
Max: 1
Detail - Optional
Loop: 2300
Elements: 3
User Option (Usage): Situational
Purpose: To supply information on conditions
Element Summary:
Ref
Id
Element Name
Req
Type
Min/Max
Usage
CRC01
1136
Code Category
M
ID
2/2
Required
Description: Specifies the situation or category to which the code applies
CodeList Summary (Total Codes: 341, Included: 1)
Code Name
75
CRC02
1073
Functional Limitations
Yes/No Condition or Response Code
M
ID
1/1
Required
2/2
Required
Description: Code indicating a Yes or No condition or response
CodeList Summary (Total Codes: 4, Included: 1)
Code Name
Y
CRC03
1321
Yes
Condition Indicator
M
ID
Description: Code indicating a condition
Industry: Homebound Indicator
CodeList Summary (Total Codes: 1079, Included: 1)
Code Name
IH
Independent at Home
NSF Reference:
EA0-50.0
Semantics:
1. CRC01 qualifies CRC03 through CRC07.
2. CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03
through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply.
Notes:
1. Required for Medicare claims/encounters when an independent laboratory renders an EKG tracing or obtains a
specimen from a homebound or institutionalized patient.
Example:
CRC*75*Y*IH~
837P_CG.ecs
487
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 220
CRC EPSDT Referral
Max: 1
Detail - Optional
Loop: 2300
Elements: 5
User Option (Usage): Situational
Purpose: To supply information on conditions
Element Summary:
Ref
Id
Element Name
Req
Type
Min/Max
Usage
CRC01
1136
Code Category
M
ID
2/2
Required
Description: Specifies the situation or category to which the code applies
CodeList Summary (Total Codes: 341, Included: 1)
Code Name
ZZ
CRC02
1073
Mutually Defined
EPSDT Screening referral information.
Yes/No Condition or Response Code
M
ID
1/1
Required
Description: Code indicating a Yes or No condition or response
Industry: Certification Condition Indicator
Alias: Certification Condition Code Applies Indicator
Was an EPSDT referral given to the patient?
CodeList Summary (Total Codes: 4, Included: 2)
Code Name
CRC03
1321
N
No
If no, then choose “NU” in CRC03 indicating no referral given.
Y
Yes
Condition Indicator
M
ID
2/2
Required
Description: Code indicating a condition
Industry: Condition Code
Alias: Condition Indicator
The codes for CRC03 also can be used for CRC04 through CRC07.
CodeList Summary (Total Codes: 1079, Included: 4)
Code Name
837P_CG.ecs
AV
Available - Not Used
Patient refused referral.
NU
Not Used
This conditioner indicator must be used when the submitter answers “N” in CRC02.
S2
Under Treatment
Patient is currently under treatment for referred diagnostic or corrective health
problem.
ST
New Services Requested
Referral to another provider for diagnostic or corrective treatment/scheduled for
another appointment with screening provider for diagnostic or corrective treatment
for at least one health problem identified during an initial or periodic screening
service (not including dental referrals).
488
For internal use only
12/1/2010
CRC04
Health Care Claim: Professional - 837
1321
Condition Indicator
O
ID
2/2
Situational
Description: Code indicating a condition
Industry: Condition Code
Use codes listed in CRC03.
Required if additional condition codes are needed.
CodeList Summary (Total Codes: 1079, Included: 4)
Code Name
CRC05
1321
AV
Available - Not Used
Patient refused referral.
NU
Not Used
This conditioner indicator must be used when the submitter answers “N” in CRC02.
S2
Under Treatment
Patient is currently under treatment for referred diagnostic or corrective health
problem.
ST
New Services Requested
Referral to another provider for diagnostic or corrective treatment/scheduled for
another appointment with screening provider for diagnostic or corrective treatment
for at least one health problem identified during an initial or periodic screening
service (not including dental referrals).
Condition Indicator
O
ID
2/2
Situational
Description: Code indicating a condition
Industry: Condition Code
Use codes listed in CRC03.
Required if additional condition codes are needed.
CodeList Summary (Total Codes: 1079, Included: 4)
Code Name
AV
Available - Not Used
Patient refused referral.
NU
Not Used
This conditioner indicator must be used when the submitter answers “N” in CRC02.
S2
Under Treatment
Patient is currently under treatment for referred diagnostic or corrective health
problem.
ST
New Services Requested
Referral to another provider for diagnostic or corrective treatment/scheduled for
another appointment with screening provider for diagnostic or corrective treatment
for at least one health problem identified during an initial or periodic screening
service (not including dental referrals).
Semantics:
1. CRC01 qualifies CRC03 through CRC07.
2. CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03
through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply.
Notes:
1. Required on Early & Periodic Screening, Diagnosis, and Treatment (EPSDT) claims/encounters.
Example:
837P_CG.ecs
489
For internal use only
12/1/2010
Health Care Claim: Professional - 837
CRC*ZZ*Y*ST~
837P_CG.ecs
490
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 231
HI Health Care Diagnosis Code
Max: 1
Detail - Optional
Loop: 2300
Elements: 8
User Option (Usage): Situational
Purpose: To supply information related to the delivery of health care
Element Summary:
Ref
Id
Element Name
HI01
C022
Health Care Code Information
Req
Type
M
Comp
Min/Max
Usage
Required
Description: To send health care codes and their associated dates, amounts and
quantities
Alias: Principal Diagnosis
With a few exceptions, it is not recommended to put E codes in HI01. E codes may be put
in any other HI element using BF as the qualifier.
The diagnosis listed in this element is assumed to be the principal diagnosis.
HI01-01
1270
Code List Qualifier Code
M
ID
1/3
Required
Description: Code identifying a specific industry code list
Industry: Diagnosis Type Code
CodeList Summary (Total Codes: 558, Included: 1)
Code Name
BK
Principal Diagnosis
ICD-9 Codes
CODE SOURCE:
131: International Classification of Diseases Clinical Mod (ICD-9-CM) Procedure
HI01-02
1271
Industry Code
M
AN
1/30
Required
Description: Code indicating a code from a specific industry code list
Industry: Diagnosis Code
NSF Reference: EA0-32.0, GX0-31.0, GU0-12.0
ExternalCodeList
Name: 131D
Description: International Classification of Diseases Clinical Mod (ICD-9-CM) Diagnosis
HI02
C022
Health Care Code Information
O
Comp
Situational
Description: To send health care codes and their associated dates, amounts and
quantities
Alias: Diagnosis
Refer to HI01-1(C022-01) and HI01-3(C022-03) for C022-01 and C022-03.
Required if needed to report an additional diagnoses and if the preceeding HI data
elements have been used to report other diagnoses.
HI02-01
1270
Code List Qualifier Code
M
ID
1/3
Required
Description: Code identifying a specific industry code list
Industry: Diagnosis Type Code
CodeList Summary (Total Codes: 558, Included: 1)
837P_CG.ecs
491
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Code Name
BF
Diagnosis
ICD-9 Codes
CODE SOURCE:
131: International Classification of Diseases Clinical Mod (ICD-9-CM) Procedure
HI02-02
1271
Industry Code
M
AN
1/30
Required
Description: Code indicating a code from a specific industry code list
Industry: Diagnosis Code
NSF Reference: EA0-33.0, GX0-32.0, GU0-13.0
ExternalCodeList
Name: 131D
Description: International Classification of Diseases Clinical Mod (ICD-9-CM) Diagnosis
HI03
C022
Health Care Code Information
O
Comp
Situational
Description: To send health care codes and their associated dates, amounts and
quantities
Alias: Diagnosis
Refer to HI01-1(C022-01) and HI01-3(C022-03) for C022-01 and C022-03.
Required if needed to report an additional diagnoses and if the preceeding HI data
elements have been used to report other diagnoses.
HI03-01
1270
Code List Qualifier Code
M
ID
1/3
Required
Description: Code identifying a specific industry code list
Industry: Diagnosis Type Code
CodeList Summary (Total Codes: 558, Included: 1)
Code Name
BF
Diagnosis
ICD-9 Codes
CODE SOURCE:
131: International Classification of Diseases Clinical Mod (ICD-9-CM) Procedure
HI03-02
1271
Industry Code
M
AN
1/30
Required
Description: Code indicating a code from a specific industry code list
Industry: Diagnosis Code
NSF Reference: EA0-34.0, GX0-33.0, GU0-14.0
ExternalCodeList
Name: 131D
Description: International Classification of Diseases Clinical Mod (ICD-9-CM) Diagnosis
HI04
C022
Health Care Code Information
O
Comp
Situational
Description: To send health care codes and their associated dates, amounts and
quantities
Alias: Diagnosis
Refer to HI01-1(C022-01) and HI01-3(C022-03) for C022-01 and C022-03.
Required if needed to report an additional diagnoses and if the preceeding HI data
elements have been used to report other diagnoses.
837P_CG.ecs
492
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Ref
Id
Element Name
HI04-01
1270
Code List Qualifier Code
Req
Type
Min/Max
Usage
M
ID
1/3
Required
Description: Code identifying a specific industry code list
Industry: Diagnosis Type Code
CodeList Summary (Total Codes: 558, Included: 1)
Code Name
BF
Diagnosis
ICD-9 Codes
CODE SOURCE:
131: International Classification of Diseases Clinical Mod (ICD-9-CM) Procedure
HI04-02
1271
Industry Code
M
AN
1/30
Required
Description: Code indicating a code from a specific industry code list
Industry: Diagnosis Code
NSF Reference: EA0-35.0, GX0-34.0, GU0-15.0
ExternalCodeList
Name: 131D
Description: International Classification of Diseases Clinical Mod (ICD-9-CM) Diagnosis
HI05
C022
Health Care Code Information
O
Comp
Situational
Description: To send health care codes and their associated dates, amounts and
quantities
Alias: Diagnosis
Refer to HI01-1(C022-01) and HI01-3(C022-03) for C022-01 and C022-03.
Required if needed to report an additional diagnoses and if the preceeding HI data
elements have been used to report other diagnoses.
HI05-01
1270
Code List Qualifier Code
M
ID
1/3
Required
Description: Code identifying a specific industry code list
Industry: Diagnosis Type Code
CodeList Summary (Total Codes: 558, Included: 1)
Code Name
BF
Diagnosis
ICD-9 Codes
CODE SOURCE:
131: International Classification of Diseases Clinical Mod (ICD-9-CM) Procedure
HI05-02
1271
Industry Code
M
AN
1/30
Required
Description: Code indicating a code from a specific industry code list
Industry: Diagnosis Code
ExternalCodeList
Name: 131D
Description: International Classification of Diseases Clinical Mod (ICD-9-CM) Diagnosis
HI06
C022
Health Care Code Information
O
Comp
Situational
Description: To send health care codes and their associated dates, amounts and
837P_CG.ecs
493
For internal use only
12/1/2010
Ref
Health Care Claim: Professional - 837
Id
Element Name
quantities
Alias: Diagnosis
Req
Type
Min/Max
Usage
Refer to HI01-1(C022-01) and HI01-3(C022-03) for C022-01 and C022-03.
Required if needed to report an additional diagnoses and if the preceeding HI data
elements have been used to report other diagnoses.
HI06-01
1270
Code List Qualifier Code
M
ID
1/3
Required
Description: Code identifying a specific industry code list
Industry: Diagnosis Type Code
CodeList Summary (Total Codes: 558, Included: 1)
Code Name
BF
Diagnosis
ICD-9 Codes
CODE SOURCE:
131: International Classification of Diseases Clinical Mod (ICD-9-CM) Procedure
HI06-02
1271
Industry Code
M
AN
1/30
Required
Description: Code indicating a code from a specific industry code list
Industry: Diagnosis Code
ExternalCodeList
Name: 131D
Description: International Classification of Diseases Clinical Mod (ICD-9-CM) Diagnosis
HI07
C022
Health Care Code Information
O
Comp
Situational
Description: To send health care codes and their associated dates, amounts and
quantities
Alias: Diagnosis
Refer to HI01-1(C022-01) and HI01-3(C022-03) for C022-01 and C022-03.
Required if needed to report an additional diagnoses and if the preceeding HI data
elements have been used to report other diagnoses.
HI07-01
1270
Code List Qualifier Code
M
ID
1/3
Required
Description: Code identifying a specific industry code list
Industry: Diagnosis Type Code
CodeList Summary (Total Codes: 558, Included: 1)
Code Name
BF
Diagnosis
ICD-9 Codes
CODE SOURCE:
131: International Classification of Diseases Clinical Mod (ICD-9-CM) Procedure
HI07-02
1271
Industry Code
M
AN
1/30
Required
Description: Code indicating a code from a specific industry code list
Industry: Diagnosis Code
ExternalCodeList
Name: 131D
837P_CG.ecs
494
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Description: International Classification of Diseases Clinical Mod (ICD-9-CM) Diagnosis
HI08
C022
Health Care Code Information
O
Comp
Situational
Description: To send health care codes and their associated dates, amounts and
quantities
Alias: Diagnosis
Refer to HI01-1(C022-01) and HI01-3(C022-03) for C022-01 and C022-03.
Required if needed to report an additional diagnoses and if the preceeding HI data
elements have been used to report other diagnoses.
HI08-01
1270
Code List Qualifier Code
M
ID
1/3
Required
Description: Code identifying a specific industry code list
Industry: Diagnosis Type Code
CodeList Summary (Total Codes: 558, Included: 1)
Code Name
BF
Diagnosis
ICD-9 Codes
CODE SOURCE:
131: International Classification of Diseases Clinical Mod (ICD-9-CM) Procedure
HI08-02
1271
Industry Code
M
AN
1/30
Required
Description: Code indicating a code from a specific industry code list
Industry: Diagnosis Code
ExternalCodeList
Name: 131D
Description: International Classification of Diseases Clinical Mod (ICD-9-CM) Diagnosis
Notes:
1. Required on all claims/encounters except claims for which there are no diagnoses (e.g., taxi claims).
2. Do not transmit the decimal points in the diagnosis codes. The decimal point is assumed.
Example:
HI*BK:8901*BF:87200*BF:5559~
837P_CG.ecs
495
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 241
HCP Claim Pricing/Repricing
Max: 1
Detail - Optional
Information
Loop: 2300
Elements: 10
User Option (Usage): Situational
Purpose: To specify pricing or repricing information about a health care claim or line item
Element Summary:
Ref
Id
Element Name
HCP01
1473
Pricing Methodology
Req
Type
Min/Max
Usage
C
ID
2/2
Required
Description: Code specifying pricing methodology at which the claim or line item has been
priced or repriced
Alias: Pricing/repricing methodology
Trading partners need to agree on the codes to use in this element. There do not appear to
be standard definitions for the code elements.
CodeList Summary (Total Codes: 15, Included: 14)
Code Name
00
01
02
03
04
05
07
08
09
10
11
12
13
14
HCP02
782
Zero Pricing (Not Covered Under Contract)
Priced as Billed at 100%
Priced at the Standard Fee Schedule
Priced at a Contractual Percentage
Bundled Pricing
Peer Review Pricing
Flat Rate Pricing
Combination Pricing
Maternity Pricing
Other Pricing
Lower of Cost
Ratio of Cost
Cost Reimbursed
Adjustment Pricing
Monetary Amount
O
R
1/18
Required
Description: Monetary amount
Industry: Repriced Allowed Amount
Alias: Allowed amount, Pricing
Used only by repricers as needed. This information is specific to the destination payer
reported in the 2010BB loop.
HCP03
782
Monetary Amount
O
R
1/18
Situational
Description: Monetary amount
Industry: Repriced Saving Amount
Alias: Savings amount, Pricing
Used only by repricers as needed. This information is specific to the destination payer
reported in the 2010BB loop.
HCP04
837P_CG.ecs
127
Reference Identification
O
496
AN
1/30
Situational
For internal use only
12/1/2010
Ref
Health Care Claim: Professional - 837
Id
Element Name
Req
Type
Min/Max
Usage
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Repricing Organization Identifier
Used only by repricers as needed. This information is specific to the destination payer
reported in the 2010BB loop.
HCP05
118
Rate
O
R
1/9
Situational
Description: Rate expressed in the standard monetary denomination for the currency
specified
Industry: Repricing Per Diem or Flat Rate Amount
Alias: Pricing rate
Used only by repricers as needed. This information is specific to the destination payer
reported in the 2010BB loop.
HCP06
127
Reference Identification
O
AN
1/30
Situational
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Repriced Approved Ambulatory Patient Group Code
Alias: Approved APG code, Pricing
Used only by repricers as needed. This information is specific to the destination payer
reported in the 2010BB loop.
HCP07
782
Monetary Amount
O
R
1/18
Situational
Description: Monetary amount
Industry: Repriced Approved Ambulatory Patient Group Amount
Alias: Approved APG amount, Pricing
Used only by repricers as needed. This information is specific to the destination payer
reported in the 2010BB loop.
HCP13
901
Reject Reason Code
C
ID
2/2
Situational
Description: Code assigned by issuer to identify reason for rejection
Alias: Reject reason code
Used only by repricers as needed. This information is specific to the destination payer
reported in the 2010BB loop.
CodeList Summary (Total Codes: 181, Included: 6)
Code Name
T1
T2
T3
T4
T5
T6
HCP14
1526
Cannot Identify Provider as TPO (Third Party Organization) Participant
Cannot Identify Payer as TPO (Third Party Organization) Participant
Cannot Identify Insured as TPO (Third Party Organization) Participant
Payer Name or Identifier Missing
Certification Information Missing
Claim does not contain enough information for re-pricing
Policy Compliance Code
O
ID
1/2
Situational
Description: Code specifying policy compliance
Alias: Policy compliance code
Used only by repricers as needed. This information is specific to the destination payer
reported in the 2010BB loop.
837P_CG.ecs
497
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Ref
Id
Element Name
Req
Type
All valid standard codes are used. (Total Codes: 5)
HCP15
1527
Exception Code
O
ID
Min/Max
Usage
1/2
Situational
Description: Code specifying the exception reason for consideration of out-of-network
health care services
Alias: Exception code
Used only by repricers as needed. This information is specific to the destination payer
reported in the 2010BB loop.
All valid standard codes are used. (Total Codes: 6)
Syntax Rules:
1. R0113 - At least one of HCP01 or HCP13 is required.
2. P0910 - If either HCP09 or HCP10 is present, then the other is required.
3. P1112 - If either HCP11 or HCP12 is present, then the other is required.
Semantics:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
HCP02 is the allowed amount.
HCP03 is the savings amount.
HCP04 is the repricing organization identification number.
HCP05 is the pricing rate associated with per diem or flat rate repricing.
HCP06 is the approved DRG code.
HCP07 is the approved DRG amount.
HCP08 is the approved revenue code.
HCP10 is the approved procedure code.
HCP12 is the approved service units or inpatient days.
HCP13 is the rejection message returned from the third party organization.
HCP15 is the exception reason generated by a third party organization.
Comments:
1. HCP06, HCP07, HCP08, HCP10, and HCP12 are fields that will contain different values from the original
submitted values.
Notes:
1. Used only by repricers as needed. This information is specific to the destination payer reported in the 2010BB
loop.
2. For capitated encounters, pricing or repricing information usually is not applicable and is provided to qualify
other information within the claim.
Example:
HCP*03*100*10*RPO12345~
837P_CG.ecs
498
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 242
Loop Home Health Care Plan
Information
Repeat: 6
Optional
Loop: 2305 Elements: N/A
User Option (Usage): Situational
Purpose: To supply information related to the home health care plan of treatment and services
Loop Summary:
Pos
Id
Segment Name
242
243
CR7
HSD
Home Health Care Plan Information
Health Care Services Delivery
Req
Max Use
O
O
1
3
Repeat
Usage
Situational
Situational
Semantics:
1. CR702 is the total visits on this bill rendered prior to the recertification "to" date.
2. CR703 is the total visits projected during this certification period.
Notes:
1. Required on home health claims/encounters that involve billing/reporting home health visits.
Example:
CR7*PT*4*12~
837P_CG.ecs
499
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 242
CR7 Home Health Care Plan
Max: 1
Detail - Optional
Information
Loop: 2305
Elements: 3
User Option (Usage): Situational
Purpose: To supply information related to the home health care plan of treatment and services
Element Summary:
Ref
Id
Element Name
CR701
921
Discipline Type Code
Req
Type
Min/Max
Usage
M
ID
2/2
Required
Description: Code indicating disciplines ordered by a physician
Alias: Discipline type code
All valid standard codes are used. (Total Codes: 6)
CR702
1470
Number
M
N0
1/9
Required
M
N0
1/9
Required
Description: A generic number
Industry: Total Visits Rendered Count
Alias: Total visits rendered, home health
CR703
1470
Number
Description: A generic number
Industry: Certification Period Projected Visit Count
Alias: Total visits projected, home health
Semantics:
1. CR702 is the total visits on this bill rendered prior to the recertification "to" date.
2. CR703 is the total visits projected during this certification period.
Notes:
1. Required on home health claims/encounters that involve billing/reporting home health visits.
Example:
CR7*PT*4*12~
837P_CG.ecs
500
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 243
HSD Health Care Services
Max: 3
Detail - Optional
Delivery
Loop: 2305
Elements: 8
User Option (Usage): Situational
Purpose: To specify the delivery pattern of health care services
Element Summary:
Ref
Id
Element Name
HSD01
673
Quantity Qualifier
Req
Type
Min/Max
Usage
C
ID
2/2
Situational
Description: Code specifying the type of quantity
Industry: Visits
Required if the order/prescription for the service contains the data.
CodeList Summary (Total Codes: 832, Included: 1)
Code Name
VS
HSD02
380
Visits
Quantity
C
R
1/15
Situational
Description: Numeric value of quantity
Industry: Number of Visits
Required if the order/prescription for the service contains the data.
HSD03
355
Unit or Basis for Measurement Code
O
ID
2/2
Situational
Description: Code specifying the units in which a value is being expressed, or manner in
which a measurement has been taken
Industry: Frequency Period
Alias: Modulus, Unit
Required if the order/prescription for the service contains the data.
