278-13/278-11 Companion Guide
278-13/278-11 HIPAA Transaction
Companion Guide
HIPAA/V5010X217
Version: 1.0
6/1/2014
278-13/278-11 Companion Guide
Document History
DOCUMENT VERSION HISTORY TABLE
Version Sections Revised
1.0
2
Description
Initial
Revised By
Paula Arenz
Date
6/1/2014
278-13/278-11 Companion Guide
Table of Contents
Document History ......................................................................................................................................... 2
Table of Contents .......................................................................................................................................... 3
1
Introduction ......................................................................................................................................... 4
1.1
Scope ............................................................................................................................................. 4
1.2
References .................................................................................................................................... 4
1.3
Additional Information.................................................................................................................. 5
2
Getting Started ..................................................................................................................................... 5
2.1
Working with Blue Shield of California ......................................................................................... 5
2.2
Trading Partner Registration ......................................................................................................... 5
2.3
Certification and Testing Overview ............................................................................................... 5
3
Testing With Payer ............................................................................................................................... 6
3.1
4
Testing and Production Phases ..................................................................................................... 6
Connectivity with the Payer/Communications .................................................................................... 8
4.1
Process Flows ................................................................................................................................ 8
4.2
Transmission Administrative Procedures ..................................................................................... 8
4.3
Re-Transmission Procedure .......................................................................................................... 9
4.4
Communication Protocol Specifications ....................................................................................... 9
5
Contact Information ............................................................................................................................. 9
6
Control Segments/Envelopes: ............................................................................................................ 10
6.1
ISA-IEA Envelope Data................................................................................................................. 10
6.2
GS-GE-Functional Group Header ................................................................................................ 14
6.3
ST-SE Transaction Set Header ..................................................................................................... 16
7
Payer Specific Business Rules and Limitations ................................................................................... 17
8
Acknowledgments and Reports-Reports Inventory ........................................................................... 17
9
Trading Partner Agreements .............................................................................................................. 18
10
Transaction Specific Information ....................................................................................................... 18
11
Appendices ......................................................................................................................................... 18
3
278-13/278-11 Companion Guide
1 Introduction
This Companion Guide to the v5010 ASC X12N 278-13 and 278-11 Implementation Guides and
associated errata adopted under HIPAA, clarifies and specifies the data content when exchanging
eligibility data electronically with Blue Shield of California (BSC) Health Plan. Transmissions based on this
companion guide, used in tandem with the v5010 ASC X12N Implementation Guides, are compliant with
both ASC X12 syntax and those guides. This Companion Guide is intended to convey information that is
within the framework of the ASC X12N Implementation Guides adopted for use under HIPAA. The
Companion Guide is not intended to convey information that in any way exceeds the requirements or
usages of data expressed in the Implementation Guides.
1.1 Scope
This document should be used as a guide when sending or receiving authorization or certifications data
via a standard 278-13/278-11 EDI transaction to the BSC EDI system.
BSC EDI is a system through which trading partners can submit 278-13 EDI transactions as well as
receive 278-11 EDI transactions. This document describes how a submitter uses the system to submit
files and receive acknowledgements and reports.
Before using BSC EDI Channel, it is important to determine your compatibility in relation to BSC EDI
Channel.
1. You must be able to send and receive X12 health care EDI files.
2. You must be able to extract information from your system and interpret it.
3. You must have sufficient EDI technical knowledge to make adjustments to your system, as
necessary.
4. You must be able to interact with BSC EDI Channel.
5. Overview
This companion document has been separated into multiple sections:
1. Getting Started
2. Connectivity with Payer/Communications
3. Contact Information
4. Control Segments/Envelopes
1.2 References
The standard HIPAA transaction implementation guides are referenced by this guide. Copies of current
guides may be obtained from www.wpc-edi.com
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278-13/278-11 Companion Guide
1.3 Additional Information
This document was developed to provide users of BSC EDI with the necessary information in order to
exchange EDI transactions with BSC. With the assumption that the user has working level EDI
knowledge, this document focuses on the use of the BSC EDI system and does provide background
information on EDI transactions and their use.