CodeList Summary (Total Codes: 794, Included: 4)
Code Name
HSD04
1167
DA
MO
Days
Months
Month
Q1
WK
Quarter (Time)
Week
Sample Selection Modulus
O
R
1/6
Situational
Description: To specify the sampling frequency in terms of a modulus of the Unit of
Measure, e.g., every fifth bag, every 1.5 minutes
Industry: Frequency Count
Alias: Modulus, Amount
Required if the order/prescription for the service contains the data.
HSD05
615
Time Period Qualifier
C
ID
1/2
Situational
Description: Code defining periods
Industry: Duration of Visits Units
837P_CG.ecs
501
For internal use only
12/1/2010
Ref
Health Care Claim: Professional - 837
Id
Element Name
Req
Type
Min/Max
Usage
Required if the order/prescription for the service contains the data.
CodeList Summary (Total Codes: 36, Included: 2)
Code Name
7
35
HSD06
616
Day
Week
Number of Periods
O
N0
1/3
Situational
Description: Total number of periods
Industry: Duration of Visits, Number of Units
Required if the order/prescription for the service contains the data.
HSD07
678
Ship/Delivery or Calendar Pattern Code
O
ID
1/2
Situational
Description: Code which specifies the routine shipments, deliveries, or calendar pattern
Industry: Ship, Delivery or Calendar Pattern Code
Alias: Pattern Code
Required if the order/prescription for the service contains the data.
CodeList Summary (Total Codes: 44, Included: 32)
Code Name
1
2
3
4
5
6
7
A
B
C
D
E
F
G
H
J
K
L
N
O
S
W
SA
SB
SC
SD
SG
SL
837P_CG.ecs
1st Week of the Month
2nd Week of the Month
3rd Week of the Month
4th Week of the Month
5th Week of the Month
1st & 3rd Weeks of the Month
2nd & 4th Weeks of the Month
Monday through Friday
Monday through Saturday
Monday through Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Monday through Thursday
As Directed
Daily Mon. through Fri.
Once Anytime Mon. through Fri.
Whenever Necessary
Sunday, Monday, Thursday, Friday, Saturday
Tuesday through Saturday
Sunday, Wednesday, Thursday, Friday, Saturday
Monday, Wednesday, Thursday, Friday, Saturday
Tuesday through Friday
Monday, Tuesday and Thursday
502
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Code Name
SP
SX
SY
SZ
HSD08
679
Monday, Tuesday and Friday
Wednesday and Thursday
Monday, Wednesday and Thursday
Tuesday, Thursday and Friday
Ship/Delivery Pattern Time Code
O
ID
1/1
Situational
Description: Code which specifies the time for routine shipments or deliveries
Industry: Delivery Pattern Time Code
Alias: Time Code
Required if the order/prescription for the service contains the data.
CodeList Summary (Total Codes: 9, Included: 3)
Code Name
D
E
F
A.M.
P.M.
As Directed
Syntax Rules:
1. P0102 - If either HSD01 or HSD02 is present, then the other is required.
2. C0605 - If HSD06 is present, then HSD05 is required.
Notes:
1. Required on claims/encounters billing/reporting home health visits where further detail is necessary to clearly
substantiate medical treatment.
2. The HSD segment is used to specify the delivery pattern of the health care services. This is how it is used:
HSD01 qualifies HSD02: If the value in HSD02=1 and the value in HSD01=VS (Visits), this means “one visit”.
Between HSD02 and HSD03 verbally insert a “per every.”
HSD03 qualifies HSD04: If the value in HSD04=3 and the value in HSD03=DA (Day), this means “three days.”
Between HSD04 and HSD05 verbally insert a “for.”
HSD05 qualifies HSD06: If the value in HSD06=21 and the value in HSD05=7 (Days), this means “21 days.”
The total message reads:
HSD*VS*1*DA*3*7*21~ = “One visit per every three days for 21 days.”
Another similar data string of HSD*VS*2*DA*4*7*20~ = Two visits per every four days for 20 days.
An alternate way to use HSD is to employ HSD07 and/or HSD08. A data string of HSD*VS*1*****SX*D~ means “1
visit on Wednesday and Thursday morning.”
Example:
HSD*VS*1*DA*1*7*10~ (This indicates ''1 visit every (per) 1 day (daily) for 10 days'')
HSD*VS*1*DA****W~ (This indicates ''1 visit per day whenever necessary'')
837P_CG.ecs
503
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 250
Loop Referring Provider Name
Repeat: 2
Optional
Loop:
2310A
Elements: N/A
User Option (Usage): Situational
Purpose: To supply the full name of an individual or organizational entity
Loop Summary:
Pos
Id
Segment Name
250
255
271
NM1
PRV
REF
Referring Provider Name
Referring Provider Specialty Information
Referring Provider Secondary Identification
Req
Max Use
O
O
O
1
1
5
Repeat
Usage
Situational
Situational
Situational
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
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.
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. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,
then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.
4. Required if claim involved a referral.
5. When reporting the provider who ordered services such as diagnostic and lab utilize the 2310A loop at the
claim level. For ordered services such as DMERC utilize the 2420E Loop at the line level.
Example:
NM1*DN*1*WELBY*MARCUS*W**JR*34*444332222~
837P_CG.ecs
504
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 250
NM1 Referring Provider Name
Max: 1
Detail - Optional
Loop:
2310A
Elements: 8
User Option (Usage): Situational
Purpose: To supply the full name of an individual or organizational entity
Element Summary:
Ref
Id
Element Name
NM101
98
Entity Identifier Code
Req
Type
Min/Max
Usage
M
ID
2/3
Required
Description: Code identifying an organizational entity, a physical location, property or an
individual
The entity identifier in NM101 applies to all segments in this Loop ID-2310.
CodeList Summary (Total Codes: 1312, Included: 2)
Code Name
NM102
1065
DN
Referring Provider
Use on first iteration of this loop. Use if loop is used only once.
P3
Primary Care Provider
Use only if loop is used twice. Use only on second iteration of this loop.
Entity Type Qualifier
M
ID
1/1
Required
AN
1/35
Required
Description: Code qualifying the type of entity
CodeList Summary (Total Codes: 14, Included: 2)
Code Name
1
2
NM103
1035
Person
Non-Person Entity
Name Last or Organization Name
O
Description: Individual last name or organizational name
Industry: Referring Provider Last Name
NSF Reference: EA0-24.0
NM104
1036
Name First
O
AN
1/25
Situational
O
AN
1/25
Situational
Description: Individual first name
Industry: Referring Provider First Name
NSF Reference: EA0-25.0
Required if NM102=1 (person).
NM105
1037
Name Middle
Description: Individual middle name or initial
Industry: Referring Provider Middle Name
NSF Reference: EA0-26.0
Required if NM102=1 and the middle name/initial of the person is known.
NM107
1039
Name Suffix
O
AN
1/10
Situational
Description: Suffix to individual name
837P_CG.ecs
505
For internal use only
12/1/2010
Ref
Health Care Claim: Professional - 837
Id
Element Name
Industry: Referring Provider Name Suffix
Req
Type
Min/Max
Usage
C
ID
1/2
Situational
Alias: Referring Provider Generation
Required if known.
NM108
66
Identification Code Qualifier
Description: Code designating the system/method of code structure used for Identification
Code (67)
Required if Employer’s Identification/Social Security number (Tax ID) or National Provider
Identifier is known.
CodeList Summary (Total Codes: 215, Included: 3)
Code Name
24
34
XX
NM109
67
Employer's Identification Number
Social Security Number
Health Care Financing Administration National Provider Identifier
Identification Code
C
AN
2/80
Situational
Description: Code identifying a party or other code
Industry: Referring Provider Identifier
Alias: Referring Provider Primary Identifier
NSF Reference: EA0-20.0
Required if Employer’s Identification/Social Security number (Tax ID) or National Provider
Identifier is known.
ExternalCodeList
Name: 537
Description: Health Care Financing Administration National Provider Identifier
Syntax Rules:
1. P0809 - If either NM108 or NM109 is present, then the other is required.
2. C1110 - If NM111 is present, then NM110 is required.
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
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.
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. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,
then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.
4. Required if claim involved a referral.
5. When reporting the provider who ordered services such as diagnostic and lab utilize the 2310A loop at the
claim level. For ordered services such as DMERC utilize the 2420E Loop at the line level.
837P_CG.ecs
506
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Example:
NM1*DN*1*WELBY*MARCUS*W**JR*34*444332222~
837P_CG.ecs
507
For internal use only
12/1/2010
Health Care Claim: Professional - 837
PRV Referring Provider Specialty
Information
Pos: 255
Max: 1
Detail - Optional
Loop:
2310A
Elements: 3
User Option (Usage): Situational
Purpose: To specify the identifying characteristics of a provider
Element Summary:
Ref
Id
Element Name
Req
Type
Min/Max
Usage
PRV01
1221
Provider Code
M
ID
1/3
Required
ID
2/3
Required
Description: Code identifying the type of provider
CodeList Summary (Total Codes: 26, Included: 1)
Code Name
RF
PRV02
128
Referring
Reference Identification Qualifier
M
Description: Code qualifying the Reference Identification
ZZ is used to indicate the “Health Care Provider Taxonomy” code list (provider specialty
code) which is available on the Washington Publishing Company web site:
http://www.wpc-edi.com. This taxonomy is maintained by the Blue Cross Blue Shield
Association and ASC X12N TG2 WG15.
CodeList Summary (Total Codes: 1503, Included: 1)
Code Name
ZZ
PRV03
127
Mutually Defined
Health Care Provider Taxonomy Code list
Reference Identification
M
AN
1/30
Required
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Provider Taxonomy Code
Alias: Provider Specialty Code
ExternalCodeList
Name: HCPT
Description: Health Care Provider Taxonomy
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.
2. Required when adjudication is known to be impacted by provider taxonomy code.
3. PRV02 qualifies PRV03.
Example:
PRV*RF*ZZ*363LP0200N~
837P_CG.ecs
508
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 271
REF Referring Provider
Max: 5
Detail - Optional
Secondary Identification
Loop:
2310A
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 12)
Code Name
REF02
127
0B
1B
1C
1D
1G
1H
EI
G2
LU
N5
SY
State License Number
Blue Shield Provider Number
Medicare Provider Number
Medicaid Provider Number
Provider UPIN Number
CHAMPUS Identification Number
Employer's Identification Number
Provider Commercial Number
Location Number
Provider Plan Network Identification Number
Social Security Number
The social security number may not be used for Medicare.
X5
State Industrial Accident Provider Number
Reference Identification
C
AN
1/30
Required
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Referring Provider Secondary Identifier
NSF Reference: EA0-20.0
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. Required if NM108/09 in this loop is not used or if a secondary number is necessary to identify the provider.
Until the NPI is mandated for use, this REF may be required if necessary to adjudicate the claim.
Example:
REF*1D*A12345~
837P_CG.ecs
509
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 250
Loop Rendering Provider Name
Repeat: 1
Optional
Loop:
2310B
Elements: N/A
User Option (Usage): Situational
Purpose: To supply the full name of an individual or organizational entity
Loop Summary:
Pos
Id
Segment Name
250
255
271
NM1
PRV
REF
Rendering Provider Name
Rendering Provider Specialty Information
Rendering Provider Secondary
Identification
Req
Max Use
O
O
O
1
1
5
Repeat
Usage
Situational
Situational
Situational
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
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.
2. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,
then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.
3. Required when the Rendering Provider NM1 information is different than that carried in either the Billing
Provider NM1 or the Pay-to Provider NM1 in the 2010AA/AB loops respectively.
4. 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 subsitute provider (locum
tenans) was used, that person should be entered here.
Example:
NM1*82*1*BEATTY*GARY*C**SR*XX*12345678~
837P_CG.ecs
510
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 250
NM1 Rendering Provider Name
Max: 1
Detail - Optional
Loop:
2310B
Elements: 8
User Option (Usage): Situational
Purpose: To supply the full name of an individual or organizational entity
Element Summary:
Ref
Id
Element Name
NM101
98
Entity Identifier Code
Req
Type
Min/Max
Usage
M
ID
2/3
Required
Description: Code identifying an organizational entity, a physical location, property or an
individual
The entity identifier in NM101 applies to all segments in this Loop ID-2310.
CodeList Summary (Total Codes: 1312, Included: 1)
Code Name
82
NM102
1065
Rendering Provider
Entity Type Qualifier
M
ID
1/1
Required
AN
1/35
Required
Description: Code qualifying the type of entity
CodeList Summary (Total Codes: 14, Included: 2)
Code Name
1
2
NM103
1035
Person
Non-Person Entity
Name Last or Organization Name
O
Description: Individual last name or organizational name
Industry: Rendering Provider Last or Organization Name
Alias: Rendering Provider Last Name
NSF Reference: FB1-14.0
NM104
1036
Name First
O
AN
1/25
Situational
O
AN
1/25
Situational
Description: Individual first name
Industry: Rendering Provider First Name
NSF Reference: FB1-15.0
Required if NM102=1 (person).
NM105
1037
Name Middle
Description: Individual middle name or initial
Industry: Rendering Provider Middle Name
NSF Reference: FB1-16.0
Required if NM102=1 and the middle name/initial of the person is known.
NM107
1039
Name Suffix
O
AN
1/10
Situational
Description: Suffix to individual name
Industry: Rendering Provider Name Suffix
Alias: Rendering Provider Generation
837P_CG.ecs
511
For internal use only
12/1/2010
Ref
Health Care Claim: Professional - 837
Id
Element Name
Req
Type
Min/Max
Usage
C
ID
1/2
Required
Required if known.
NM108
66
Identification Code Qualifier
Description: Code designating the system/method of code structure used for Identification
Code (67)
NSF Reference: FA0-57.0
FA0-57.0 crosswalk is only used in Medicare COB payer-to-payer claims.
CodeList Summary (Total Codes: 215, Included: 3)
Code Name
24
34
XX
NM109
67
Employer's Identification Number
Social Security Number
Health Care Financing Administration National Provider Identifier
Identification Code
C
AN
2/80
Required
Description: Code identifying a party or other code
Industry: Rendering Provider Identifier
Alias: Rendering Provider Primary Identifier
NSF Reference: FA0-23.0, FA0-58.0
FA0-58.0 crosswalk is only used in Medicare COB payer-to-payer claims.
ExternalCodeList
Name: 537
Description: Health Care Financing Administration National Provider Identifier
Syntax Rules:
1. P0809 - If either NM108 or NM109 is present, then the other is required.
2. C1110 - If NM111 is present, then NM110 is required.
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
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.
2. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,
then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.
3. Required when the Rendering Provider NM1 information is different than that carried in either the Billing
Provider NM1 or the Pay-to Provider NM1 in the 2010AA/AB loops respectively.
4. 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 subsitute provider (locum
tenans) was used, that person should be entered here.
Example:
NM1*82*1*BEATTY*GARY*C**SR*XX*12345678~
837P_CG.ecs
512
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 255
PRV Rendering Provider
Max: 1
Detail - Optional
Specialty Information
Loop:
2310B
Elements: 3
User Option (Usage): Situational
Purpose: To specify the identifying characteristics of a provider
Element Summary:
Ref
Id
Element Name
Req
Type
Min/Max
Usage
PRV01
1221
Provider Code
M
ID
1/3
Required
ID
2/3
Required
Description: Code identifying the type of provider
CodeList Summary (Total Codes: 26, Included: 1)
Code Name
PE
PRV02
128
Performing
Reference Identification Qualifier
M
Description: Code qualifying the Reference Identification
ZZ is used to indicate the “Health Care Provider Taxonomy” code list (provider specialty
code) which is available on the Washington Publishing Company web site:
http://www.wpc-edi.com. This taxonomy is maintained by the Blue Cross Blue Shield
Association and ASC X12N TG2 WG15.
CodeList Summary (Total Codes: 1503, Included: 1)
Code Name
ZZ
PRV03
127
Mutually Defined
Health Care Provider Taxonomy Code list
Reference Identification
M
AN
1/30
Required
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Provider Taxonomy Code
Alias: Provider Specialty Code
NSF Reference: FA0-37.0
ExternalCodeList
Name: HCPT
Description: Health Care Provider Taxonomy
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.
2. PRV02 qualifies PRV03.
3. Required when adjudication is known to be impacted by provider taxonomy code.
Example:
PRV*PE*ZZ*203BA0200N~
837P_CG.ecs
513
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 271
REF Rendering Provider
Max: 5
Detail - Optional
Secondary Identification
Loop:
2310B
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
Description: Code qualifying the Reference Identification
NSF Reference: FA0-57.0
CodeList Summary (Total Codes: 1503, Included: 12)
Code Name
REF02
127
0B
1B
1C
1D
1G
1H
EI
G2
LU
N5
SY
State License Number
Blue Shield Provider Number
Medicare Provider Number
Medicaid Provider Number
Provider UPIN Number
CHAMPUS Identification Number
Employer's Identification Number
Provider Commercial Number
Location Number
Provider Plan Network Identification Number
Social Security Number
The social security number may not be used for Medicare.
X5
State Industrial Accident Provider Number
Reference Identification
C
AN
1/30
Required
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Rendering Provider Secondary Identifier
NSF Reference: FA0-58.0
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. Required when a secondary identification number is necessary to identify the entity. The primary identification
number should be carried in NM109 in this loop.
Example:
REF*1D*A12345~
837P_CG.ecs
514
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Loop Purchased Service Provider
Name
Pos: 250
Repeat: 1
Optional
Loop:
2310C
Elements: N/A
User Option (Usage): Situational
Purpose: To supply the full name of an individual or organizational entity
Loop Summary:
Pos
Id
Segment Name
250
271
NM1
REF
Purchased Service Provider Name
Purchased Service Provider Secondary
Identification
Req
Max Use
O
O
1
5
Repeat
Usage
Situational
Situational
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
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.
2. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,
then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.
3. Required if purchased services are being billed/reported on this claim. Purchased services are situations where
(for example) a physician purchases a diagnostic exam from an outside entity. Purchased services do not include
substitute (locum tenens) provider situations. All payer-specific identifying numbers belong to the destination
payer identified in the 2010BB loop.
Example:
NM1*QB*2******FI*111223333~
User Note 6:
To indicate Self Referral for Point of Service (POS)
For Professional EDI claims
Loop 2310A SELF REFERRAL to NM103 and
Submit REF segment in 2310A Loop, with “1B” in REF01 and “SLF000” as REF02
NM102 = 2
NM103 = SELFREFERRAL
Sample NM1*DN*2*SELFREFERRAL*****XX*1002233777~
REF*1B*SLF000~
837P_CG.ecs
515
For internal use only
12/1/2010
Health Care Claim: Professional - 837
NM1 Purchased Service Provider
Name
Pos: 250
Max: 1
Detail - Optional
Loop:
2310C
Elements: 7
User Option (Usage): Situational
Purpose: To supply the full name of an individual or organizational entity
Element Summary:
Ref
Id
Element Name
NM101
98
Entity Identifier Code
Req
Type
Min/Max
Usage
M
ID
2/3
Required
Description: Code identifying an organizational entity, a physical location, property or an
individual
CodeList Summary (Total Codes: 1312, Included: 1)
Code Name
QB
NM102
1065
Purchase Service Provider
Entity Type Qualifier
M
ID
1/1
Required
AN
1/35
Required
Description: Code qualifying the type of entity
CodeList Summary (Total Codes: 14, Included: 2)
Code Name
1
2
NM103
1035
Person
Non-Person Entity
Name Last or Organization Name
O
Description: Individual last name or organizational name
NM104
1036
Name First
O
AN
1/25
Situational
O
AN
1/25
Situational
Description: Individual first name
Required if NM102 = 1.
NM105
1037
Name Middle
Description: Individual middle name or initial
Required if NM102=1 and the middle name/initial of the person is known.
NM108
66
Identification Code Qualifier
C
ID
1/2
Situational
Description: Code designating the system/method of code structure used for Identification
Code (67)
Required if either Employer’s Identification/Social Security Number or National Provider
Identifier is known.
CodeList Summary (Total Codes: 215, Included: 3)
Code Name
24
34
XX
NM109
67
Employer's Identification Number
Social Security Number
Health Care Financing Administration National Provider Identifier
Identification Code
C
AN
2/80
Situational
Description: Code identifying a party or other code
837P_CG.ecs
516
For internal use only
12/1/2010
Ref
Health Care Claim: Professional - 837
Id
Element Name
Req
Industry: Purchased Service Provider Identifier
Type
Min/Max
Usage
Alias: Purchased Service Provider Primary Identifier
NSF Reference: FB0-11.0
Required if either Employer’s Identification/Social Security Number or National Provider
Identifier is known.
ExternalCodeList
Name: 537
Description: Health Care Financing Administration National Provider Identifier
Syntax Rules:
1. P0809 - If either NM108 or NM109 is present, then the other is required.
2. C1110 - If NM111 is present, then NM110 is required.
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
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.
2. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,
then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.
3. Required if purchased services are being billed/reported on this claim. Purchased services are situations where
(for example) a physician purchases a diagnostic exam from an outside entity. Purchased services do not include
substitute (locum tenens) provider situations. All payer-specific identifying numbers belong to the destination
payer identified in the 2010BB loop.
Example:
NM1*QB*2******FI*111223333~
837P_CG.ecs
517
For internal use only
12/1/2010
Health Care Claim: Professional - 837
REF Purchased Service Provider
Secondary Identification
Pos: 271
Max: 5
Detail - Optional
Loop:
2310C
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 14)
Code Name
REF02
127
0B
1A
1B
1C
1D
1G
1H
EI
G2
LU
N5
SY
State License Number
Blue Cross Provider Number
Blue Shield Provider Number
Medicare Provider Number
Medicaid Provider Number
Provider UPIN Number
CHAMPUS Identification Number
Employer's Identification Number
Provider Commercial Number
Location Number
Provider Plan Network Identification Number
Social Security Number
The social security number may not be used for Medicare.
U3
X5
Unique Supplier Identification Number (USIN)
State Industrial Accident Provider Number
Reference Identification
C
AN
1/30
Required
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Purchased Service Provider Secondary Identifier
NSF Reference: FB0-11.0
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. Required when a secondary identification number is necessary to identify the entity. The primary identification
number should be carried in NM108/9 in this loop.
Example:
REF*1D*A12345~
837P_CG.ecs
518
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 250
Loop Service Facility Location
Repeat: 1
Optional
Loop:
2310D
Elements: N/A
User Option (Usage): Situational
Purpose: To supply the full name of an individual or organizational entity
Loop Summary:
Pos
Id
Segment Name
Req
Max Use
250
265
270
271
NM1
N3
N4
REF
Service Facility
Service Facility
Service Facility
Service Facility
Identification
O
O
O
O
1
1
1
5
Location
Location Address
Location City/State/ZIP
Location Secondary
Repeat
Usage
Situational
Required
Required
Situational
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
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.
2. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,
then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.
3. This loop is required when the location of health care service is different than that carried in the 2010AA (Billing
Provider) or 2010AB (Pay-to Provider) loops.
4. Required if the service was rendered in a Health Professional Shortage Area (QB or QU modifier billed) and the
place of service is different than the HPSA billing address.
5. The purpose of this loop is to identify specifically where the service was rendered. In cases where it was
rendered at the patient’s home, do not use this loop. In that case, the place of service code in CLM05- 1 should
indicate that the service occurred in the patient’s home.
Example:
NM1*TL*2*A-OK MOBILE CLINIC*****24*11122333~
837P_CG.ecs
519
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 250
NM1 Service Facility Location
Max: 1
Detail - Optional
Loop:
2310D
Elements: 5
User Option (Usage): Situational
Purpose: To supply the full name of an individual or organizational entity
Element Summary:
Ref
Id
Element Name
NM101
98
Entity Identifier Code
Req
Type
Min/Max
Usage
M
ID
2/3
Required
Description: Code identifying an organizational entity, a physical location, property or an
individual
CodeList Summary (Total Codes: 1312, Included: 4)
Code Name
NM102
1065
77
Service Location
Use when other codes in this element do not apply.
FA
LI
TL
Facility
Independent Lab
Testing Laboratory
Entity Type Qualifier
M
ID
1/1
Required
AN
1/35
Situational
Description: Code qualifying the type of entity
CodeList Summary (Total Codes: 14, Included: 1)
Code Name
2
NM103
1035
Non-Person Entity
Name Last or Organization Name
O
Description: Individual last name or organizational name
Industry: Laboratory or Facility Name
Alias: Laboratory/Facility Name
NSF Reference: EA0-39.0
Required except when service was rendered in the patient’s home.
NM108
66
Identification Code Qualifier
C
ID
1/2
Situational
Description: Code designating the system/method of code structure used for Identification
Code (67)
Required if either Employer’s Identification/Social Security Number or National Provider
Identifier is known.
CodeList Summary (Total Codes: 215, Included: 3)
Code Name
24
34
XX
NM109
67
Employer's Identification Number
Social Security Number
Health Care Financing Administration National Provider Identifier
Identification Code
C
AN
2/80
Situational
Description: Code identifying a party or other code
837P_CG.ecs
520
For internal use only
12/1/2010
Ref
Health Care Claim: Professional - 837
Id
Element Name
Req
Industry: Laboratory or Facility Primary Identifier
Type
Min/Max
Usage
Alias: Laboratory/Facility Primary Identifier
NSF Reference: EA1-04.0, EA0-53.0
Required if either Employer’s Identification/Social Security Number or National Provider
Identifier is known.
ExternalCodeList
Name: 537
Description: Health Care Financing Administration National Provider Identifier
Syntax Rules:
1. P0809 - If either NM108 or NM109 is present, then the other is required.
2. C1110 - If NM111 is present, then NM110 is required.
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
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.
2. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,
then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.
3. This loop is required when the location of health care service is different than that carried in the 2010AA (Billing
Provider) or 2010AB (Pay-to Provider) loops.
4. Required if the service was rendered in a Health Professional Shortage Area (QB or QU modifier billed) and the
place of service is different than the HPSA billing address.
5. The purpose of this loop is to identify specifically where the service was rendered. In cases where it was
rendered at the patient’s home, do not use this loop. In that case, the place of service code in CLM05- 1 should
indicate that the service occurred in the patient’s home.
Example:
NM1*TL*2*A-OK MOBILE CLINIC*****24*11122333~
837P_CG.ecs
521
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 265
N3 Service Facility Location
Max: 1
Detail - Optional
Address
Loop:
2310D
Elements: 2
User Option (Usage): Required
Purpose: To specify the location of the named party
Element Summary:
Ref
Id
Element Name
N301
166
Address Information
Req
Type
Min/Max
Usage
M
AN
1/55
Required
O
AN
1/55
Situational
Description: Address information
Industry: Laboratory or Facility Address Line
Alias: Laboratory/Facility Address 1
NSF Reference: EA1-06.0
N302
166
Address Information
Description: Address information
Industry: Laboratory or Facility Address Line
Alias: Laboratory/Facility Address 2
NSF Reference: EA1-07.0
Required if a second address line exists.
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 (e.g., “crossroad of State Road 34 and 45" or ”Exit near Mile marker 265 on Interstate 80".)
Example:
N3*123 MAIN STREET~
837P_CG.ecs
522
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 270
N4 Service Facility Location
Max: 1
Detail - Optional
City/State/ZIP
Loop:
2310D
Elements: 4
User Option (Usage): Required
Purpose: To specify the geographic place of the named party
Element Summary:
Ref
Id
Element Name
N401
19
City Name
Req
Type
Min/Max
Usage
O
AN
2/30
Required
O
ID
2/2
Required
Description: Free-form text for city name
Industry: Laboratory or Facility City Name
Alias: Laboratory/Facility City
NSF Reference: EA1-08.0
N402
156
State or Province Code
Description: Code (Standard State/Province) as defined by appropriate government
agency
Industry: Laboratory or Facility State or Province Code
Alias: Laboratory/Facility State
CODE SOURCE: 22: States and Outlying Areas of the U.S.
NSF Reference: EA1-09.0
ExternalCodeList
Name: 22
Description: States and Outlying Areas of the U.S.
N403
116
Postal Code
O
ID
3/15
Required
Description: Code defining international postal zone code excluding punctuation and
blanks (zip code for United States)
Industry: Laboratory or Facility Postal Zone or ZIP Code
Alias: Laboratory/Facility Zip Code
CODE SOURCE: 51: ZIP Code
NSF Reference: EA1-10.0
ExternalCodeList
Name: 51
Description: ZIP Code
N404
26
Country Code
O
ID
2/3
Situational
Description: Code identifying the country
Alias: Laboratory/Facility Country Code
CODE SOURCE: 5: Countries, Currencies and Funds
Required if the address is out of the U.S.
ExternalCodeList
Name: 5
Description: Countries, Currencies and Funds
837P_CG.ecs
523
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Syntax Rules:
1. C0605 - If N406 is present, then N405 is required.
Comments:
1. A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
2. N402 is required only if city name (N401) is in the U.S. or Canada.
Notes:
1. If service facility location is in an area where there are no street addresses, enter the name of the nearest town,
state and zip of where the service was rendered.
Example:
N4*ANY TOWN*TX*75123~
837P_CG.ecs
524
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 271
REF Service Facility Location
Max: 5
Detail - Optional
Secondary Identification
Loop:
2310D
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
1/30
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 13)
Code Name
0B
1A
1B
1C
1D
1G
1H
G2
LU
N5
TJ
X4
X5
REF02
127
State License Number
Blue Cross Provider Number
Blue Shield Provider Number
Medicare Provider Number
Medicaid Provider Number
Provider UPIN Number
CHAMPUS Identification Number
Provider Commercial Number
Location Number
Provider Plan Network Identification Number
Federal Taxpayer's Identification Number
Clinical Laboratory Improvement Amendment Number
State Industrial Accident Provider Number
Reference Identification
C
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Laboratory or Facility Secondary Identifier
Alias: Laboratory/Facility Secondary Identification Number
NSF Reference: EA1-04.0, EA0-53.0
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. Required when a secondary identification number is necessary to identify the entity. The primary identification
number should be carried in NM109 in this loop.
Example:
REF*1D*A12345~
837P_CG.ecs
525
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 250
Loop Supervising Provider Name
Repeat: 1
Optional
Loop:
2310E
Elements: N/A
User Option (Usage): Situational
Purpose: To supply the full name of an individual or organizational entity
Loop Summary:
Pos
Id
Segment Name
250
271
NM1
REF
Supervising Provider Name
Supervising Provider Secondary
Identification
Req
Max Use
O
O
1
5
Repeat
Usage
Situational
Situational
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
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.
2. Required when the rendering provider is supervised by a physician.
3. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,
then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.
Example:
NM1*DQ*1*KILLIAN*BART*B**II*24*222334444~
837P_CG.ecs
526
For internal use only
12/1/2010
Health Care Claim: Professional - 837
NM1 Supervising Provider Name
Pos: 250
Max: 1
Detail - Optional
Loop:
2310E
Elements: 8
User Option (Usage): Situational
Purpose: To supply the full name of an individual or organizational entity
Element Summary:
Ref
Id
Element Name
NM101
98
Entity Identifier Code
Req
Type
Min/Max
Usage
M
ID
2/3
Required
Description: Code identifying an organizational entity, a physical location, property or an
individual
CodeList Summary (Total Codes: 1312, Included: 1)
Code Name
DQ
NM102
1065
Supervising Physician
Entity Type Qualifier
M
ID
1/1
Required
AN
1/35
Required
Description: Code qualifying the type of entity
CodeList Summary (Total Codes: 14, Included: 1)
Code Name
1
NM103
1035
Person
Name Last or Organization Name
O
Description: Individual last name or organizational name
Industry: Supervising Provider Last Name
NSF Reference: EA1-18.0
NM104
1036
Name First
O
AN
1/25
Required
O
AN
1/25
Situational
Description: Individual first name
Industry: Supervising Provider First Name
NSF Reference: EA1-19.0
NM105
1037
Name Middle
Description: Individual middle name or initial
Industry: Supervising Provider Middle Name
NSF Reference: EA1-20.0
Required if NM102=1 and the middle name/initial of the person is known.
NM107
1039
Name Suffix
O
AN
1/10
Situational
C
ID
1/2
Situational
Description: Suffix to individual name
Industry: Supervising Provider Name Suffix
Alias: Supervising Provider Generation
Required if known.
NM108
66
Identification Code Qualifier
Description: Code designating the system/method of code structure used for Identification
837P_CG.ecs
527
For internal use only
12/1/2010
Ref
Health Care Claim: Professional - 837
Id
Element Name
Req
Type
Min/Max
Usage
Code (67)
Required if either Employer’s Identification/Social Security Number or National Provider
Identifier is known.
CodeList Summary (Total Codes: 215, Included: 3)
Code Name
NM109
67
24
34
Employer's Identification Number
Social Security Number
The social security number may not be used for Medicare.
XX
Health Care Financing Administration National Provider Identifier
Identification Code
C
AN
2/80
Situational
Description: Code identifying a party or other code
Industry: Supervising Provider Identifier
Alias: Supervising Provider Primary Identifier
NSF Reference: EA1-16.0
Required if either Employer’s Identification/Social Security Number or National Provider
Identifier is known.
ExternalCodeList
Name: 537
Description: Health Care Financing Administration National Provider Identifier
Syntax Rules:
1. P0809 - If either NM108 or NM109 is present, then the other is required.
2. C1110 - If NM111 is present, then NM110 is required.
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
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.
2. Required when the rendering provider is supervised by a physician.
3. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,
then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.
Example:
NM1*DQ*1*KILLIAN*BART*B**II*24*222334444~
837P_CG.ecs
528
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 271
REF Supervising Provider
Max: 5
Detail - Optional
Secondary Identification
Loop:
2310E
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 12)
Code Name
REF02
127
0B
1B
1C
1D
1G
1H
EI
G2
LU
N5
SY
State License Number
Blue Shield Provider Number
Medicare Provider Number
Medicaid Provider Number
Provider UPIN Number
CHAMPUS Identification Number
Employer's Identification Number
Provider Commercial Number
Location Number
Provider Plan Network Identification Number
Social Security Number
The social security number may not be used for Medicare.
X5
State Industrial Accident Provider Number
Reference Identification
C
AN
1/30
Required
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Supervising Provider Secondary Identifier
NSF Reference: EA1-16.0
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. Required when a secondary identification number is necessary to identify the entity. The primary identification
number should be carried in NM108/9 in this loop.
Example:
REF*1D*A12345~
837P_CG.ecs
529
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Loop Other Subscriber Information
Pos: 290
Repeat: 10
Optional
Loop: 2320 Elements: N/A
User Option (Usage): Situational
Purpose: To record information specific to the primary insured and the insurance carrier for that insured
Loop Summary:
Pos
Id
Segment Name
290
295
300
SBR
CAS
AMT
300
AMT
300
AMT
300
AMT
300
AMT
300
AMT
300
AMT
300
AMT
300
AMT
300
AMT
305
310
320
DMG
OI
MOA
Other Subscriber Information
Claim Level Adjustments
Coordination of Benefits (COB) Payer Paid
Amount
Coordination of Benefits (COB) Approved
Amount
Coordination of Benefits (COB) Allowed
Amount
Coordination of Benefits (COB) Patient
Responsibility Amount
Coordination of Benefits (COB) Covered
Amount
Coordination of Benefits (COB) Discount
Amount
Coordination of Benefits (COB) Per Day
Limit Amount
Coordination of Benefits (COB) Patient
Paid Amount
Coordination of Benefits (COB) Tax
Amount
Coordination of Benefits (COB) Total Claim
Before Taxes Amount
Subscriber Demographic Information
Other Insurance Coverage Information
Medicare Outpatient Adjudication
Information
Loop 2330A
Loop 2330B
Loop 2330C
Loop 2330D
Loop 2330E
Loop 2330F
Loop 2330G
Loop 2330H
325
325
325
325
325
325
325
325
Req
Max Use
O
O
O
1
5
1
Situational
Situational
Situational
O
1
Situational
O
1
Situational
O
1
Situational
O
1
Situational
O
1
Situational
O
1
Situational
O
1
Situational
O
1
Situational
O
1
Situational
O
O
O
1
1
1
Situational
Required
Situational
O
O
O
O
O
O
O
O
Repeat
1
1
1
2
1
1
1
1
Usage
Required
Required
Situational
Situational
Situational
Situational
Situational
Situational
Semantics:
1.
2.
3.
4.
SBR02 specifies the relationship to the person insured.
SBR03 is policy or group number.
SBR04 is plan name.
SBR07 is destination payer code. A "Y" value indicates the payer is the destination payer; an "N" value
indicates the payer is not the destination payer.
837P_CG.ecs
530
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Notes:
1. Required if other payers are known to potentially be involved in paying on this claim.
2. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,
then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.
3. 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, run the 2320 Loop again with it’s respective 2330 Loops.
See Section 1.4.4 for more information on handling COB.
4. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.
Example:
SBR*S*01*GR00786**MC****OF~
837P_CG.ecs
531
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 290
SBR Other Subscriber
Max: 1
Detail - Optional
Information
Loop: 2320
Elements: 6
User Option (Usage): Situational
Purpose: To record information specific to the primary insured and the insurance carrier for that insured
Element Summary:
Ref
Id
Element Name
SBR01
1138
Payer Responsibility Sequence Number
Code
Req
Type
Min/Max
Usage
M
ID
1/1
Required
Description: Code identifying the insurance carrier's level of responsibility for a payment
of a claim
Alias: Payer responsibility sequence number code
NSF Reference: DA0-02.0, DA1-02.0, DA2-02.0
CodeList Summary (Total Codes: 6, Included: 3)
Code Name
P
S
T
SBR02
1069
Primary
Secondary
Tertiary
Individual Relationship Code
O
ID
2/2
Required
Description: Code indicating the relationship between two individuals or entities
Alias: Individual relationship code
NSF Reference: DA0-17.0
CodeList Summary (Total Codes: 153, Included: 24)
Code Name
01
04
05
07
10
15
17
18
19
20
21
22
23
24
29
32
33
36
39
837P_CG.ecs
Spouse
Grandfather or Grandmother
Grandson or Granddaughter
Nephew or Niece
Foster Child
Ward
Stepson or Stepdaughter
Self
Child
Employee
Unknown
Handicapped Dependent
Sponsored Dependent
Dependent of a Minor Dependent
Significant Other
Mother
Father
Emancipated Minor
Organ Donor
532
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Code Name
40
41
43
53
G8
SBR03
127
Cadaver Donor
Injured Plaintiff
Child Where Insured Has No Financial Responsibility
Life Partner
Other Relationship
Reference Identification
O
AN
1/30
Situational
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Insured Group or Policy Number
Alias: Group or Policy Number
NSF Reference: DA0-10.0
Required if the subscriber’s payer identification includes Group or Plan Number. This data
element is intended to carry the subscriber’s Group Number, not the number that uniquely
identifies the subscriber (Subscriber ID, Loop 2010BA-NM109).
SBR04
93
Name
O
AN
1/60
Situational
Description: Free-form name
Industry: Other Insured Group Name
Alias: Group or Plan Name
NSF Reference: DA0-11.0
Required if the subscriber’s payer identification includes a Group or Plan Name.
SBR05
1336
Insurance Type Code
O
ID
1/3
Required
Description: Code identifying the type of insurance policy within a specific insurance
program
Alias: Insurance type code
NSF Reference: DA0-06.0
CodeList Summary (Total Codes: 45, Included: 15)
Code Name
AP
C1
CP
GP
HM
IP
LD
LT
MB
MC
MI
MP
OT
PP
SP
SBR09
837P_CG.ecs
1032
Auto Insurance Policy
Commercial
Medicare Conditionally Primary
Group Policy
Health Maintenance Organization (HMO)
Individual Policy
Long Term Policy
Litigation
Medicare Part B
Medicaid
Medigap Part B
Medicare Primary
Other
Personal Payment (Cash - No Insurance)
Supplemental Policy
Claim Filing Indicator Code
O
533
ID
1/2
Situational
For internal use only
12/1/2010
Ref
Health Care Claim: Professional - 837
Id
Element Name
Req
Type
Min/Max
Usage
Description: Code identifying type of claim
Alias: Claim filing indicator code
NSF Reference: DA0-05.0
Required prior to mandated used of PlanID. Not used after PlanID is mandated.
CodeList Summary (Total Codes: 45, Included: 23)
Code Name
09
10
Self-pay
Central Certification
NSF Reference:
CA0-23.0 (K), DA0-05.0 (K)
11
12
13
14
15
16
AM
BL
CH
CI
DS
HM
LI
LM
MB
MC
OF
TV
VA
Other Non-Federal Programs
Preferred Provider Organization (PPO)
Point of Service (POS)
Exclusive Provider Organization (EPO)
Indemnity Insurance
Health Maintenance Organization (HMO) Medicare Risk
Automobile Medical
Blue Cross/Blue Shield
Champus
Commercial Insurance Co.
Disability
Health Maintenance Organization
Liability
Liability Medical
Medicare Part B
Medicaid
Other Federal Program
Title V
Veteran Administration Plan
Refers to Veterans Affairs Plan.
WC
ZZ
Workers' Compensation Health Claim
Mutually Defined
Unknown
Semantics:
1.
2.
3.
4.
SBR02 specifies the relationship to the person insured.
SBR03 is policy or group number.
SBR04 is plan name.
SBR07 is destination payer code. A "Y" value indicates the payer is the destination payer; an "N" value
indicates the payer is not the destination payer.
Notes:
1. Required if other payers are known to potentially be involved in paying on this claim.
2. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,
then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.
3. 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
837P_CG.ecs
534
For internal use only
12/1/2010
Health Care Claim: Professional - 837
carried, run the 2320 Loop again with it’s respective 2330 Loops.
See Section 1.4.4 for more information on handling COB.
4. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.
Example:
SBR*S*01*GR00786**MC****OF~
837P_CG.ecs
535
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 295
CAS Claim Level Adjustments
Max: 5
Detail - Optional
Loop: 2320
Elements: 19
User Option (Usage): Situational
Purpose: To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service
within the claim being paid
Element Summary:
Ref
Id
Element Name
CAS01
1033
Claim Adjustment Group Code
Req
Type
Min/Max
Usage
M
ID
1/2
Required
Description: Code identifying the general category of payment adjustment
Alias: Claim Adjustment Group Code
CodeList Summary (Total Codes: 8, Included: 5)
Code Name
CO
CR
OA
PI
PR
CAS02
1034
Contractual Obligations
Correction and Reversals
Other adjustments
Payor Initiated Reductions
Patient Responsibility
Claim Adjustment Reason Code
M
ID
1/5
Required
Description: Code identifying the detailed reason the adjustment was made
Industry: Adjustment Reason Code
Alias: Adjustment Reason Code - Claim Level
CODE SOURCE: 139: Claim Adjustment Reason Code
NSF Reference: DA3-04.0, DA3-06.0, DA3-08.0, DA3-10.0, DA3-12.0, DA3-14.0,
DA3-16.0, DA1-16.0, DA1-30.0
ExternalCodeList
Name: 139
Description: Claim Adjustment Reason Code
CAS03
782
Monetary Amount
M
R
1/18
Required
Description: Monetary amount
Industry: Adjustment Amount
Alias: Adjusted Amount - Claim Level
NSF Reference: DA1-09.0, DA1-10.0, DA1-11.0, DA1-12.0, DA1-13.0, DA3-05.0,
DA3-07.0, DA3-09.0, DA3-11.0, DA3-13.0, DA3-15.0, DA3-17.0, DA1-30.0, DA1-33.0,
DA3-25.0, DA3-26.0
CAS04
380
Quantity
O
R
1/15
Situational
C
ID
1/5
Situational
Description: Numeric value of quantity
Industry: Adjustment Quantity
Alias: Adjusted Units - Claim Level
Use as needed to show payer adjustment.
CAS05
837P_CG.ecs
1034
Claim Adjustment Reason Code
536
For internal use only
12/1/2010
Ref
Health Care Claim: Professional - 837
Id
Element Name
Req
Type
Min/Max
Usage
Description: Code identifying the detailed reason the adjustment was made
Industry: Adjustment Reason Code
Alias: Adjustment Reason Code - Claim Level
CODE SOURCE: 139: Claim Adjustment Reason Code
NSF Reference: DA3-04.0, DA3-06.0, DA3-08.0, DA3-10.0, DA3-12.0, DA3-14.0,
DA3-16.0, DA1-17.0, DA1-30.0
Use as needed to show payer adjustment.