2 Getting Started
2.1 Working with Blue Shield of California
This guide includes the instructions you will need to get connected and start sending/receiving standard
278-13 and 278-11 transactions with BSC. Make sure you read the entire guide in order to take
advantage of the full functionality of the system.
2.2 Trading Partner Registration
Before submitting or receiving a 278-13 or 278-11 transaction, you must register as a Trading Partner
with BSC to ensure you are established and recognized in our system. To register, please fill out the
Enrollment Application and Trading Partner Agreements and submit to:
Email: [email protected]
Fax: 530-351-6150
2.3 Certification and Testing Overview
The purpose of BSC EDI testing phase is to provide you with a mechanism to produce the same reports
and acknowledgments that are produced once you are in production. This allows you to test your ability
to produce correct data content and to receive and process the acknowledgments and files we produce
for you. By testing with BSC EDI, you will be allowed to send transactions. Transactions go from you to
BSC Non-Production Environment, as would be the case in a Production Environment. A general
breakdown of the process goes like this:
1. You will be set up with connectivity to perform connectivity testing.
2. You would receive one of 3 acknowledgments: a 278-11 response, a TA1 acknowledgment, or a 999
rejection.
3. The 999 will show any errors or problems that were found in the transaction sent. The errors or
problems could be related to the HIPAA standards or directly to the BSC Companion Guide.
4. You will continue to test until you have resolved any issues. Then, request to have your status for the
specific transaction you have been testing changed from test to production.
5. Your test to production status change request will be reviewed by BSC and you will be notified via
email when your request has been approved. When your request has been approved you will be notified
that you are now able to send transactions in Production.
More than one transaction type can be run simultaneously. You can also be granted production status for
one type of transaction and still be in test mode for other transactions.
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278-13/278-11 Companion Guide
There are no technical limits to the number of transactions you can submit in a single batch file; however,
there are some practical limits. Files with large numbers of transactions will generate reports with large
amounts of data. Keep this in mind as you prepare your systems to send files to BSC EDI. For RealTime transactions you will need to send one 278-13 transaction request per file.
The communication protocol is tested as a part of first-time testing. Any time a communication protocol is
changed, some testing is needed. The communication protocols for sending transactions to BSC EDI are
the same for testing as for production.
3 Testing With Payer
After we receive and process your EDI Registration Form, your BSC EDI Analyst will work with you
through our testing process. Our testing process is required for all trading partners in order to minimize
production problems.
If you have questions or concerns about testing, please call our EDI Analyst. See Section 5 for contact
information.
Proper preparation before testing will ease the testing process and promote its success.
Trading Partners must:
-
Read and make sure that you understand the terms and conditions of the BSC Trading Partner
Agreement (TPA), accept the conditions and terms of the TPA.
-
Read all chapters and appendices of this Companion Guide.
-
Complete and email, fax or mail the BSC Registration Form with the required attachments to your
BSC EDI Analyst.
-
After we receive and process you completed EDI Registration Form, your BSC EDI Analyst will
contact you to discuss your testing schedule and the testing process.
3.1 Testing and Production Phases
You will need to repeat the following Phase I and Phase II testing procedures for each transaction type
that you want to submit.
Phase I: Testing EDI Connections in Non-Production Environment (Using Limited Test Data)
The BSC Trading Partner X12 testing process has 2 phases as well for the 278-13.
1. Checks the outer envelope in the order of the transaction segments
2. Checks values to ensure that they comply with the specifications in the X12 Implementation
nd
Guides. During this 2 section, you will submit test files and receive acknowledgments in
response to your files.
Upon Receipt of your BSC Trading Partner Registration form and the required attachments, your BSC
EDI Analyst will contact you to schedule Phase I testing.
6
278-13/278-11 Companion Guide
Creating and Submitting Your Test Files
Please ensure that your Phase I test files abide by the following instructions:
-
Create test files with X12 version 005010.
-
Limited set of agreed upon test scenarios.
-
Create test files using the same means you will use to create files for productions data. The test
files must contain realistic data. Do not handcraft data specifically for testing.
-
Include a representative sampling of the types of transactions you typically submit.
-
In the Interchange Control Header, ISA15 (Usage Indicator), enter T to indicate test data.