ExternalCodeList
Name: 139
Description: Claim Adjustment Reason Code
CAS06
782
Monetary Amount
C
R
1/18
Situational
Description: Monetary amount
Industry: Adjustment Amount
Alias: Adjusted Amount - Claim Level
NSF Reference: DA3-05.0, DA3-07.0, DA3-09.0, DA3-11.0, DA3-13.0, DA3-15.0,
DA3-17.0, DA1-30.0, DA1-33.0, DA3-25.0, DA3-26.0
Use as needed to show payer adjustment.
CAS07
380
Quantity
C
R
1/15
Situational
C
ID
1/5
Situational
Description: Numeric value of quantity
Industry: Adjustment Quantity
Alias: Adjusted Units - Claim Level
Use as needed to show payer adjustment.
CAS08
1034
Claim Adjustment Reason Code
Description: Code identifying the detailed reason the adjustment was made
Industry: Adjustment Reason Code
Alias: Adjustment Reason Code - Claim Level
CODE SOURCE: 139: Claim Adjustment Reason Code
NSF Reference: DA3-04.0, DA3-06.0, DA3-08.0, DA3-10.0, DA3-12.0, DA3-14.0,
DA3-16.0, DA1-30.0, DA1-18.0
Use as needed to show payer adjustment.
ExternalCodeList
Name: 139
Description: Claim Adjustment Reason Code
CAS09
782
Monetary Amount
C
R
1/18
Situational
Description: Monetary amount
Industry: Adjustment Amount
Alias: Adjusted Amount - Claim Level
NSF Reference: DA3-05.0, DA3-07.0, DA3-09.0, DA3-11.0, DA3-13.0, DA3-15.0, DA3-17.
0, DA1-30.0, DA1-33.0, DA3-25.0, DA3-26.0
Use as needed to show payer adjustment.
837P_CG.ecs
537
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Ref
Id
Element Name
CAS10
380
Quantity
Req
Type
Min/Max
Usage
C
R
1/15
Situational
C
ID
1/5
Situational
Description: Numeric value of quantity
Industry: Adjustment Quantity
Alias: Adjusted Units - Claim Level
Use as needed to show payer adjustment.
CAS11
1034
Claim Adjustment Reason Code
Description: Code identifying the detailed reason the adjustment was made
Industry: Adjustment Reason Code
Alias: Adjustment Reason Code - Claim Level
CODE SOURCE: 139: Claim Adjustment Reason Code
NSF Reference: DA3-04.0, DA3-06.0, DA3-08.0, DA3-10.0, DA3-12.0, DA3-14.0,
DA3-16.0, DA1-30.0
Use as needed to show payer adjustment.
ExternalCodeList
Name: 139
Description: Claim Adjustment Reason Code
CAS12
782
Monetary Amount
C
R
1/18
Situational
Description: Monetary amount
Industry: Adjustment Amount
Alias: Adjusted Amount - Claim Level
NSF Reference: DA3-05.0, DA3-07.0, DA3-09.0, DA3-11.0, DA3-13.0, DA3-15.0,
DA3-17.0, DA1-30.0, DA1-33.0, DA3-25.0, DA3-26.0
Use as needed to show payer adjustment.
CAS13
380
Quantity
C
R
1/15
Situational
C
ID
1/5
Situational
Description: Numeric value of quantity
Industry: Adjustment Quantity
Alias: Adjusted Units - Claim Level
Use as needed to show payer adjustment.
CAS14
1034
Claim Adjustment Reason Code
Description: Code identifying the detailed reason the adjustment was made
Industry: Adjustment Reason Code
Alias: Adjustment Reason Code - Claim Level
CODE SOURCE: 139: Claim Adjustment Reason Code
NSF Reference: DA3-04.0, DA3-06.0, DA3-08.0, DA3-10.0, DA3-12.0, DA3-14.0,
DA3-16.0, DA1-30.0
Use as needed to show payer adjustment.
ExternalCodeList
Name: 139
Description: Claim Adjustment Reason Code
CAS15
837P_CG.ecs
782
Monetary Amount
C
538
R
1/18
Situational
For internal use only
12/1/2010
Ref
Health Care Claim: Professional - 837
Id
Element Name
Req
Type
Min/Max
Usage
Description: Monetary amount
Industry: Adjustment Amount
Alias: Adjusted Amount - Claim Level
NSF Reference: DA3-05.0, DA3-07.0, DA3-09.0, DA3-11.0, DA3-13.0, DA3-15.0,
DA3-17.0, DA1-30.0, DA1-33.0, DA3-25.0, DA3-26.0
Use as needed to show payer adjustment.
CAS16
380
Quantity
C
R
1/15
Situational
C
ID
1/5
Situational
Description: Numeric value of quantity
Industry: Adjustment Quantity
Alias: Adjusted Units - Claim Level
Use as needed to show payer adjustment.
CAS17
1034
Claim Adjustment Reason Code
Description: Code identifying the detailed reason the adjustment was made
Industry: Adjustment Reason Code
Alias: Adjustment Reason Code - Claim Level
CODE SOURCE: 139: Claim Adjustment Reason Code
NSF Reference: DA3-04.0, DA3-06.0, DA3-08.0, DA3-10.0, DA3-12.0, DA3-14.0,
DA3-16.0, DA1-30.0
Use as needed to show payer adjustment.
ExternalCodeList
Name: 139
Description: Claim Adjustment Reason Code
CAS18
782
Monetary Amount
C
R
1/18
Situational
Description: Monetary amount
Industry: Adjustment Amount
Alias: Adjusted Amount - Claim Level
NSF Reference: DA3-05.0, DA3-07.0, DA3-09.0, DA3-11.0, DA3-13.0, DA3-15.0,
DA3-17.0, DA1-30.0, DA1-33.0, DA3-25.0, DA3-26.0
Use as needed to show payer adjustment.
CAS19
380
Quantity
C
R
1/15
Situational
Description: Numeric value of quantity
Industry: Adjustment Quantity
Alias: Adjusted Units - Claim Level
Use as needed to show payer adjustment.
Syntax Rules:
1.
2.
3.
4.
5.
6.
L050607 - If CAS05 is present, then at least one of CAS06 or CAS07 is required.
C0605 - If CAS06 is present, then CAS05 is required.
C0705 - If CAS07 is present, then CAS05 is required.
L080910 - If CAS08 is present, then at least one of CAS09 or CAS10 is required.
C0908 - If CAS09 is present, then CAS08 is required.
C1008 - If CAS10 is present, then CAS08 is required.
837P_CG.ecs
539
For internal use only
12/1/2010
7.
8.
9.
10.
11.
12.
13.
14.
15.
Health Care Claim: Professional - 837
L111213 - If CAS11 is present, then at least one of CAS12 or CAS13 is required.
C1211 - If CAS12 is present, then CAS11 is required.
C1311 - If CAS13 is present, then CAS11 is required.
L141516 - If CAS14 is present, then at least one of CAS15 or CAS16 is required.
C1514 - If CAS15 is present, then CAS14 is required.
C1614 - If CAS16 is present, then CAS14 is required.
L171819 - If CAS17 is present, then at least one of CAS18 or CAS19 is required.
C1817 - If CAS18 is present, then CAS17 is required.
C1917 - If CAS19 is present, then CAS17 is required.
Semantics:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
CAS03
CAS04
CAS06
CAS07
CAS09
CAS10
CAS12
CAS13
CAS15
CAS16
CAS18
CAS19
is
is
is
is
is
is
is
is
is
is
is
is
the amount of adjustment.
the units of service being adjusted.
the amount of the adjustment.
the units of service being adjusted.
the amount of the adjustment.
the units of service being adjusted.
the amount of the adjustment.
the units of service being adjusted.
the amount of the adjustment.
the units of service being adjusted.
the amount of the adjustment.
the units of service being adjusted.
Comments:
1. Adjustment information is intended to help the provider balance the remittance information. Adjustment
amounts should fully explain the difference between submitted charges and the amount paid.
2. When the submitted charges are paid in full, the value for CAS03 should be zero.
Notes:
1. Submitters should 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.
3. Codes and associated amounts should come from 835s (Remittance Advice) received on the claim. If no
previous payments have been made, omit this segment.
4. Required if claim has been adjudicated by payer identified in this loop and has claim level adjustment
information.
5. To locate the claim adjustment group codes (CAS01) and claim adjustment reason codes (CAS02, 05, 08, 11,
14, and 17) see the Washington Publishing Company web site: http://www.wpc-edi.com. Follow the buttons to
Code Lists - Claim Adjustment Reason Codes.
6. There several NSF fields which are not directly crosswalked from the 837 to NSF, particularly with respect to
payer-to-payer COB situations. Below is a list of some of these NSF fields and some suggestions regarding how
to handle them in the 837. Provider Adjustment Amt (DA3-25.0). This would equal the sum of all the adjustment
amounts in CAS03, 06, 09, 12, 15, and 18 at both the claim and the line level. See the 835 for how to balance the
CAS adjustments against the total billed amount. Beneficiary liability amount (FA0-53.0) This amount would equal
the sum of all the adjustment amounts in CAS03, 06, 09, 12, 15, and 18 at both the claim and the line level when
CAS01 = PR (patient responsibility).
Amount paid to Provider (DA1-33.0). This would be calculated through the use of the CAS codes. Please see the
detail on the codes and the discussion of how to use them in the 835 implementation guide. Balance bill limit
charge (FA0-54.0). This would equal any CAS adjustment where CAS01=CO and one of the adjustment reason
code elements equaled “45".
Beneficiary Adjustment Amt (DA3-26.0) Amount paid to beneficiary (DA1-30.0)). The amount paid to the
837P_CG.ecs
540
For internal use only
12/1/2010
Health Care Claim: Professional - 837
beneficiary is indicated by the use of CAS code ”100 - Payment made to patient/insured/responsible party."
Original Paid Amount (DA3-28.0): The original paid amount can be calculated from the original COB claim by
subtracting all claim adjustments carried in the claim and line level CAS from the original billed amount.
Example:
CAS*PR*1*7.93~
CAS*OA*93*15.06~
837P_CG.ecs
541
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 300
AMT Coordination of Benefits
Max: 1
Detail - Optional
(COB) Payer Paid Amount
Loop: 2320
Elements: 2
User Option (Usage): Situational
Purpose: To indicate the total monetary amount
Element Summary:
Ref
Id
Element Name
AMT01
522
Amount Qualifier Code
Req
Type
Min/Max
Usage
M
ID
1/3
Required
R
1/18
Required
Description: Code to qualify amount
CodeList Summary (Total Codes: 1473, Included: 1)
Code Name
D
AMT02
782
Payor Amount Paid
Monetary Amount
M
Description: Monetary amount
Industry: Payer Paid Amount
This is a crosswalk from CLP04 in 835 when doing COB.
Notes:
1. Required if claim has been adjudicated by payer identified in this loop. It is acceptable to show “0" amount paid.
Example:
AMT*D*411~
837P_CG.ecs
542
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 300
AMT Coordination of Benefits
Max: 1
Detail - Optional
(COB) Approved Amount
Loop: 2320
Elements: 2
User Option (Usage): Situational
Purpose: To indicate the total monetary amount
Element Summary:
Ref
Id
Element Name
AMT01
522
Amount Qualifier Code
Req
Type
Min/Max
Usage
M
ID
1/3
Required
R
1/18
Required
Description: Code to qualify amount
CodeList Summary (Total Codes: 1473, Included: 1)
Code Name
AAE
AMT02
782
Approved Amount
Monetary Amount
M
Description: Monetary amount
Industry: Approved Amount
NSF Reference: DA1-37.0
Notes:
1. Used primarily in payer-to-payer COB situations by the payer who is sending this claim to another payer.
Providers (in a provider-to-payer COB situation) do not usually complete this information but may do so if the
information is available.
2. The approved amount equals the amount for the total claim that was approved by the payer sending this 837 to
another payer.
Example:
AMT*AAE*500.35~
837P_CG.ecs
543
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 300
AMT Coordination of Benefits
Max: 1
Detail - Optional
(COB) Allowed Amount
Loop: 2320
Elements: 2
User Option (Usage): Situational
Purpose: To indicate the total monetary amount
Element Summary:
Ref
Id
Element Name
AMT01
522
Amount Qualifier Code
Req
Type
Min/Max
Usage
M
ID
1/3
Required
R
1/18
Required
Description: Code to qualify amount
CodeList Summary (Total Codes: 1473, Included: 1)
Code Name
B6
AMT02
782
Allowed - Actual
Monetary Amount
M
Description: Monetary amount
Industry: Allowed Amount
Notes:
1. Used primarily in payer-to-payer COB situations by the payer who is sending this claim to another payer.
Providers (in a provider-to-payer COB situation) do not usually complete this information but may do so if the
information is available.
2. The allowed amount equals the amount for the total claim that was allowed by the payer sending this 837 to
another payer.
Example:
AMT*B6*519.21~
837P_CG.ecs
544
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 300
AMT Coordination of Benefits
Max: 1
Detail - Optional
(COB) Patient Responsibility Loop: 2320
Amount
Elements: 2
User Option (Usage): Situational
Purpose: To indicate the total monetary amount
Element Summary:
Ref
Id
Element Name
AMT01
522
Amount Qualifier Code
Req
Type
Min/Max
Usage
M
ID
1/3
Required
R
1/18
Required
Description: Code to qualify amount
CodeList Summary (Total Codes: 1473, Included: 1)
Code Name
F2
AMT02
782
Patient Responsibility - Actual
Monetary Amount
M
Description: Monetary amount
Industry: Other Payer Patient Responsibility Amount
This is a crosswalk from CLP05 in 835 when doing COB.
Notes:
1. Required if patient is responsible for payment according to another payer’s adjudication. This is the amount of
money which is the responsibility of the patient according to the payer identified in this loop (2330B NM1).
Example:
AMT*F2*15~
837P_CG.ecs
545
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 300
AMT Coordination of Benefits
Max: 1
Detail - Optional
(COB) Covered Amount
Loop: 2320
Elements: 2
User Option (Usage): Situational
Purpose: To indicate the total monetary amount
Element Summary:
Ref
Id
Element Name
AMT01
522
Amount Qualifier Code
Req
Type
Min/Max
Usage
M
ID
1/3
Required
R
1/18
Required
Description: Code to qualify amount
CodeList Summary (Total Codes: 1473, Included: 1)
Code Name
AU
AMT02
782
Coverage Amount
Monetary Amount
M
Description: Monetary amount
Industry: Other Payer Covered Amount
This is a crosswalk from AMT in 835 (Loop CLP, position 062) when AMT01 = AU.
Notes:
1. Used primarily in payer-to-payer COB situations by the payer who is sending this claim to another payer.
Providers (in a provider-to-payer COB situation) do not usually complete this information but may do so if the
information is available.
2. The covered amount equals the amount for the total claim that was covered by the payer sending this 837 to
another payer.
Example:
AMT*AU*50~
837P_CG.ecs
546
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 300
AMT Coordination of Benefits
Max: 1
Detail - Optional
(COB) Discount Amount
Loop: 2320
Elements: 2
User Option (Usage): Situational
Purpose: To indicate the total monetary amount
Element Summary:
Ref
Id
Element Name
AMT01
522
Amount Qualifier Code
Req
Type
Min/Max
Usage
M
ID
1/3
Required
R
1/18
Required
Description: Code to qualify amount
CodeList Summary (Total Codes: 1473, Included: 1)
Code Name
D8
AMT02
782
Discount Amount
Monetary Amount
M
Description: Monetary amount
Industry: Other Payer Discount Amount
This is a crosswalk from AMT in 835 (Loop CLP, position 062) when AMT01 = D8.
Notes:
1. Required if claim has been adjudicated by the payer identified in this loop and if this information was included
in the remittance advice reporting those adjudication results.
Example:
AMT*D8*35~
837P_CG.ecs
547
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 300
AMT Coordination of Benefits
Max: 1
Detail - Optional
(COB) Per Day Limit Amount Loop: 2320
Elements: 2
User Option (Usage): Situational
Purpose: To indicate the total monetary amount
Element Summary:
Ref
Id
Element Name
AMT01
522
Amount Qualifier Code
Req
Type
Min/Max
Usage
M
ID
1/3
Required
R
1/18
Required
Description: Code to qualify amount
CodeList Summary (Total Codes: 1473, Included: 1)
Code Name
DY
AMT02
782
Per Day Limit
Monetary Amount
M
Description: Monetary amount
Industry: Other Payer Per Day Limit Amount
This is a crosswalk from AMT in 835 (Loop CLP, position 062) when AMT01 = DY.
Notes:
1. Required if claim has been adjudicated by the payer identified in this loop and if this information was included
in the remittance advice reporting those adjudication results.
Example:
AMT*DY*46~
837P_CG.ecs
548
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 300
AMT Coordination of Benefits
Max: 1
Detail - Optional
(COB) Patient Paid Amount
Loop: 2320
Elements: 2
User Option (Usage): Situational
Purpose: To indicate the total monetary amount
Element Summary:
Ref
Id
Element Name
AMT01
522
Amount Qualifier Code
Req
Type
Min/Max
Usage
M
ID
1/3
Required
R
1/18
Required
Description: Code to qualify amount
CodeList Summary (Total Codes: 1473, Included: 1)
Code Name
F5
AMT02
782
Patient Amount Paid
Monetary Amount
M
Description: Monetary amount
Industry: Other Payer Patient Paid Amount
This is a crosswalk from AMT in 835 (Loop CLP, position 062) when AMT01 = F5.
Notes:
1. Required if claim has been adjudicated by the payer identified in this loop and if this information was included
in the remittance advice reporting those adjudication results.
2. The amount carried in this segment is the total amount of money paid by the payer to the patient (rather than to
the provider) on this claim.
Example:
AMT*F5*152.45~
837P_CG.ecs
549
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 300
AMT Coordination of Benefits
Max: 1
Detail - Optional
(COB) Tax Amount
Loop: 2320
Elements: 2
User Option (Usage): Situational
Purpose: To indicate the total monetary amount
Element Summary:
Ref
Id
Element Name
AMT01
522
Amount Qualifier Code
Req
Type
Min/Max
Usage
M
ID
1/3
Required
R
1/18
Required
Description: Code to qualify amount
CodeList Summary (Total Codes: 1473, Included: 1)
Code Name
T
AMT02
782
Tax
Monetary Amount
M
Description: Monetary amount
Industry: Other Payer Tax Amount
This is a crosswalk from AMT in 835 (Loop CLP, position 062) when AMT01 = T.
Notes:
1. Required if claim has been adjudicated by the payer identified in this loop and if this information was included
in the remittance advice reporting those adjudication results.
Example:
AMT*T*45~
837P_CG.ecs
550
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 300
AMT Coordination of Benefits
Max: 1
Detail - Optional
(COB) Total Claim Before
Taxes Amount
Loop: 2320
Elements: 2
User Option (Usage): Situational
Purpose: To indicate the total monetary amount
Element Summary:
Ref
Id
Element Name
AMT01
522
Amount Qualifier Code
Req
Type
Min/Max
Usage
M
ID
1/3
Required
R
1/18
Required
Description: Code to qualify amount
CodeList Summary (Total Codes: 1473, Included: 1)
Code Name
T2
AMT02
782
Total Claim Before Taxes
Monetary Amount
M
Description: Monetary amount
Industry: Other Payer Pre-Tax Claim Total Amount
This is a crosswalk from AMT in 835 (Loop CLP, position 062) when AMT01 = T2.
Notes:
1. Required if claim has been adjudicated by the payer identified in this loop and if this information was included
in the remittance advice reporting those adjudication results.
Example:
AMT*T2*456~
837P_CG.ecs
551
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 305
DMG Subscriber Demographic
Max: 1
Detail - Optional
Information
Loop: 2320
Elements: 3
User Option (Usage): Situational
Purpose: To supply demographic information
Element Summary:
Ref
Id
Element Name
DMG01
1250
Date Time Period Format Qualifier
Req
Type
Min/Max
Usage
C
ID
2/3
Required
Description: Code indicating the date format, time format, or date and time format
CodeList Summary (Total Codes: 39, Included: 1)
Code Name
D8
DMG02
1251
Date Expressed in Format CCYYMMDD
Date Time Period
C
AN
1/35
Required
Description: Expression of a date, a time, or range of dates, times or dates and times
Industry: Other Insured Birth Date
Alias: Date of Birth - Subscriber
NSF Reference: DA0-24.0
DMG03
1068
Gender Code
O
ID
1/1
Required
Description: Code indicating the sex of the individual
Industry: Other Insured Gender Code
Alias: Gender - Subscriber
NSF Reference: DA0-23.0
CodeList Summary (Total Codes: 7, Included: 3)
Code Name
F
M
U
Female
Male
Unknown
Syntax Rules:
1. P0102 - If either DMG01 or DMG02 is present, then the other is required.
Semantics:
1. DMG02 is the date of birth.
2. DMG07 is the country of citizenship.
3. DMG09 is the age in years.
Notes:
1. Required when 2330A NM102 = 1 (person).
2. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.
Example:
DMG*D8*19671105*F~
837P_CG.ecs
552
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 310
OI Other Insurance Coverage
Max: 1
Detail - Optional
Information
Loop: 2320
Elements: 3
User Option (Usage): Required
Purpose: To specify information associated with other health insurance coverage
Element Summary:
Ref
Id
Element Name
OI03
1073
Yes/No Condition or Response Code
Req
Type
Min/Max
Usage
O
ID
1/1
Required
1/1
Situational
Description: Code indicating a Yes or No condition or response
Industry: Benefits Assignment Certification Indicator
Alias: Assignment of Benefits Indicator
NSF Reference: DA0-15.0
This is a crosswalk from CLM08 when doing COB.
CodeList Summary (Total Codes: 4, Included: 2)
Code Name
N
Y
OI04
1351
No
Yes
Patient Signature Source Code
O
ID
Description: Code indicating how the patient or subscriber authorization signatures were
obtained and how they are being retained by the provider
Alias: Patient Signature Source Code
NSF Reference: DA0-16.0
Required except in cases where ‘‘N’’ is used in OI06.
This is a crosswalk from CLM10 when doing COB.
All valid standard codes are used. (Total Codes: 5)
OI06
1363
Release of Information Code
O
ID
1/1
Required
Description: Code indicating whether the provider has on file a signed statement by the
patient authorizing the release of medical data to other organizations
Alias: Release of Information Code
This is a crosswalk from CLM09 when doing COB.
All valid standard codes are used. (Total Codes: 6)
Semantics:
1. OI03 is the assignment of benefits indicator. A "Y" value indicates insured or authorized person authorizes
benefits to be assigned to the provider; an "N" value indicates benefits have not been assigned to the
provider.
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. It is specific only to that payer.
2. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.
Example:
OI***Y*B**Y~
837P_CG.ecs
553
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 320
MOA Medicare Outpatient
Max: 1
Detail - Optional
Adjudication Information
Loop: 2320
Elements: 9
User Option (Usage): Situational
Purpose: To convey claim-level data related to the adjudication of Medicare claims not related to an inpatient setting
Element Summary:
Ref
Id
Element Name
MOA01
954
Percent
Req
Type
Min/Max
Usage
O
R
1/10
Situational
1/18
Situational
1/30
Situational
Description: Percentage expressed as a decimal
Industry: Reimbursement Rate
Alias: Outpatient Reimbursement Rate
Required if returned in the electronic remittance advice (835).
MOA02
782
Monetary Amount
O
R
Description: Monetary amount
Industry: HCPCS Payable Amount
Required if returned in the electronic remittance advice (835).
MOA03
127
Reference Identification
O
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Remark Code
Alias: Remarks Code
NSF Reference: DA3-18.0, DA3-19.0, DA3-20.0, DA3-21.0, DA3-22.0
Required if returned in the electronic remittance advice (835).
ExternalCodeList
Name: 411
Description: Remittance Remark Codes
MOA04
127
Reference Identification
O
AN
1/30
Situational
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Remark Code
Alias: Remarks Code
NSF Reference: DA3-18.0, DA3-19.0, DA3-20.0, DA3-21.0, DA3-22.0
Required if returned in the electronic remittance advice (835).
ExternalCodeList
Name: 411
Description: Remittance Remark Codes
MOA05
127
Reference Identification
O
AN
1/30
Situational
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Remark Code
837P_CG.ecs
554
For internal use only
12/1/2010
Ref
Health Care Claim: Professional - 837
Id
Element Name
Req
Type
Min/Max
Usage
Alias: Remarks Code
NSF Reference: DA3-18.0, DA3-19.0, DA3-20.0, DA3-21.0, DA3-22.0
Required if returned in the electronic remittance advice (835).
ExternalCodeList
Name: 411
Description: Remittance Remark Codes
MOA06
127
Reference Identification
O
AN
1/30
Situational
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Remark Code
Alias: Remarks Code
NSF Reference: DA3-18.0, DA3-19.0, DA3-20.0, DA3-21.0, DA3-22.0
Required if returned in the electronic remittance advice (835).
ExternalCodeList
Name: 411
Description: Remittance Remark Codes
MOA07
127
Reference Identification
O
AN
1/30
Situational
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Remark Code
Alias: Remarks Code
NSF Reference: DA3-18.0, DA3-19.0, DA3-20.0, DA3-21.0, DA3-22.0
Required if returned in the electronic remittance advice (835).
ExternalCodeList
Name: 411
Description: Remittance Remark Codes
MOA08
782
Monetary Amount
O
R
1/18
Situational
1/18
Situational
Description: Monetary amount
Industry: End Stage Renal Disease Payment Amount
Alias: ESRD Paid Amount
Required if returned in the electronic remittance advice (835).
MOA09
782
Monetary Amount
O
R
Description: Monetary amount
Industry: Non-Payable Professional Component Billed Amount
Alias: Professional Component
Required if returned in the electronic remittance advice (835).
Semantics:
1. MOA01 is the reimbursement rate.
2. MOA02 is the claim Health Care Financing Administration Common Procedural Coding System (HCPCS)
payable amount.
837P_CG.ecs
555
For internal use only
12/1/2010
3.
4.
5.
6.
7.
8.
9.
Health Care Claim: Professional - 837
MOA03 is the Claim Payment Remark Code. See Code Source 411.
MOA04 is the Claim Payment Remark Code. See Code Source 411.
MOA05 is the Claim Payment Remark Code. See Code Source 411.
MOA06 is the Claim Payment Remark Code. See Code Source 411.
MOA07 is the Claim Payment Remark Code. See Code Source 411.
MOA08 is the End Stage Renal Disease (ESRD) payment amount.
MOA09 is the professional component amount billed but not payable.
Notes:
1. Required if returned in the electronic remittance advice (835).
Example:
MOA***A4~
837P_CG.ecs
556
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 325
Loop Other Subscriber Name
Repeat: 1
Optional
Loop:
2330A
Elements: N/A
User Option (Usage): Required
Purpose: To supply the full name of an individual or organizational entity
Loop Summary:
Pos
Id
Segment Name
325
332
340
355
NM1
N3
N4
REF
Other
Other
Other
Other
Subscriber Name
Subscriber Address
Subscriber City/State/ZIP Code
Subscriber Secondary Identification
Req
Max Use
O
O
O
O
1
1
1
3
Repeat
Usage
Required
Situational
Situational
Situational
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
Notes:
1. Submitters are required to send information on all known other subscribers in Loop ID-2330.
2. This 2330 loop is required when Loop ID-2320 - Other Subscriber Information is used. Otherwise, this loop is
not used.
3. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.
Example:
NM1*IL*1*DOE*JOHN*T**JR*MI*123456~
837P_CG.ecs
557
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 325
NM1 Other Subscriber Name
Max: 1
Detail - Optional
Loop:
2330A
Elements: 8
User Option (Usage): Required
Purpose: To supply the full name of an individual or organizational entity
Element Summary:
Ref
Id
Element Name
NM101
98
Entity Identifier Code
Req
Type
Min/Max
Usage
M
ID
2/3
Required
Description: Code identifying an organizational entity, a physical location, property or an
individual
CodeList Summary (Total Codes: 1312, Included: 1)
Code Name
IL
NM102
1065
Insured or Subscriber
Entity Type Qualifier
M
ID
1/1
Required
AN
1/35
Required
Description: Code qualifying the type of entity
CodeList Summary (Total Codes: 14, Included: 2)
Code Name
1
2
NM103
1035
Person
Non-Person Entity
Name Last or Organization Name
O
Description: Individual last name or organizational name
Industry: Other Insured Last Name
Alias: Subscriber Last Name
NSF Reference: DA0-19.0
NM104
1036
Name First
O
AN
1/25
Situational
O
AN
1/25
Situational
Description: Individual first name
Industry: Other Insured First Name
Alias: Subscriber First Name
NSF Reference: DA0-20.0
Required if NM102=1 (person).
NM105
1037
Name Middle
Description: Individual middle name or initial
Industry: Other Insured Middle Name
Alias: Subscriber Middle Name
NSF Reference: DA0-21.0
Required if NM102=1 and the middle name/initial of the person is known.
NM107
1039
Name Suffix
O
AN
1/10
Situational
Description: Suffix to individual name
Industry: Other Insured Name Suffix
837P_CG.ecs
558
For internal use only
12/1/2010
Ref
Health Care Claim: Professional - 837
Id
Element Name
Req
Type
Min/Max
Usage
C
ID
1/2
Required
Alias: Subscriber Generation
NSF Reference: DA0-22.0
Required if known.
Examples: I, II, III, IV, Jr, Sr
NM108
66
Identification Code Qualifier
Description: Code designating the system/method of code structure used for Identification
Code (67)
CodeList Summary (Total Codes: 215, Included: 2)
Code Name
NM109
67
MI
Member Identification Number
The code MI is intended to be the subscriber’s identification number as assigned
by the payer. Payers use different terminology to convey the
same number. Therefore the 837 Professional Workgroup recommends using MI Member Identification Number to convey the following terms: Insured’s ID,
Subscriber’s ID, Health Insurance Claim Number (HIC), etc.
ZZ
Mutually Defined
The value ‘ZZ’, when used in this data element shall be defined as “HIPAA
Individual Identifier” once this identifier has been adopted. Under the Health
Insurance Portability and Accountability Act of 1996, the Secretary of the
Department of Health and Human Services must adopt a standard individual
identifier for use in this transaction.
Identification Code
C
AN
2/80
Required
Description: Code identifying a party or other code
Industry: Other Insured Identifier
Alias: Other Subscriber Primary Identifier
NSF Reference: DA0-18.0
Syntax Rules:
1. P0809 - If either NM108 or NM109 is present, then the other is required.
2. C1110 - If NM111 is present, then NM110 is required.
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
Notes:
1. Submitters are required to send information on all known other subscribers in Loop ID-2330.
2. This 2330 loop is required when Loop ID-2320 - Other Subscriber Information is used. Otherwise, this loop is
not used.
3. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.
Example:
NM1*IL*1*DOE*JOHN*T**JR*MI*123456~
837P_CG.ecs
559
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 332
N3 Other Subscriber Address
Max: 1
Detail - Optional
Loop:
2330A
Elements: 2
User Option (Usage): Situational
Purpose: To specify the location of the named party
Element Summary:
Ref
Id
Element Name
N301
166
Address Information
Req
Type
Min/Max
Usage
M
AN
1/55
Required
O
AN
1/55
Situational
Description: Address information
Industry: Other Insured Address Line
Alias: Subscriber Address 1
NSF Reference: DA2-04.0
N302
166
Address Information
Description: Address information
Industry: Other Insured Address Line
Alias: Subscriber Address 2
NSF Reference: DA2-05.0
Required if a second address line exists.
Notes:
1. Required when information is available.
2. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.
Example:
N3*4320 WASHINGTON ST*SUITE 100~
837P_CG.ecs
560
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 340
N4 Other Subscriber
Max: 1
Detail - Optional
City/State/ZIP Code
Loop:
2330A
Elements: 4
User Option (Usage): Situational
Purpose: To specify the geographic place of the named party
Element Summary:
Ref
Id
Element Name
N401
19
City Name
Req
Type
Min/Max
Usage
O
AN
2/30
Situational
O
ID
2/2
Situational
Description: Free-form text for city name
Industry: Other Insured City Name
Alias: Subscriber City Name
NSF Reference: DA2-06.0
Required when information is available.
N402
156
State or Province Code
Description: Code (Standard State/Province) as defined by appropriate government
agency
Industry: Other Insured State Code
Alias: Subscriber State Code
CODE SOURCE: 22: States and Outlying Areas of the U.S.
NSF Reference: DA2-07.0
Required when information is available.
ExternalCodeList
Name: 22
Description: States and Outlying Areas of the U.S.
N403
116
Postal Code
O
ID
3/15
Situational
Description: Code defining international postal zone code excluding punctuation and
blanks (zip code for United States)
Industry: Other Insured Postal Zone or ZIP Code
Alias: Subscriber Zip Code
CODE SOURCE: 51: ZIP Code
NSF Reference: DA2-08.0
Required when information is available.
ExternalCodeList
Name: 51
Description: ZIP Code
N404
26
Country Code
O
ID
2/3
Situational
Description: Code identifying the country
Alias: Subscriber Country Code
CODE SOURCE: 5: Countries, Currencies and Funds
Required if the address is out of the U.S.
837P_CG.ecs
561
For internal use only
12/1/2010
Ref
Health Care Claim: Professional - 837
Id
Element Name
Req
Type
Min/Max
Usage
ExternalCodeList
Name: 5
Description: Countries, Currencies and Funds
Syntax Rules:
1. C0605 - If N406 is present, then N405 is required.
Comments:
1. A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
2. N402 is required only if city name (N401) is in the U.S. or Canada.
Notes:
1. Required when information is available.
2. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.
Example:
N4*PALISADES*OR*23119~
837P_CG.ecs
562
For internal use only
12/1/2010
Health Care Claim: Professional - 837
REF Other Subscriber Secondary
Identification
Pos: 355
Max: 3
Detail - Optional
Loop:
2330A
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 4)
Code Name
REF02
127
1W
23
Member Identification Number
Client Number
This code is intended to be used only in claims submitted to the Indian Health
Service/Contract Health Services (IHC/CHS) Fiscal Intermediary for the purpose
of reporting the Health Record Number.
IG
SY
Insurance Policy Number
Social Security Number
The social security number may not be used for Medicare.
Reference Identification
C
AN
1/30
Required
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Other Insured Additional Identifier
Alias: Other Subscriber Secondary Identification
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. Required if additional identification numbers are necessary to adjudicate the claim/encounter.
2. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.
Example:
REF*SY*528446666~
837P_CG.ecs
563
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 325
Loop Other Payer Name
Repeat: 1
Optional
Loop:
2330B
Elements: N/A
User Option (Usage): Required
Purpose: To supply the full name of an individual or organizational entity
Loop Summary:
Pos
Id
Segment Name
325
345
350
355
355
NM1
PER
DTP
REF
REF
355
REF
Other Payer Name
Other Payer Contact Information
Claim Adjudication Date
Other Payer Secondary Identifier
Other Payer Prior Authorization or Referral
Number
Other Payer Claim Adjustment Indicator
Req
Max Use
Repeat
Usage
O
O
O
O
O
1
2
1
2
2
Required
Situational
Situational
Situational
Situational
O
2
Situational
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
Notes:
1. Submitters are required to send all known information on other payers in this Loop ID-2330.
2. This 2330 loop is required when Loop ID-2320 - Other Subscriber Information is used. Otherwise, this loop is
not used.
3. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.
Example:
NM1*PR*2*UNION MUTUAL OF OREGON*****PI*11122333~
837P_CG.ecs
564
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 325
NM1 Other Payer Name
Max: 1
Detail - Optional
Loop:
2330B
Elements: 5
User Option (Usage): Required
Purpose: To supply the full name of an individual or organizational entity
Element Summary:
Ref
Id
Element Name
NM101
98
Entity Identifier Code
Req
Type
Min/Max
Usage
M
ID
2/3
Required
Description: Code identifying an organizational entity, a physical location, property or an
individual
CodeList Summary (Total Codes: 1312, Included: 1)
Code Name
PR
NM102
1065
Payer
Entity Type Qualifier
M
ID
1/1
Required
AN
1/35
Required
1/2
Required
Description: Code qualifying the type of entity
CodeList Summary (Total Codes: 14, Included: 1)
Code Name
2
NM103
1035
Non-Person Entity
Name Last or Organization Name
O
Description: Individual last name or organizational name
Industry: Other Payer Last or Organization Name
Alias: Payer Name
NSF Reference: DA0-09.0
NM108
66
Identification Code Qualifier
C
ID
Description: Code designating the system/method of code structure used for Identification
Code (67)
CodeList Summary (Total Codes: 215, Included: 2)
Code Name
PI
XV
Payor Identification
Health Care Financing Administration National Payer Identification Number
(PAYERID)
CODE SOURCE:
540: Health Care Financing Administration National PlanID
NM109
67
Identification Code
C
AN
2/80
Required
Description: Code identifying a party or other code
Industry: Other Payer Primary Identifier
Alias: Other Payer Primary Identification Number
NSF Reference: DA0-07.0
This number must be identical to SVD01 (Loop ID-2430) for COB.
837P_CG.ecs
565
For internal use only
12/1/2010
Health Care Claim: Professional - 837
ExternalCodeList
Name: 540
Description: Health Care Financing Administration National PlanID
Syntax Rules:
1. P0809 - If either NM108 or NM109 is present, then the other is required.
2. C1110 - If NM111 is present, then NM110 is required.
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
Notes:
1. Submitters are required to send all known information on other payers in this Loop ID-2330.
2. This 2330 loop is required when Loop ID-2320 - Other Subscriber Information is used. Otherwise, this loop is
not used.
3. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.
Example:
NM1*PR*2*UNION MUTUAL OF OREGON*****PI*11122333~
837P_CG.ecs
566
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 345
PER Other Payer Contact
Max: 2
Detail - Optional
Information
Loop:
2330B
Elements: 8
User Option (Usage): Situational
Purpose: To identify a person or office to whom administrative communications should be directed
Element Summary:
Ref
Id
Element Name
PER01
366
Contact Function Code
Req
Type
Min/Max
Usage
M
ID
2/2
Required
Description: Code identifying the major duty or responsibility of the person or group
named
CodeList Summary (Total Codes: 230, Included: 1)
Code Name
IC
PER02
93
Information Contact
Name
O
AN
1/60
Required
C
ID
2/2
Required
Description: Free-form name
Industry: Other Payer Contact Name
PER03
365
Communication Number Qualifier
Description: Code identifying the type of communication number
CodeList Summary (Total Codes: 40, Included: 4)
Code Name
ED
EM
FX
TE
PER04
364
Electronic Data Interchange Access Number
Electronic Mail
Facsimile
Telephone
Communication Number
C
AN
1/80
Required
Description: Complete communications number including country or area code when
applicable
PER05
365
Communication Number Qualifier
C
ID
2/2
Situational
Description: Code identifying the type of communication number
Used at the discretion of the submitter.
CodeList Summary (Total Codes: 40, Included: 5)
Code Name
ED
EM
EX
FX
TE
PER06
364
Electronic Data Interchange Access Number
Electronic Mail
Telephone Extension
Facsimile
Telephone
Communication Number
C
AN
1/80
Situational
Description: Complete communications number including country or area code when
837P_CG.ecs
567
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Ref
Id
Element Name
applicable
Used at the discretion of the submitter.
PER07
365
Communication Number Qualifier
Req
Type
Min/Max
Usage
C
ID
2/2
Situational
Description: Code identifying the type of communication number
Used at the discretion of the submitter.
CodeList Summary (Total Codes: 40, Included: 5)
Code Name
ED
EM
EX
FX
TE
PER08
364
Electronic Data Interchange Access Number
Electronic Mail
Telephone Extension
Facsimile
Telephone
Communication Number
C
AN
1/80
Situational
Description: Complete communications number including country or area code when
applicable
Used at the discretion of the submitter.
Syntax Rules:
1. P0304 - If either PER03 or PER04 is present, then the other is required.
2. P0506 - If either PER05 or PER06 is present, then the other is required.
3. P0708 - If either PER07 or PER08 is present, then the other is required.
Notes:
1. This segment is used only in payer-to-payer COB situations. This segment may be completed by a payer who
has adjudicated the claim and is passing it on to a secondary payer. It is not completed by submitting providers.
2. 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 should 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 (e.g., (534) 224-2525 would be represented as
5342242525). The extension, when applicable, should be included in the communication number immediately
after the telephone number.
3. There are 2 repetitions of the PER segment to allow for six possible combination of communication numbers
including extensions.
Example:
PER*IC*SHELLY*TE*5552340000~
837P_CG.ecs
568
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 350
DTP Claim Adjudication Date
Max: 1
Detail - Optional
Loop:
2330B
Elements: 3
User Option (Usage): Situational
Purpose: To specify any or all of a date, a time, or a time period
Element Summary:
Ref
Id
Element Name
DTP01
374
Date/Time Qualifier
Req
Type
Min/Max
Usage
M
ID
3/3
Required
Description: Code specifying type of date or time, or both date and time
Industry: Date Time Qualifier
CodeList Summary (Total Codes: 1112, Included: 1)
Code Name
573
DTP02
1250
Date Claim Paid
Date Time Period Format Qualifier
M
ID
2/3
Required
Description: Code indicating the date format, time format, or date and time format
CodeList Summary (Total Codes: 39, Included: 1)
Code Name
D8
DTP03
1251
Date Expressed in Format CCYYMMDD
Date Time Period
M
AN
1/35
Required
Description: Expression of a date, a time, or range of dates, times or dates and times
Industry: Adjudication or Payment Date
NSF Reference: DA1-27.0
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
Notes:
1. This segment is required when the payer identified in this iteration of the 2330 loop has previously adjudicated
the claim and Loop-ID 2430 (Line Adjudication Information) is not used.
Example:
DTP*573*D8*19980314~
837P_CG.ecs
569
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 355
REF Other Payer Secondary
Max: 2
Detail - Optional
Identifier
Loop:
2330B
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 5)
Code Name
2U
F8
Payer Identification Number
Original Reference Number
Use to indicate the payer’s claim number for this claim for the payer identified in
this iteration of the 2330B loop.
FY
NF
Claim Office Number
National Association of Insurance Commissioners (NAIC) Code
CODE SOURCE:
TJ
Federal Taxpayer's Identification Number
245: National Association of Insurance Commissioners (NAIC) Code
REF02
127
Reference Identification
C
AN
1/30
Required
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Other Payer Secondary Identifier
NSF Reference: DA3-29.0
The DA3-29.0 crosswalk is only used in payer-to-payer COB situations.
ExternalCodeList
Name: 245
Description: National Association of Insurance Commissioners (NAIC) Code
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. Required when a secondary identification number is necessary to identify the entity. The primary identification
number should be carried in NM109 in this loop.
2. Used when it is necessary to identify the ’other’ payer’s claim number in a payer-to-payer COB situation (use
code F8). Code F8 is not used by providers.
3. There can only be a maximum of three REF segments in any one iteration of the 2330 loop.
4. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.
Example:
837P_CG.ecs
570
For internal use only
12/1/2010
Health Care Claim: Professional - 837
REF*FY*435261708~
837P_CG.ecs
571
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 355
REF Other Payer Prior
Max: 2
Detail - Optional
Authorization or Referral
Number
Loop:
2330B
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
1/30
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 2)
Code Name
9F
G1
REF02
127
Referral Number
Prior Authorization Number
Reference Identification
C
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Other Payer Prior Authorization or Referral Number
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. Used when the payer identified in this loop has given a prior authorization or referral number to this claim. This
element is primarily used in payer-to-payer COB situations.
2. There can only be a maximum of three REF segments in any one iteration of the 2330 loop.
3. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.
Example:
REF*G1*AB333-Y5~
837P_CG.ecs
572
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 355
REF Other Payer Claim
Max: 2
Detail - Optional
Adjustment Indicator
Loop:
2330B
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
1/30
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 1)
Code Name
T4
REF02
127
Signal Code
Reference Identification
C
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Other Payer Claim Adjustment Indicator
NSF Reference: DA3-24.0
Allowable values are “Y” indicating that the payer in this loop has previously adjudicated
this claim and sent a record of that adjudication to the destination payer identified in the
2010BB loop. The claim being transmitted in this iteration of the 2300 loop is a
re-adjudicated version of that claim.
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. Used only in payer-to-payer COB. In that situation, the destination payer is secondary to the payer identified in
this loop. Providers/other submitters do not use this segment.
2. Required when the payer identified in this loop has previously paid this claim and has indicated so to the
destination payer. In this case the payer identified in this loop has readjudicated the claim and is sending the
adjusted payment information to the destination payer. This REF segment is used to indicate that this claim is an
adjustment of a previously adjudicated claim. If the claim has not been previously adjudicated this REF is not
used.
3. There can only be a maximum of three REF segments in any one iteration of the 2330 loop.
Example:
REF*T4*Y~
837P_CG.ecs
573
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 325
Loop Other Payer Patient
Information
Repeat: 1
Optional
Loop:
2330C
Elements: N/A
User Option (Usage): Situational
Purpose: To supply the full name of an individual or organizational entity
Loop Summary:
Pos
Id
Segment Name
325
355
NM1
REF
Other Payer Patient Information
Other Payer Patient Identification
Req
Max Use
O
O
1
3
Repeat
Usage
Situational
Situational
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
Notes:
1. Required when it is necessary, in COB situations, to send one or more payer-specific patient identification
numbers. The patient identification number(s) carried in this iteration of the 2330 loop are those patient ID’s which
belong to non-destination (COB) payers. The patient ID(s) forr the destination payer are carried in the 2010CA
loop NM1 and REF segments. See Section 1.4.5 Crosswalking COB Data Elements for more information on
handling non-destination payer patient identifiers and other COB elements.
2. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,
then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.
Example:
NM1*QC*1******MI*6677U801~
837P_CG.ecs
574
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 325
NM1 Other Payer Patient
Max: 1
Detail - Optional
Information
Loop:
2330C
Elements: 4
User Option (Usage): Situational
Purpose: To supply the full name of an individual or organizational entity
Element Summary:
Ref
Id
Element Name
NM101
98
Entity Identifier Code
Req
Type
Min/Max
Usage
M
ID
2/3
Required
Description: Code identifying an organizational entity, a physical location, property or an
individual
CodeList Summary (Total Codes: 1312, Included: 1)
Code Name
QC
NM102
1065
Patient
Entity Type Qualifier
M
ID
1/1
Required
ID
1/2
Required
Description: Code qualifying the type of entity
CodeList Summary (Total Codes: 14, Included: 1)
Code Name
1
NM108
66
Person
Identification Code Qualifier
C
Description: Code designating the system/method of code structure used for Identification
Code (67)
CodeList Summary (Total Codes: 215, Included: 1)
Code Name
MI
NM109
67
Member Identification Number
The code MI is intended to be the subscriber’s identification number as assigned
by the payer. Payers use different terminology to convey the
same number. Therefore the 837 Professional Workgroup recommends using MI Member Identification Number to convey the following terms: Insured’s ID,
Subscriber’s ID, Health Insurance Claim Number (HIC), etc.
Identification Code
C
AN
2/80
Required
Description: Code identifying a party or other code
Industry: Other Payer Patient Primary Identifier
Alias: Patient’s Other Payer Primary Identification Number
Syntax Rules:
1. P0809 - If either NM108 or NM109 is present, then the other is required.
2. C1110 - If NM111 is present, then NM110 is required.
Semantics:
1. NM102 qualifies NM103.
Comments:
837P_CG.ecs
575
For internal use only
12/1/2010
Health Care Claim: Professional - 837
1. NM110 and NM111 further define the type of entity in NM101.
Notes:
1. Required when it is necessary, in COB situations, to send one or more payer-specific patient identification
numbers. The patient identification number(s) carried in this iteration of the 2330 loop are those patient ID’s which
belong to non-destination (COB) payers. The patient ID(s) forr the destination payer are carried in the 2010CA
loop NM1 and REF segments. See Section 1.4.5 Crosswalking COB Data Elements for more information on
handling non-destination payer patient identifiers and other COB elements.
2. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,
then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.
Example:
NM1*QC*1******MI*6677U801~
837P_CG.ecs
576
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 355
REF Other Payer Patient
Max: 3
Detail - Optional
Identification
Loop:
2330C
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 4)
Code Name
REF02
127
1W
Member Identification Number
If NM108 = M1 do not use this code.
23
Client Number
This code is intended to be used only in claims submitted to the Indian Health
Service/Contract Health Services (IHC/CHS) Fiscal Intermediary for the purpose
of reporting the Health Record Number.
IG
SY
Insurance Policy Number
Social Security Number
Do not use for Medicare.
Reference Identification
C
AN
1/30
Required
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Other Payer Patient Secondary Identifier
Alias: Patient’s Other Payer Secondary Identifier
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. Used when a COB payer (listed in 2330B loop) has one or more proprietary patient identification numbers for
this claim. The patient (name, DOB, etc) is identified in the 2010BA or 2010CA loop.
2. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.
Example:
REF*AZ*B333-Y5~
837P_CG.ecs
577
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 325
Loop Other Payer Referring
Provider
Repeat: 2
Optional
Loop:
2330D
Elements: N/A
User Option (Usage): Situational
Purpose: To supply the full name of an individual or organizational entity
Loop Summary:
Pos
Id
Segment Name
325
355
NM1
REF
Other Payer Referring Provider
Other Payer Referring Provider
Identification
Req
Max Use
O
O
1
3
Repeat
Usage
Situational
Required
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
Notes:
1. Used when it is necessary to send an additional payer-specific provider identification number for
non-destination (COB) payers.
2. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,
then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.
3. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.
Example:
NM1*DN*1~
837P_CG.ecs
578
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 325
NM1 Other Payer Referring
Max: 1
Detail - Optional
Provider
Loop:
2330D
Elements: 2
User Option (Usage): Situational
Purpose: To supply the full name of an individual or organizational entity
Element Summary:
Ref
Id
Element Name
NM101
98
Entity Identifier Code
Req
Type
Min/Max
Usage
M
ID
2/3
Required
Description: Code identifying an organizational entity, a physical location, property or an
individual
CodeList Summary (Total Codes: 1312, Included: 2)
Code Name
NM102
1065
DN
Referring Provider
Use on first iteration of this loop. Use if loop is used only once.
P3
Primary Care Provider
Use only if loop is used twice. Use only on second iteration of this loop.
Entity Type Qualifier
M
ID
1/1
Required
Description: Code qualifying the type of entity
CodeList Summary (Total Codes: 14, Included: 2)
Code Name
1
2
Person
Non-Person Entity
Syntax Rules:
1. P0809 - If either NM108 or NM109 is present, then the other is required.
2. C1110 - If NM111 is present, then NM110 is required.
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
Notes:
1. Used when it is necessary to send an additional payer-specific provider identification number for
non-destination (COB) payers.
2. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,
then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.
3. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.
Example:
NM1*DN*1~
837P_CG.ecs
579
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 355
REF Other Payer Referring
Max: 3
Detail - Optional
Provider Identification
Loop:
2330D
Elements: 2
User Option (Usage): Required
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
1/30
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 7)
Code Name
1B
1C
1D
EI
G2
LU
N5
REF02
127
Blue Shield Provider Number
Medicare Provider Number
Medicaid Provider Number
Employer's Identification Number
Provider Commercial Number
Location Number
Provider Plan Network Identification Number
Reference Identification
C
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Other Payer Referring Provider Identifier
Alias: Other Payer Referring Provider Identification
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. Non-destination (COB) payers’ provider identification number(s).
2. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.
Example:
REF*N5*RF446~
837P_CG.ecs
580
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 325
Loop Other Payer Rendering
Provider
Repeat: 1
Optional
Loop:
2330E
Elements: N/A
User Option (Usage): Situational
Purpose: To supply the full name of an individual or organizational entity
Loop Summary:
Pos
Id
Segment Name
325
355
NM1
REF
Other Payer Rendering Provider
Other Payer Rendering Provider
Secondary Identification
Req
Max Use
O
O
1
3
Repeat
Usage
Situational
Required
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
Notes:
1. Used when it is necessary to send an additional payer-specific provider identification number for
non-destination (COB) payers.
2. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,
then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.
3. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.
Example:
NM1*82*1~
837P_CG.ecs
581
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 325
NM1 Other Payer Rendering
Max: 1
Detail - Optional
Provider
Loop:
2330E
Elements: 2
User Option (Usage): Situational
Purpose: To supply the full name of an individual or organizational entity
Element Summary:
Ref
Id
Element Name
NM101
98
Entity Identifier Code
Req
Type
Min/Max
Usage
M
ID
2/3
Required
Description: Code identifying an organizational entity, a physical location, property or an
individual
CodeList Summary (Total Codes: 1312, Included: 1)
Code Name
82
NM102
1065
Rendering Provider
Entity Type Qualifier
M
ID
1/1
Required
Description: Code qualifying the type of entity
CodeList Summary (Total Codes: 14, Included: 2)
Code Name
1
2
Person
Non-Person Entity
Syntax Rules:
1. P0809 - If either NM108 or NM109 is present, then the other is required.
2. C1110 - If NM111 is present, then NM110 is required.
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
Notes:
1. Used when it is necessary to send an additional payer-specific provider identification number for
non-destination (COB) payers.
2. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,
then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.
3. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.
Example:
NM1*82*1~
837P_CG.ecs
582
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 355
REF Other Payer Rendering
Max: 3
Detail - Optional
Provider Secondary
Identification
Loop:
2330E
Elements: 2
User Option (Usage): Required
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
1/30
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 7)
Code Name
1B
1C
1D
EI
G2
LU
N5
REF02
127
Blue Shield Provider Number
Medicare Provider Number
Medicaid Provider Number
Employer's Identification Number
Provider Commercial Number
Location Number
Provider Plan Network Identification Number
Reference Identification
C
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Other Payer Rendering Provider Secondary Identifier
Other Payer Rendering Provider Secondary Identification
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. Non-destination (COB) payers’ provider identification number(s).
2. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.
Example:
REF*LU*SLC987~
837P_CG.ecs
583
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 325
Loop Other Payer Purchased
Service Provider
Repeat: 1
Optional
Loop:
2330F
Elements: N/A
User Option (Usage): Situational
Purpose: To supply the full name of an individual or organizational entity
Loop Summary:
Pos
Id
Segment Name
325
355
NM1
REF
Other Payer Purchased Service Provider
Other Payer Purchased Service Provider
Identification
Req
Max Use
O
O
1
3
Repeat
Usage
Situational
Required
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
Notes:
1. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,
then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.
2. Used when it is necessary to send an additional payer-specific provider identification number for
non-destination (COB) payers.
3. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.
Example:
NM1*QB*2~
837P_CG.ecs
584
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 325
NM1 Other Payer Purchased
Max: 1
Detail - Optional
Service Provider
Loop:
2330F
Elements: 2
User Option (Usage): Situational
Purpose: To supply the full name of an individual or organizational entity
Element Summary:
Ref
Id
Element Name
NM101
98
Entity Identifier Code
Req
Type
Min/Max
Usage
M
ID
2/3
Required
Description: Code identifying an organizational entity, a physical location, property or an
individual
CodeList Summary (Total Codes: 1312, Included: 1)
Code Name
QB
NM102
1065
Purchase Service Provider
Entity Type Qualifier
M
ID
1/1
Required
Description: Code qualifying the type of entity
CodeList Summary (Total Codes: 14, Included: 2)
Code Name
1
2
Person
Non-Person Entity
Syntax Rules:
1. P0809 - If either NM108 or NM109 is present, then the other is required.
2. C1110 - If NM111 is present, then NM110 is required.
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
Notes:
1. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,
then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.
2. Used when it is necessary to send an additional payer-specific provider identification number for
non-destination (COB) payers.
3. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.
Example:
NM1*QB*2~
837P_CG.ecs
585
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 355
REF Other Payer Purchased
Max: 3
Detail - Optional
Service Provider
Identification
Loop:
2330F
Elements: 2
User Option (Usage): Required
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
1/30
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 8)
Code Name
1A
1B
1C
1D
EI
G2
LU
N5
REF02
127
Blue Cross Provider Number
Blue Shield Provider Number
Medicare Provider Number
Medicaid Provider Number
Employer's Identification Number
Provider Commercial Number
Location Number
Provider Plan Network Identification Number
Reference Identification
C
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Other Payer Purchased Service Provider Identifier
Other Payer Purchased Service Provider Identification
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. Non-destination (COB) payers’ provider identification number(s).
2. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.
Example:
REF*G2*8893U21~
837P_CG.ecs
586
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 325
Loop Other Payer Service Facility
Location
Repeat: 1
Optional
Loop:
2330G
Elements: N/A
User Option (Usage): Situational
Purpose: To supply the full name of an individual or organizational entity
Loop Summary:
Pos
Id
Segment Name
325
355
NM1
REF
Other Payer Service Facility Location
Other Payer Service Facility Location
Identification
Req
Max Use
O
O
1
3
Repeat
Usage
Situational
Required
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
Notes:
1. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,
then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.
2. Used when it is necessary to send an additional payer-specific provider identification number for
non-destination (COB) payers.
3. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.
Example:
NM1*TL*2~
837P_CG.ecs
587
For internal use only
12/1/2010
Health Care Claim: Professional - 837
NM1 Other Payer Service Facility
Location
Pos: 325
Max: 1
Detail - Optional
Loop:
2330G
Elements: 2
User Option (Usage): Situational
Purpose: To supply the full name of an individual or organizational entity
Element Summary:
Ref
Id
Element Name
NM101
98
Entity Identifier Code
Req
Type
Min/Max
Usage
M
ID
2/3
Required
Description: Code identifying an organizational entity, a physical location, property or an
individual
CodeList Summary (Total Codes: 1312, Included: 4)
Code Name
NM102
1065
77
Service Location
Use when other codes in this element do not apply.
FA
LI
TL
Facility
Independent Lab
Testing Laboratory
Entity Type Qualifier
M
ID
1/1
Required
Description: Code qualifying the type of entity
CodeList Summary (Total Codes: 14, Included: 1)
Code Name
2
Non-Person Entity
Syntax Rules:
1. P0809 - If either NM108 or NM109 is present, then the other is required.
2. C1110 - If NM111 is present, then NM110 is required.
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
Notes:
1. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,
then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.
2. Used when it is necessary to send an additional payer-specific provider identification number for
non-destination (COB) payers.
3. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.
Example:
NM1*TL*2~
837P_CG.ecs
588
For internal use only
12/1/2010
Health Care Claim: Professional - 837
REF Other Payer Service Facility
Location Identification
Pos: 355
Max: 3
Detail - Optional
Loop:
2330G
Elements: 2
User Option (Usage): Required
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
1/30
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 7)
Code Name
1A
1B
1C
1D
G2
LU
N5
REF02
127
Blue Cross Provider Number
Blue Shield Provider Number
Medicare Provider Number
Medicaid Provider Number
Provider Commercial Number
Location Number
Provider Plan Network Identification Number
Reference Identification
C
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Other Payer Service Facility Location Identifier
Alias: Other Payer Service Facility Location Identification
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. Non-destination (COB) payers’ provider identification number(s).
2. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.
Example:
REF*G2*LAB1234~
837P_CG.ecs
589
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 325
Loop Other Payer Supervising
Provider
Repeat: 1
Optional
Loop:
2330H
Elements: N/A
User Option (Usage): Situational
Purpose: To supply the full name of an individual or organizational entity
Loop Summary:
Pos
Id
Segment Name
325
355
NM1
REF
Other Payer Supervising Provider
Other Payer Supervising Provider
Identification
Req
Max Use
O
O
1
3
Repeat
Usage
Situational
Required
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
Notes:
1. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,
then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.
2. Used when it is necessary to send an additional payer-specific provider identification number for
non-destination (COB) payers.
3. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.
Example:
NM1*DQ*1~
837P_CG.ecs
590
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 325
NM1 Other Payer Supervising
Max: 1
Detail - Optional
Provider
Loop:
2330H
Elements: 2
User Option (Usage): Situational
Purpose: To supply the full name of an individual or organizational entity
Element Summary:
Ref
Id
Element Name
NM101
98
Entity Identifier Code
Req
Type
Min/Max
Usage
M
ID
2/3
Required
Description: Code identifying an organizational entity, a physical location, property or an
individual
CodeList Summary (Total Codes: 1312, Included: 1)
Code Name
DQ
NM102
1065
Supervising Physician
Entity Type Qualifier
M
ID
1/1
Required
Description: Code qualifying the type of entity
CodeList Summary (Total Codes: 14, Included: 1)
Code Name
1
Person
Syntax Rules:
1. P0809 - If either NM108 or NM109 is present, then the other is required.
2. C1110 - If NM111 is present, then NM110 is required.
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
Notes:
1. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used,
then this segment is a “Required” segment. See Appendix A for further details on ASC X12 syntax rules.
2. Used when it is necessary to send an additional payer-specific provider identification number for
non-destination (COB) payers.
3. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.
Example:
NM1*DQ*1~
837P_CG.ecs
591
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 355
REF Other Payer Supervising
Max: 3
Detail - Optional
Provider Identification
Loop:
2330H
Elements: 2
User Option (Usage): Required
Purpose: To specify identifying information
Element Summary:
Ref
Id
Element Name
REF01
128
Reference Identification Qualifier
Req
Type
Min/Max
Usage
M
ID
2/3
Required
1/30
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1503, Included: 6)
Code Name
1B
1C
1D
EI
G2
N5
REF02
127
Blue Shield Provider Number
Medicare Provider Number
Medicaid Provider Number
Employer's Identification Number
Provider Commercial Number
Provider Plan Network Identification Number
Reference Identification
C
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Industry: Other Payer Supervising Provider Identifier
Alias: Other Payer Supervising Provider Identification
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
Notes:
1. Non-destination (COB) payers’ provider identification number(s).
2. See Section 1.4.5 Crosswalking COB Data Elements for more information on handling COB in the 837.
Example:
REF*G2*53334~
837P_CG.ecs
592
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 365
Loop Service Line
Repeat: 50
Optional
Loop: 2400 Elements: N/A
User Option (Usage): Required
Purpose: To reference a line number in a transaction set
Loop Summary:
Pos
Id
Segment Name
365
370
400
420
425
430
435
445
450
450
450
455
455
455
455
455
455
455
LX
SV1
SV5
PWK
CR1
CR2
CR3
CR5
CRC
CRC
CRC
DTP
DTP
DTP
DTP
DTP
DTP
DTP
455
455
455
455
455
455
462
465
470
470
DTP
DTP
DTP
DTP
DTP
DTP
MEA
CN1
REF
REF
470
470
470
470
REF
REF
REF
REF
470
REF
470
470
470
REF
REF
REF
Service Line
Professional Service
Durable Medical Equipment Service
DMERC CMN Indicator
Ambulance Transport Information
Spinal Manipulation Service Information
Durable Medical Equipment Certification
Home Oxygen Therapy Information
Ambulance Certification
Hospice Employee Indicator
DMERC Condition Indicator
Date - Service Date
Date - Certification Revision Date
Date - Begin Therapy Date
Date - Last Certification Date
Date - Date Last Seen
Date - Test
Date - Oxygen Saturation/Arterial Blood
Gas Test
Date - Shipped
Date - Onset of Current Symptom/Illness
Date - Last X-ray
Date - Acute Manifestation
Date - Initial Treatment
Date - Similar Illness/Symptom Onset
Test Result
Contract Information
Repriced Line Item Reference Number
Adjusted Repriced Line Item Reference
Number
Prior Authorization or Referral Number
Line Item Control Number
Mammography Certification Number
Clinical Laboratory Improvement
Amendment (CLIA) Identification
Referring Clinical Laboratory Improvement
Amendment (CLIA) Facility Identification
Immunization Batch Number
Ambulatory Patient Group (APG)
Oxygen Flow Rate
837P_CG.ecs
593
Req
Max Use
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
1
1
1
1
1
5
1
1
3
1
2
1
1
1
1
1
2
3
Repeat
Required
Required
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Required
Situational
Situational
Situational
Situational
Situational
Situational
Usage
O
O
O
O
O
O
O
O
O
O
1
1
1
1
1
1
20
1
1
1
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
O
O
O
O
2
1
1
1
Situational
Situational
Situational
Situational
O
1
Situational
O
O
O
1
4
1
Situational
Situational
Situational
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos
Id
Segment Name
470
475
475
475
480
485
488
491
492
494
500
500
500
500
500
500
500
540
551
REF
AMT
AMT
AMT
K3
NTE
PS1
HSD
HCP
Universal Product Number (UPN)
Sales Tax Amount
Approved Amount
Postage Claimed Amount
File Information
Line Note
Purchased Service Information
Health Care Services Delivery
Line Pricing/Repricing Information
Loop 2410
Loop 2420A
Loop 2420B
Loop 2420C
Loop 2420D
Loop 2420E
Loop 2420F
Loop 2420G
Loop 2430
Loop 2440
Req
Max Use
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
1
1
1
1
10
1
1
1
1
Repeat
Usage
25
1
1
1
1
1
2
4
25
5
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Notes:
1. The Service Line LX segment begins with 1 and is incremented by one for each additional service line of a
claim. The LX functions as a line counter.
2. The datum in the LX is not usually returned in the 835 (Remittance Advice) transaction. LX01 may be used as
a line item control number by the payer in the 835 if a line item control number has not been submitted on the
service line. See that REF for more information. LX01 is used to indicate bundling/unbundling in SVC06. See
Section 1.4.3 for more information on bundling and unbundling.
3. Because this is a required segment, this is a required loop. See Appendix A for further details on ASC X12
syntax rules.
Example:
LX*1~
837P_CG.ecs
594
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 365
LX Service Line
Max: 1
Detail - Optional
Loop: 2400
Elements: 1
User Option (Usage): Required
Purpose: To reference a line number in a transaction set
Element Summary:
Ref
Id
Element Name
LX01
554
Assigned Number
Req
Type
Min/Max
Usage
M
N0
1/6
Required
Description: Number assigned for differentiation within a transaction set
Alias: Line Counter
NSF Reference: FA0-02.0, FB0-02.0, FB1-02.0, GA0-02.0, GC0-02.0, GX0-02.0, GX2-02.
0, HA0-02.0, FB2-02.0, GU0-02.0
The service line number incremented by 1 for each service line.
Notes:
1. The Service Line LX segment begins with 1 and is incremented by one for each additional service line of a
claim. The LX functions as a line counter.
2. The datum in the LX is not usually returned in the 835 (Remittance Advice) transaction. LX01 may be used as
a line item control number by the payer in the 835 if a line item control number has not been submitted on the
service line. See that REF for more information. LX01 is used to indicate bundling/unbundling in SVC06. See
Section 1.4.3 for more information on bundling and unbundling.
3. Because this is a required segment, this is a required loop. See Appendix A for further details on ASC X12
syntax rules.
Example:
LX*1~
837P_CG.ecs
595
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 370
SV1 Professional Service
Max: 1
Detail - Optional
Loop: 2400
Elements: 10
User Option (Usage): Required
Purpose: To specify the claim service detail for a Health Care professional
Element Summary:
Ref
Id
Element Name
SV101
C003
Composite Medical Procedure
Identifier
Req
Type
M
Comp
Min/Max
Usage
Required
Description: To identify a medical procedure by its standardized codes and applicable
modifiers
Alias: Procedure identifier
SV101-01
235
Product/Service ID Qualifier
M
ID
2/2
Required
Description: Code identifying the type/source of the descriptive number used in
Product/Service ID (234)
Industry: Product or Service ID Qualifier
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.
CodeList Summary (Total Codes: 477, Included: 3)
Code Name
HC
Health Care Financing Administration Common Procedural Coding System
(HCPCS) Codes
Because the AMA’s CPT codes are also level 1 HCPCS codes, they are reported
under HC.
CODE SOURCE:
130: Health Care Financing Administration Common Procedural Coding System
IV
Home Infusion EDI Coalition (HIEC) Product/Service Code
This code set is not allowed for use under HIPAA at the time of this writing. The
qualifier can only be used:
1) If a new rule names HIEC as an allowable code set under HIPAA.
2) For Property & Casualty claims/encounters that are not covered under HIPAA.
CODE SOURCE:
513: Home Infusion EDI Coalition (HIEC) Product/Service Code List
ZZ
SV101-02
234
Mutually Defined
Jurisdictionally Defined Procedure and Supply Codes. (Used for Worker’s
Compensation claims). Contact your local (State) Jurisdiction for a list of these
codes.
Product/Service ID
M
AN
1/48
Required
Description: Identifying number for a product or service
Industry: Procedure Code
NSF Reference: FA0-09.0, FB0-15.0, GU0-07.0
ExternalCodeList
Name: 130
837P_CG.ecs
596
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Description: Health Care Financing Administration Common Procedural Coding System
ExternalCodeList
Name: 513
Description: Home Infusion EDI Coalition (HIEC) Product/Service Code List
SV101-03
1339
Procedure Modifier
O
AN
2/2
Situational
Description: This identifies special circumstances related to the performance of the
service, as defined by trading partners
Alias: Procedure Modifier 1
NSF Reference: FA0-10.0, GU0-08.0
Use this modifier for the first procedure code modifier.
Required when a modifier clarifies/improves the reporting accuracy of the associated
procedure code.
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
SV101-04
1339
Procedure Modifier
O
AN
2/2
Situational
Description: This identifies special circumstances related to the performance of the
service, as defined by trading partners
Alias: Procedure Modifier 2
NSF Reference: FA0-11.0
Use this modifier for the second procedure code modifier.
Required when a modifier clarifies/improves the reporting accuracy of the associated
procedure code.
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
SV101-05
1339
Procedure Modifier
O
AN
2/2
Situational
Description: This identifies special circumstances related to the performance of the
service, as defined by trading partners
Alias: Procedure Modifier 3
NSF Reference: FA0-12.0
Use this modifier for the third procedure code modifier.
Required when a modifier clarifies/improves the reporting accuracy of the associated
procedure code.
ExternalCodeList
Name: 130
Description: Health Care Financing Administration Common Procedural Coding System
ExternalCodeList
837P_CG.ecs
597
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Name: 513
Description: Home Infusion EDI Coalition (HIEC) Product/Service Code List
SV101-06
1339
Procedure Modifier
O
AN
2/2
Situational
Description: This identifies special circumstances related to the performance of the
service, as defined by trading partners
Alias: Procedure Modifier 4
NSF Reference: FA0-36.0
Use this modifier for the fourth procedure code modifier.
Required when a modifier clarifies/improves the reporting accuracy of the associated
procedure code.
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
SV102
782
Monetary Amount
O
R
1/18
Required
2/2
Required
Description: Monetary amount
Industry: Line Item Charge Amount
Alias: Submitted charge amount
NSF Reference: FA0-13.0
For encounter transmissions, zero (0) may be a valid amount.
SV103
355
Unit or Basis for Measurement Code
C
ID
Description: Code specifying the units in which a value is being expressed, or manner in
which a measurement has been taken
NSF Reference: FA0-50.0
FA0-50.0 is only used in Medicare COB payer-to-payer situations.
CodeList Summary (Total Codes: 794, Included: 3)
Code Name
SV104
380
F2
International Unit
International Unit is used to indicate dosage amount. Dosage amount is only used
for drug claims when the dosage of the drug is variable within a single NDC
number (e.g., blood factors).
MJ
UN
Minutes
Unit
Quantity
C
R
1/15
Required
Description: Numeric value of quantity
Industry: Service Unit Count
Alias: Units or Minutes
NSF Reference: FA0-18.0, FA0-19.0, FB0-16.0
Note: If a decimal is needed to report units, include it in this element, e.g., “15.6".
SV105
837P_CG.ecs
1331
Facility Code Value
O
598
AN
1/2
Situational
For internal use only
12/1/2010
Ref
Health Care Claim: Professional - 837
Id
Element Name
Req
Type
Min/Max
Usage
Description: Code identifying the type of facility where services were performed; the first
and second positions of the Uniform Bill Type code or the Place of Service code from the
Electronic Media Claims National Standard Format
Industry: Place of Service Code
Alias: Place of Service Code
NSF Reference: FA0-07.0, GU0-05.0
Required if value is different than value carried in CLM05-1 in Loop ID-2300.
Use this element for codes identifying a place of service from code source 237. As a
courtesy, the codes are listed below, however, the code list is thought to be complete at the
time of publication of this implementation guideline. Since this list is subject to change, only
codes contained in the document available from code source 237 are to be supported in
this transaction and take precedence over any and all codes listed here.
11 Office
12 Home
21 Inpatient Hospital
22 Outpatient Hospital
23 Emergency Room - Hospital
24 Ambulatory Surgical Center
25 Birthing Center
26 Military Treatment Facility
31 Skilled Nursing Facility
32 Nursing Facility
33 Custodial Care Facility
34 Hospice
41 Ambulance - Land
42 Ambulance - Air or Water
51 Inpatient Psychiatric Facility
52 Psychiatric Facility Partial Hospitalization
53 Community Mental Health Center
54 Intermediate Care Facility/Mentally Retarded
55 Residential Substance Abuse Treatment Facility
56 Psychiatric Residential Treatment Center
50 Federally Qualified Health Center
60 Mass Immunization Center
61 Comprehensive Inpatient Rehabilitation Facility
62 Comprehensive Outpatient Rehabilitation Facility
65 End Stage Renal Disease Treatment Facility
71 State or Local Public Health Clinic
72 Rural Health Clinic
81 Independent Laboratory
99 Other Unlisted Facility
ExternalCodeList
Name: 237
Description: Place of Service from Health Care Financing Administration Claim Form
SV107
C004
Composite Diagnosis Code Pointer
O
Comp
Situational
Description: To identify one or more diagnosis code pointers
Alias: Diagnosis Code Pointer
Required if HI segment in Loop ID-2300 is used.
SV107-01
1328
Diagnosis Code Pointer
M
N0
1/2
Required
Description: A pointer to the claim diagnosis code in the order of importance to this
service
NSF Reference: FA0-14.0
837P_CG.ecs
599
For internal use only
12/1/2010
Ref
Health Care Claim: Professional - 837
Id
Element Name
Req
Type
Min/Max
Usage
Use this pointer for the first diagnosis code pointer (primary diagnosis for this service line).
Use remaining diagnosis pointers in declining level of importance to service line.
Acceptable values are 1 through 8, inclusive.
SV107-02
1328
Diagnosis Code Pointer
O
N0
1/2
Situational
Description: A pointer to the claim diagnosis code in the order of importance to this
service
NSF Reference: FA0-15.0
Use this pointer for the second diagnosis code pointer.
Required if the service relates to that specific diagnosis and is needed to substantiate the
medical treatment. Acceptable values are 1 through 8, inclusive.
SV107-03
1328
Diagnosis Code Pointer
O
N0
1/2
Situational
Description: A pointer to the claim diagnosis code in the order of importance to this
service
NSF Reference: FA0-16.0
Use this pointer for the third diagnosis code pointer.
Required if the service relates to that specific diagnosis and is needed to substantiate the
medical treatment. Acceptable values are 1 through 8, inclusive.
SV107-04
1328
Diagnosis Code Pointer
O
N0
1/2
Situational
Description: A pointer to the claim diagnosis code in the order of importance to this
service
NSF Reference: FA0-17.0
Use this pointer for the fourth diagnosis code pointer.
Required if the service relates to that specific diagnosis and is needed to substantiate the
medical treatment. Acceptable values are 1 through 8, inclusive.
SV109
1073
Yes/No Condition or Response Code
O
ID
1/1
Situational
Description: Code indicating a Yes or No condition or response
Industry: Emergency Indicator
NSF Reference: FA0-20.0
Required when the service is known to be an emergency by the provider.
Emergency definition: The patient requires immediate medical intervention as a result of
severe, life threatening, or potentially disabling conditions.
CodeList Summary (Total Codes: 4, Included: 1)
Code Name
Y
SV111
1073
Yes
Yes/No Condition or Response Code
O
ID
1/1
Situational
Description: Code indicating a Yes or No condition or response
Industry: EPSDT Indicator
NSF Reference: FB0-22.0
Required if Medicaid services are the result of a screening referral.
CodeList Summary (Total Codes: 4, Included: 1)
Code Name
Y
SV112
837P_CG.ecs
1073
Yes
Yes/No Condition or Response Code
600
O
ID
1/1
Situational
For internal use only
12/1/2010
Ref
Health Care Claim: Professional - 837
Id
Element Name
Req
Type
Min/Max
Usage
Description: Code indicating a Yes or No condition or response
Industry: Family Planning Indicator
NSF Reference: FB0-23.0
Required if applicable for Medicaid claims.
CodeList Summary (Total Codes: 4, Included: 1)
Code Name
Y
SV115
1327
Yes
Copay Status Code
O
ID
1/1
Situational
Description: Code indicating whether or not co-payment requirements were met on a line
by line basis
Industry: Co-Pay Status Code
Alias: Co-Pay Waiver
NSF Reference: FB0-21.0
Required if patient was exempt from co-pay.
CodeList Summary (Total Codes: 4, Included: 1)
Code Name
0
Copay exempt
Syntax Rules:
1. P0304 - If either SV103 or SV104 is present, then the other is required.
Semantics:
1.
2.
3.
4.
5.
6.
7.
8.
9.
SV102 is the submitted charge amount.
SV105 is the place of service.
SV108 is the independent lab charges.
SV109 is the emergency-related indicator; a "Y" value indicates service provided was emergency related; an
"N" value indicates service provided was not emergency related.
SV111 is early and periodic screen for diagnosis and treatment of children (EPSDT) involvement; a "Y" value
indicates EPSDT involvement; an "N" value indicates no EPSDT involvement.
SV112 is the family planning involvement indicator. A "Y" value indicates family planning services
involvement; an "N" value indicates no family planning services involvement.
SV117 is the health care manpower shortage area (HMSA) facility identification.
SV118 is the health care manpower shortage area (HMSA) zip code.
SV119 is a noncovered charge amount.
Comments:
1. If SV113 is equal to "L" or "N", then SV114 is required.
Example:
SV1*HC:99211:25*12.25*UN*1*11**1:2:3**N~
837P_CG.ecs
601
For internal use only
12/1/2010
Health Care Claim: Professional - 837
SV5 Durable Medical Equipment
Service
Pos: 400
Max: 1
Detail - Optional
Loop: 2400
Elements: 6
User Option (Usage): Situational
Purpose: To specify the claim service detail for durable medical equipment
Element Summary:
Ref
Id
Element Name
SV501
C003
Composite Medical Procedure
Identifier
Req
Type
M
Comp
Min/Max
Usage
Required
Description: To identify a medical procedure by its standardized codes and applicable
modifiers
SV501-01
235
Product/Service ID Qualifier
M
ID
2/2
Required
Description: Code identifying the type/source of the descriptive number used in
Product/Service ID (234)
Industry: Procedure Identifier
CodeList Summary (Total Codes: 477, Included: 1)
Code Name
HC
Health Care Financing Administration Common Procedural Coding System
(HCPCS) Codes
CODE SOURCE:
130: Health Care Financing Administration Common Procedural Coding System
SV501-02
234
Product/Service ID
M
AN
1/48
Required
Description: Identifying number for a product or service
Industry: Procedure Code
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
M
ID
2/2
Required
Description: Code specifying the units in which a value is being expressed, or manner in
which a measurement has been taken
CodeList Summary (Total Codes: 794, Included: 1)
Code Name
DA
SV503
380
Days
Quantity
M
R
1/15
Required
X
R
1/18
Situational
Description: Numeric value of quantity
Industry: Length of Medical Necessity
SV504
782
Monetary Amount
Description: Monetary amount
Industry: DME Rental Price
837P_CG.ecs
602
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Ref
Id
Element Name
SV505
782
Monetary Amount
Req
Type
Min/Max
Usage
X
R
1/18
Situational
O
ID
1/1
Situational
Description: Monetary amount
Industry: DME Purchase Price
SV506
594
Frequency Code
Description: Code indicating frequency or type of payment
Industry: Rental Unit Price Indicator
CodeList Summary (Total Codes: 16, Included: 3)
Code Name
1
4
6
Weekly
Monthly
Daily
Syntax Rules:
1. R0405 - At least one of SV504 or SV505 is required.
2. C0604 - If SV506 is present, then SV504 is required.
Semantics:
1.
2.
3.
4.
SV503
SV504
SV505
SV506
is the length of medical treatment required.
is the rental price.
is the purchase price.
is the frequency at which the rental equipment is billed.
Notes:
1. Required when reporting rental and purchase price information for durable medical equipment.
Example:
SV5*HC:A4631*DA*30*50*5000*4~
837P_CG.ecs
603
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 420
PWK DMERC CMN Indicator
Max: 1
Detail - Optional
Loop: 2400
Elements: 2
User Option (Usage): Situational
Purpose: To identify the type or transmission or both of paperwork or supporting information
Element Summary:
Ref
Id
Element Name
PWK01
755
Report Type Code
Req
Type
Min/Max
Usage
M
ID
2/2
Required
Description: Code indicating the title or contents of a document, report or supporting item
Industry: Attachment Report Type Code
Alias: DMERC Report Type Code
CodeList Summary (Total Codes: 522, Included: 1)
Code Name
CT
PWK02
756
Certification
Report Transmission Code
O
ID
1/2
Required
Description: Code defining timing, transmission method or format by which reports are to
be sent
Industry: Attachment Transmission Code
NSF Reference: EA0-40.0
CodeList Summary (Total Codes: 55, Included: 5)
Code Name
AB
AD
AF
AG
NS
Previously Submitted to Payer
Certification Included in this Claim
Narrative Segment included in this Claim
No Documentation is Required
Not Specified
NS = Paperwork is available on request at the provider’s site. This means that the
paperwork is not being sent with the claim at this time. Instead, it is available to the
payer (or appropriate entity) at their request.
Syntax Rules:
1. P0506 - If either PWK05 or PWK06 is present, then the other is required.
Comments:
1. PWK05 and PWK06 may be used to identify the addressee by a code number.
2. PWK07 may be used to indicate special information to be shown on the specified report.
3. PWK08 may be used to indicate action pertaining to a report.
Notes:
1. Required on Medicare claims when DMERC CMN is included in this claim.
Example:
PWK*CT*AB~
837P_CG.ecs
604
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 425
CR1 Ambulance Transport
Max: 1
Detail - Optional
Information
Loop: 2400
Elements: 8
User Option (Usage): Situational
Purpose: To supply information related to the ambulance service rendered to a patient
Element Summary:
Ref
Id
Element Name
CR101
355
Unit or Basis for Measurement Code
Req
Type
Min/Max
Usage
C
ID
2/2
Situational
Description: Code specifying the units in which a value is being expressed, or manner in
which a measurement has been taken
Required if CR102 is present.
CodeList Summary (Total Codes: 794, Included: 1)
Code Name
LB
CR102
81
Pound
Weight
C
R
1/10
Situational
Description: Numeric value of weight
Industry: Patient Weight
NSF Reference: GA0-05.0
Required if it is necessary to justify the medical necessity of the level of ambulance
services.
CR103
1316
Ambulance Transport Code
O
ID
1/1
Required
1/1
Required
Description: Code indicating the type of ambulance transport
Alias: Ambulance transport code
NSF Reference: GA0-07.0
All valid standard codes are used. (Total Codes: 4)
CR104
1317
Ambulance Transport Reason Code
O
ID
Description: Code indicating the reason for ambulance transport
Alias: Ambulance Transport Reason Code
NSF Reference: GA0-15.0
All valid standard codes are used. (Total Codes: 5)
CR105
355
Unit or Basis for Measurement Code
C
ID
2/2
Required
Description: Code specifying the units in which a value is being expressed, or manner in
which a measurement has been taken
CodeList Summary (Total Codes: 794, Included: 1)
Code Name
DH
CR106
380
Miles
Quantity
C
R
1/15
Required
Description: Numeric value of quantity
Industry: Transport Distance
NSF Reference: GA0-17.0, FA0-50.0
837P_CG.ecs
605
For internal use only
12/1/2010
Ref
Health Care Claim: Professional - 837
Id
Element Name
Req
Type
Min/Max
Usage
NSF crosswalk to FA0-50.0 is used only in Medicare payer-to-payer COB situations.
CR109
352
Description
O
AN
1/80
Situational
Description: A free-form description to clarify the related data elements and their content
Industry: Round Trip Purpose Description
Alias: Transport purpose description
NSF Reference: GA0-20.0
Required if CR103 (Ambulance Transport Code) = “X - Round Trip”; otherwise not used.
CR110
352
Description
O
AN
1/80
Situational
Description: A free-form description to clarify the related data elements and their content
Industry: Stretcher Purpose Description
NSF Reference: GA0-21.0
Required if needed to justify usage of stretcher.
Syntax Rules:
1. P0102 - If either CR101 or CR102 is present, then the other is required.
2. P0506 - If either CR105 or CR106 is present, then the other is required.
Semantics:
1.
2.
3.
4.
5.
6.
CR102 is the weight of the patient at time of transport.
CR106 is the distance traveled during transport.
CR107 is the address of origin.
CR108 is the address of destination.
CR109 is the purpose for the round trip ambulance service.
CR110 is the purpose for the usage of a stretcher during ambulance service.
Notes:
1. Required on all ambulance claims if the information is different than in the CR1 at the claim level (Loop
ID-2300).
Example:
CR1*LB*140*I*A*DH*12****UNCONSCIOUS~
837P_CG.ecs
606
For internal use only
12/1/2010
Health Care Claim: Professional - 837
CR2 Spinal Manipulation Service
Information
Pos: 430
Max: 5
Detail - Optional
Loop: 2400
Elements: 4
User Option (Usage): Situational
Purpose: To supply information related to the chiropractic service rendered to a patient
Element Summary:
Ref
Id
Element Name
CR208
1342
Nature of Condition Code
Req
Type
Min/Max
Usage
O
ID
1/1
Required
1/80
Situational
Description: Code indicating the nature of a patient's condition
Industry: Patient Condition Code
Alias: Nature of Condition Code. Spinal Manipulation
NSF Reference: GC0-11.0
All valid standard codes are used. (Total Codes: 7)
CR210
352
Description
O
AN
Description: A free-form description to clarify the related data elements and their content
Industry: Patient Condition Description
Alias: Patient Condition Description, Chiropractic
NSF Reference: GC0-14.0
Used at discretion of submitter.
CR211
352
Description
O
AN
1/80
Situational
Description: A free-form description to clarify the related data elements and their content
Industry: Patient Condition Description
Alias: Patient Condition Description, Chiropractic
NSF Reference: GC0-14.0
Used at discretion of submitter.
CR212
1073
Yes/No Condition or Response Code
O
ID
1/1
Situational
Description: Code indicating a Yes or No condition or response
Industry: X-ray Availability Indicator
Alias: X-ray Availability Indicator, Chiropractic
NSF Reference: GC0-15.0
Required for service dates prior to January 1, 2000.
CodeList Summary (Total Codes: 4, Included: 2)
Code Name
N
Y
No
Yes
Syntax Rules:
1. P0102 - If either CR201 or CR202 is present, then the other is required.
2. C0403 - If CR204 is present, then CR203 is required.
3. P0506 - If either CR205 or CR206 is present, then the other is required.
837P_CG.ecs
607
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Semantics:
1.
2.
3.
4.
5.
CR201 is the number this treatment is in the series.
CR202 is the total number of treatments in the series.
CR206 is the time period involved in the treatment series.
CR207 is the number of treatments rendered in the month of service.
CR209 is complication indicator. A "Y" value indicates a complicated condition; an "N" value indicates an
uncomplicated condition.
6. CR210 is a description of the patient's condition.
7. CR211 is an additional description of the patient's condition.
8. CR212 is X-rays availability indicator. A "Y" value indicates X-rays are maintained and available for carrier
review; an "N" value indicates X-rays are not maintained and available for carrier review.
Comments:
1. When both CR203 and CR204 are present, CR203 is the beginning level of subluxation and CR204 is the
ending level of subluxation.
Notes:
1. Required on chiropractic claims involving spinal manipulation and known to impact payer’s adjudication
process.
Example:
CR2********M****Y~
837P_CG.ecs
608
For internal use only
12/1/2010
Health Care Claim: Professional - 837
CR3 Durable Medical Equipment
Certification
Pos: 435
Max: 1
Detail - Optional
Loop: 2400
Elements: 3
User Option (Usage): Situational
Purpose: To supply information regarding a physician's certification for durable medical equipment
Element Summary:
Ref
Id
Element Name
CR301
1322
Certification Type Code
Req
Type
Min/Max
Usage
O
ID
1/1
Required
ID
2/2
Required
Description: Code indicating the type of certification
NSF Reference: GU0-04.0
CodeList Summary (Total Codes: 14, Included: 3)
Code Name
I
R
S
CR302
355
Initial
Renewal
Revised
Unit or Basis for Measurement Code
C
Description: Code specifying the units in which a value is being expressed, or manner in
which a measurement has been taken
CodeList Summary (Total Codes: 794, Included: 1)
Code Name
MO
CR303
380
Months
Quantity
C
R
1/15
Required
Description: Numeric value of quantity
Industry: Durable Medical Equipment Duration
Alias: DME Duration
NSF Reference: GU0-21.0
Length of time DME equipment is needed.
Syntax Rules:
1. P0203 - If either CR302 or CR303 is present, then the other is required.
Semantics:
1. CR302 and CR303 specify the time period covered by this certification.
2. CR305 is the prognosis of the patient.
Notes:
1. Required if it is necessary to include supporting documentation in an electronic form for Medicare DMERC
claims for which the provider is required to obtain a certificate of medical necessity (CMN) from the physician.
Example:
CR3*I*MO*6~
837P_CG.ecs
609
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 445
CR5 Home Oxygen Therapy
Max: 1
Detail - Optional
Information
Loop: 2400
Elements: 8
User Option (Usage): Situational
Purpose: To supply information regarding certification of medical necessity for home oxygen therapy
Element Summary:
Ref
Id
Element Name
CR501
1322
Certification Type Code
Req
Type
Min/Max
Usage
O
ID
1/1
Required
R
1/15
Required
R
1/15
Situational
R
1/15
Situational
1/1
Required
Description: Code indicating the type of certification
Alias: Certification Type Code. Oxygen Therapy
NSF Reference: GX0-04.0
CodeList Summary (Total Codes: 14, Included: 3)
Code Name
I
R
S
CR502
380
Initial
Renewal
Revised
Quantity
O
Description: Numeric value of quantity
Industry: Treatment Period Count
Alias: Certification Period, Home Oxygen Therapy
NSF Reference: GX0-06.0
CR510
380
Quantity
O
Description: Numeric value of quantity
Industry: Arterial Blood Gas Quantity
Alias: Arterial Blood Gas
NSF Reference: GX0-22.0
Either CR510 or CR511 is required.
Required on claims which report arterial blood gas.
CR511
380
Quantity
O
Description: Numeric value of quantity
Industry: Oxygen Saturation Quantity
Alias: Oxygen Saturation
NSF Reference: GX0-23.0
Either CR510 or CR511 is required.
Required on claims which report oxygen saturation quantity.
CR512
1349
Oxygen Test Condition Code
O
ID
Description: Code indicating the conditions under which a patient was tested
Alias: Oxygen test condition code
NSF Reference: GX0-26.0
CodeList Summary (Total Codes: 7, Included: 3)
837P_CG.ecs
610
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Code Name
E
R
S
CR513
1350
Exercising
At rest on room air
Sleeping
Oxygen Test Findings Code
O
ID
1/1
Situational
Description: Code indicating the findings of oxygen tests performed on a patient
Alias: Oxygen test finding code
NSF Reference: GX0-27.0
Required if patient’s arterial PO2 is greater than 55 mmHg and less than 60 mmHg, or
oxygen saturation is greater than 88%. Use CR513, CR514, or CR515 as appropriate.
CodeList Summary (Total Codes: 3, Included: 1)
Code Name
1
CR514
1350
Dependent edema suggesting congestive heart failure
Oxygen Test Findings Code
O
ID
1/1
Situational
Description: Code indicating the findings of oxygen tests performed on a patient
Alias: Oxygen test finding code
NSF Reference: GX0-27.0
Required if patient’s arterial PO2 is greater than 55 mmHg and less than 60 mmHg, or
oxygen saturation is greater than 88%. Use CR513, CR514, or CR515 as appropriate.
CodeList Summary (Total Codes: 3, Included: 1)
Code Name
2
CR515
1350
"P" Pulmonale on Electrocardiogram (EKG)
Oxygen Test Findings Code
O
ID
1/1
Situational
Description: Code indicating the findings of oxygen tests performed on a patient
Alias: Oxygen test finding code
NSF Reference: GX0-27.0
Required if patient’s arterial PO2 is greater than 55 mmHg and less than 60 mmHg, or
oxygen saturation is greater than 88%. Use CR513, CR514, or CR515 as appropriate.
CodeList Summary (Total Codes: 3, Included: 1)
Code Name
3
Erythrocythemia with a hematocrit greater than 56 percent
Semantics:
1.
2.
3.
4.
5.
6.
7.
8.
9.
CR502 is the number of months covered by this certification.
CR505 is the reason for equipment.
CR506 is the oxygen flow rate in liters per minute.
CR507 is the number of times per day the patient must use oxygen.
CR508 is the number of hours per period of oxygen use.
CR509 is the special orders for the respiratory therapist.
CR510 is the arterial blood gas.
CR511 is the oxygen saturation.
CR516 is the oxygen flow rate for a portable oxygen system in liters per minute.
Notes:
837P_CG.ecs
611
For internal use only
12/1/2010
Health Care Claim: Professional - 837
1. Required on all initial, renewal, and revision home oxygen therapy claims.
Example:
CR5*I*6********56**R*1~
837P_CG.ecs
612
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 450
CRC Ambulance Certification
Max: 3
Detail - Optional
Loop: 2400
Elements: 7
User Option (Usage): Situational
Purpose: To supply information on conditions
Element Summary:
Ref
Id
Element Name
Req
Type
Min/Max
Usage
CRC01
1136
Code Category
M
ID
2/2
Required
Description: Specifies the situation or category to which the code applies
CodeList Summary (Total Codes: 341, Included: 1)
Code Name
07
CRC02
1073
Ambulance Certification
Yes/No Condition or Response Code
M
ID
1/1
Required
2/2
Required
Description: Code indicating a Yes or No condition or response
Industry: Certification Condition Indicator
Alias: Certification Condition Code, Ambulance Certification
CodeList Summary (Total Codes: 4, Included: 2)
Code Name
N
Y
CRC03
1321
No
Yes
Condition Indicator
M
ID
Description: Code indicating a condition
Industry: Condition Code
Alias: Condition Indicator
The codes for CRC03 also can be used for CRC04 through CRC07.
CodeList Summary (Total Codes: 1079, Included: 10)
Code Name
01
Patient was admitted to a hospital
NSF Reference:
GA0-06.0
02
Patient was bed confined before the ambulance service
NSF Reference:
03
Patient was bed confined after the ambulance service
NSF Reference:
GA0-08.0
GA0-09.0
04
Patient was moved by stretcher
NSF Reference:
05
Patient was unconscious or in shock
NSF Reference:
GA0-10.0
837P_CG.ecs
613
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Code Name
GA0-11.0
06
Patient was transported in an emergency situation
NSF Reference:
GA0-12.0
07
Patient had to be physically restrained
NSF Reference:
GA0-13.0
08
Patient had visible hemorrhaging
NSF Reference:
GA0-14.0
09
Ambulance service was medically necessary
NSF Reference:
GA0-16.0
60
Transportation Was To the Nearest Facility
NSF Reference:
GA0-24.0
CRC04
1321
Condition Indicator
O
ID
2/2
Situational
Description: Code indicating a condition
Industry: Condition Code
Alias: Condition Indicator
Required if additional condition codes are needed.
Use the codes listed in CRC03.
CodeList Summary (Total Codes: 1079, Included: 10)
Code Name
01
Patient was admitted to a hospital
NSF Reference:
02
Patient was bed confined before the ambulance service
NSF Reference:
GA0-06.0
GA0-08.0
03
Patient was bed confined after the ambulance service
NSF Reference:
04
Patient was moved by stretcher
NSF Reference:
GA0-09.0
GA0-10.0
05
Patient was unconscious or in shock
NSF Reference:
06
Patient was transported in an emergency situation
NSF Reference:
GA0-11.0
GA0-12.0
07
837P_CG.ecs
Patient had to be physically restrained
NSF Reference:
614
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Code Name
GA0-13.0
08
Patient had visible hemorrhaging
NSF Reference:
GA0-14.0
09
Ambulance service was medically necessary
NSF Reference:
GA0-16.0
60
Transportation Was To the Nearest Facility
NSF Reference:
GA0-24.0
CRC05
1321
Condition Indicator
O
ID
2/2
Situational
Description: Code indicating a condition
Industry: Condition Code
Alias: Condition Indicator
Required if additional condition codes are needed.
Use the codes listed in CRC03.
CodeList Summary (Total Codes: 1079, Included: 10)
Code Name
01
Patient was admitted to a hospital
NSF Reference:
02
Patient was bed confined before the ambulance service
NSF Reference:
GA0-06.0
GA0-08.0
03
Patient was bed confined after the ambulance service
NSF Reference:
04
Patient was moved by stretcher
NSF Reference:
GA0-09.0
GA0-10.0
05
Patient was unconscious or in shock
NSF Reference:
06
Patient was transported in an emergency situation
NSF Reference:
GA0-11.0
GA0-12.0
07
Patient had to be physically restrained
NSF Reference:
08
Patient had visible hemorrhaging
NSF Reference:
GA0-13.0
GA0-14.0
09
837P_CG.ecs
Ambulance service was medically necessary
NSF Reference:
615
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Code Name
GA0-16.0
60
Transportation Was To the Nearest Facility
NSF Reference:
GA0-24.0
CRC06
1321
Condition Indicator
O
ID
2/2
Situational
2/2
Situational
Description: Code indicating a condition
Industry: Condition Code
Alias: Condition Indicator
Required if additional condition codes are needed.
Use the codes listed in CRC03.
CodeList Summary (Total Codes: 1079, Included: 10)
Code Name
01
Patient was admitted to a hospital
NSF Reference:
02
Patient was bed confined before the ambulance service
NSF Reference:
GA0-06.0
GA0-08.0
03
Patient was bed confined after the ambulance service
NSF Reference:
04
Patient was moved by stretcher
NSF Reference:
GA0-09.0
GA0-10.0
05
Patient was unconscious or in shock
NSF Reference:
06
Patient was transported in an emergency situation
NSF Reference:
GA0-11.0
GA0-12.0
07
Patient had to be physically restrained
NSF Reference:
08
Patient had visible hemorrhaging
NSF Reference:
GA0-13.0
GA0-14.0
09
Ambulance service was medically necessary
NSF Reference:
60
Transportation Was To the Nearest Facility
NSF Reference:
GA0-16.0
GA0-24.0
CRC07
837P_CG.ecs
1321
Condition Indicator
O
616
ID
For internal use only
12/1/2010
Ref
Health Care Claim: Professional - 837
Id
Element Name
Req
Type
Min/Max
Usage
Description: Code indicating a condition
Industry: Condition Code
Alias: Condition Indicator
Required if additional condition codes are needed.
Use the codes listed in CRC03.
CodeList Summary (Total Codes: 1079, Included: 10)
Code Name
01
Patient was admitted to a hospital
NSF Reference:
02
Patient was bed confined before the ambulance service
NSF Reference:
GA0-06.0
GA0-08.0
03
Patient was bed confined after the ambulance service
NSF Reference:
GA0-09.0
04
Patient was moved by stretcher
NSF Reference:
GA0-10.0
05
Patient was unconscious or in shock
NSF Reference:
GA0-11.0
06
Patient was transported in an emergency situation
NSF Reference:
GA0-12.0
07
Patient had to be physically restrained
NSF Reference:
GA0-13.0
08
Patient had visible hemorrhaging
NSF Reference:
GA0-14.0
09
Ambulance service was medically necessary
NSF Reference:
GA0-16.0
60
Transportation Was To the Nearest Facility
NSF Reference:
GA0-24.0
Semantics:
1. CRC01 qualifies CRC03 through CRC07.
2. CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03
through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply.
Notes:
1. The maximum number of CRC segments which can occur per 2400 loop is 3. Submitters are free to mix and
837P_CG.ecs
617
For internal use only
12/1/2010
Health Care Claim: Professional - 837
match the three types of service line level CRC segments shown in this implementation guide to meet their
billing/reporting needs but no more than a total of 3 CRC segments per 2400 loop are allowed.
2. Required on all service lines which bill/report ambulance services if the information is different when
CRC01=07 in Loop ID-2300.
Example:
CRC*07*Y*08~
837P_CG.ecs
618
For internal use only
12/1/2010
Health Care Claim: Professional - 837
CRC Hospice Employee Indicator
Pos: 450
Max: 1
Detail - Optional
Loop: 2400
Elements: 3
User Option (Usage): Situational
Purpose: To supply information on conditions
Element Summary:
Ref
Id
Element Name
Req
Type
Min/Max
Usage
CRC01
1136
Code Category
M
ID
2/2
Required
Description: Specifies the situation or category to which the code applies
CodeList Summary (Total Codes: 341, Included: 1)
Code Name
70
CRC02
1073
Hospice
Yes/No Condition or Response Code
M
ID
1/1
Required
Description: Code indicating a Yes or No condition or response
Industry: Hospice Employed Provider Indicator
Alias: Hospice Employee Indicator
NSF Reference: FA0-40.0
A “Y” value indicates the provider is employed by the hospice. A “N” value indicates the
provider is not employed by the hospice.
CodeList Summary (Total Codes: 4, Included: 2)
Code Name
N
Y
CRC03
1321
No
Yes
Condition Indicator
M
ID
2/2
Required
Description: Code indicating a condition
CodeList Summary (Total Codes: 1079, Included: 1)
Code Name
65
Open
Use this code as a place holder (element is mandatory) when reporting whether
the provider is a hospice employee.
Semantics:
1. CRC01 qualifies CRC03 through CRC07.
2. CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03
through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply.
Notes:
1. The example shows the method used to indicate whether the rendering provider is an employee of the hospice.
2. The maximum number of CRC segments which can occur per 2400 loop is 3. Submitters are free to mix and
match the three types of service line level CRC segments shown in this implementation guide to meet their
billing/reporting needs but no more than a total of 3 CRC segments per 2400 loop are allowed.
3. Required on all Medicare claims involving physician services to hospice patients.
837P_CG.ecs
619
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Example:
CRC*70*Y*65~
837P_CG.ecs
620
For internal use only
12/1/2010
Health Care Claim: Professional - 837
CRC DMERC Condition Indicator
Pos: 450
Max: 2
Detail - Optional
Loop: 2400
Elements: 7
User Option (Usage): Situational
Purpose: To supply information on conditions
Element Summary:
Ref
Id
Element Name
Req
Type
Min/Max
Usage
CRC01
1136
Code Category
M
ID
2/2
Required
Description: Specifies the situation or category to which the code applies
CodeList Summary (Total Codes: 341, Included: 2)
Code Name
09
11
CRC02
1073
Durable Medical Equipment Certification
Oxygen Therapy Certification
Yes/No Condition or Response Code
M
ID
1/1
Required
2/2
Required
Description: Code indicating a Yes or No condition or response
Industry: Certification Condition Indicator
Alias: Certification Condition Code Applies Indicator
CodeList Summary (Total Codes: 4, Included: 2)
Code Name
N
Y
CRC03
1321
No
Yes
Condition Indicator
M
ID
Description: Code indicating a condition
Alias: Condition Indicator
Use “P1" (GX0-20.0) to answer the Medicare Oxygen CMN question: ”The test was
performed either with the patient in a chronic stable state as an outpatient or within two
days prior to discharge from an inpatient facility to home."
Code ZV was approved by ASC X12 in the version 004011 Data Dictionary but is included
in this guide to provide standard way to report DMERC claims within the HIPAA
implementation time frame. It is recommended that entities who have a need to submit or
receive DMERC claims customize their 004010 translator map to allow this exception code.
CodeList Summary (Total Codes: 1080, Included: 5)
Code Name
37
Oxygen delivery equipment is stationary
NSF Reference:
GX0-05.0
38
Certification signed by the physician is on file at the supplier's office
GX0-35.0
GU0-24.0
AL
Ambulation Limitations
NSF Reference:
GX0-05.0
P1
837P_CG.ecs
Patient was Discharged from the First Facility
621
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Code Name
NSF Reference:
GX0-20.0
ZV
Replacement Item
NSF Reference:
GU0-06.0
CRC04
1321
Condition Indicator
O
ID
2/2
Situational
Description: Code indicating a condition
Alias: Condition Indicator
Required if additional condition codes are needed.
Use the codes listed in CRC03.
CodeList Summary (Total Codes: 1080, Included: 5)
Code Name
37
Oxygen delivery equipment is stationary
NSF Reference:
GX0-05.0
38
Certification signed by the physician is on file at the supplier's office
NSF Reference:
GX0-35.0
GU0-24.0
AL
Ambulation Limitations
NSF Reference:
GX0-05.0
P1
Patient was Discharged from the First Facility
NSF Reference:
GX0-20.0
ZV
Replacement Item
NSF Reference:
GU0-06.0
CRC05
1321
Condition Indicator
O
ID
2/2
Situational
Description: Code indicating a condition
Alias: Condition Indicator
Required if additional condition codes are needed.
Use the codes listed in CRC03.
CodeList Summary (Total Codes: 1080, Included: 5)
Code Name
37
Oxygen delivery equipment is stationary
NSF Reference:
GX0-05.0
38
Certification signed by the physician is on file at the supplier's office
NSF Reference:
GX0-35.0
GU0-24.0
AL
837P_CG.ecs
Ambulation Limitations
622
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Code Name
NSF Reference:
GX0-05.0
P1
Patient was Discharged from the First Facility
NSF Reference:
GX0-20.0
ZV
Replacement Item
NSF Reference:
GU0-06.0
CRC06
1321
Condition Indicator
O
ID
2/2
Situational
Description: Code indicating a condition
Alias: Condition Indicator
Required if additional condition codes are needed.
Use the codes listed in CRC03.
CodeList Summary (Total Codes: 1080, Included: 5)
Code Name
37
Oxygen delivery equipment is stationary
NSF Reference:
38
Certification signed by the physician is on file at the supplier's office
NSF Reference:
GX0-05.0
GX0-35.0
GU0-24.0
AL
Ambulation Limitations
NSF Reference:
GX0-05.0
P1
Patient was Discharged from the First Facility
NSF Reference:
GX0-20.0
ZV
Replacement Item
NSF Reference:
GU0-06.0
CRC07
1321
Condition Indicator
O
ID
2/2
Situational
Description: Code indicating a condition
Alias: Condition Indicator
Required if additional condition codes are needed.
Use the codes listed in CRC03.
CodeList Summary (Total Codes: 1080, Included: 5)
Code Name
37
Oxygen delivery equipment is stationary
NSF Reference:
38
Certification signed by the physician is on file at the supplier's office
NSF Reference:
GX0-05.0
837P_CG.ecs
623
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Code Name
GX0-35.0
GU0-24.0
AL
Ambulation Limitations
NSF Reference:
GX0-05.0
P1
Patient was Discharged from the First Facility
NSF Reference:
ZV
Replacement Item
NSF Reference:
GX0-20.0
GU0-06.0
Semantics:
1. CRC01 qualifies CRC03 through CRC07.
2. CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03
through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply.
Notes:
1. Required on all oxygen therapy and DME claims that require a certificate of medical necessity (CMN).
2. The maximum number of CRC segments which can occur per 2400 loop is 3. Submitters are free to mix and
match the three types of service line level CRC segments shown in this implementation guide to meet their
billing/reporting needs but no more than a total of 3 CRC segments per 2400 loop are allowed.
3. The first example shows a case where an item billed was not a replacement item.
Example:
CRC*09*N*ZV~
CRC*11*Y*37*38*P1~
837P_CG.ecs
624
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Pos: 455
DTP Date - Service Date
Max: 1
Detail - Optional
Loop: 2400
Elements: 3
User Option (Usage): Required
Purpose: To specify any or all of a date, a time, or a time period
Element Summary:
Ref
Id
Element Name
DTP01
374
Date/Time Qualifier
Req
Type
Min/Max
Usage
M
ID
3/3
Required
Description: Code specifying type of date or time, or both date and time
Industry: Date Time Qualifier
CodeList Summary (Total Codes: 1112, Included: 1)
Code Name
472
DTP02
1250
Service
Use RD8 in DTP02 to indicate begin/end or from/to dates.
Date Time Period Format Qualifier
M
ID
2/3
Required
Description: Code indicating the date format, time format, or date and time format
CodeList Summary (Total Codes: 39, Included: 2)
Code Name
D8
RD8
DTP03
1251
Date Expressed in Format CCYYMMDD
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
Use RD8 if it is necessary to indicate begin/end dates. Date range indicates drug
duration for which the supply of drug be will 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 (e.g., 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.
Date Time Period
M
AN
1/35
Required
Description: Expression of a date, a time, or range of dates, times or dates and times
Industry: Service Date
NSF Reference: FA0-05.0, FA0-06.0
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
Notes:
1. The total number of DTP segments in the 2400 loop cannot exceed 15.
2. In cases where a drug is being billed on a service line, the Date of Service DTP may be used to indicate the
range of dates through which the drug will be used by the patient. Use RD8 for this purpose.
3. In cases where a drug is being billed on a service line, the Date of Service DTP is used to indicate the date the
prescription was written (or otherwise communicated by the prescriber if not written).
837P_CG.ecs
625
For internal use only
12/1/2010
Health Care Claim: Professional - 837
Example:
DTP*472*RD8*19970607-19970608~
837P_CG.ecs
626
For internal use only
12/1/2010
Health Care Claim: Professional - 837
DTP Date - Certification Revision
Date
Pos: 455
Max: 1
Detail - Optional
Loop: 2400
Elements: 3
User Option (Usage): Situational
Purpose: To specify any or all of a date, a time,