Upon successful completion of Phase I, Phase II can begin. Phase II checks values to ensure that they
comply with the specification in the X12 Implementation Guides. During Phase II, you will submit test files
and receive reports in response to your files. To test 27X files, you will construct and submit test files as
explained in this section.
Phase II: Production (validation testing) to make sure TP setup has been promoted to Production
environment.
Once you have received production status for a transaction, BSC recommends that you send a limited
run of production data. This will help ensure that it will be easier to troubleshoot problems that may arise
during the first few production runs. It is up to you how many transactions you send, but you should use
prudence as you select the size and scope of the first few production runs.
Once out of testing mode, you will send real transactions that will be processed by BSC production
applications. You will receive reports related to your production file submissions and the actual X12
transactions generated by BSC production applications in response to your production file submissions.
Note: Ensure that your ISA15 is set to “P” when submitting transactions for Production.
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278-13/278-11 Companion Guide
4 Connectivity with the Payer/Communications
4.1 Process Flows
The following is a high level process flow of a 278-13/278-11 Transaction
Trading Partner transmits
Authorization Request
transaction to BSC
BSC receives transaction
and verifies Trading Partner
BSC Validates X12 Format
and Content
BSC accepts authorizaton
request for further
processing
BSC generates authorization
acknowledgement
transaction
BSC returns response to
Trading Partner
4.2 Transmission Administrative Procedures
Schedule, Availability, and Downtime Notification
Effective January 2013, the BSC 278-13/278-11 system is available:
Real Time: Sunday 22:00 through Saturday 21:59 PST
Batch Transactions: 24x7 Sunday through Saturday
BSC will notify Trading Partners of any additional planned downtime via e-mail.
Any unplanned downtime will be communicated to Trading Partners via e-mail. A follow up e-mail will be
sent once the system becomes available.
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278-13/278-11 Companion Guide
4.3 Re-Transmission Procedure
Trading Partners may contact BSC for assistance in researching problems with their transactions.
However, BSC will not edit Trading Partner authorization data and/or resubmit transactions for processing
on behalf of a Trading Partner. The transaction must be corrected and re-submitted by the Trading
Partner.
4.4 Communication Protocol Specifications
BSC receives and transmits transactions using MQ and HTTP/s protocols for real-time mode, and sFTP
and HTTP/s for batch mode.
For MQ, both server-to-server and client-to-server connections are supported. B2B VPN connectivity
must be established between both the Trading Partner and BSC. Separate MQ connections must be
made for each inquiry transaction type, however a single MQ connection may be used for the receipt of
all registered transaction responses from BSC.
BSC supports CORE Phase II HTTP/s open connectivity standards, HTTP MIME Multipart and
SOAP+WSDL, for both real-time and batch modes.
Specific connectivity information, including passwords, will be provided to you once you send in your
Trading Partner Registration.
Unique file naming conventions are required for batch mode transactions:
1.) A standard naming convention is required to be used for the files you will be sending to BSC.
The file convention is stated as the following:
SubmitterID_Date_Time.278
i.e.: Submitter ID_YYYYMMDD_HHMMSS.278
2.) The outbound file naming convention for 278-11 files in response to 278-13 files shall be as
follows:
[InterchangeRecieverID]_HHmmsssSSSSyyyyMMddX217.278 Where
HHmmsssSSSSyyyyMMdd is two digit hour, two digit minutes, seconds with leading zeros,
milliseconds with leading zero, four digit year, two digit month and two digit day followed by value
“X217” to identify 278-11 files in response to a 278-13 request.
Example: 12345_1600001043220140713X217.278
5 Contact Information
EDI Customer Service: 1-800-480-1221
EDI Technical Assistance: 1-877-747-6800
Provider Service Number: www.blueshieldca.com/provider Phone#: 1-800-258-3091 Opt #3 for
provider contract related questions.
Applicable Websites/E-Mail:
www.blueshieldca.com/provider
[email protected]
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278-13/278-11 Companion Guide
www.blueshieldca.com
6 Control Segments/Envelopes:
6.1 ISA-IEA Envelope Data
The Interchange Control Header (ISA) is the first record of the entire Interchange. Every X12 Interchange
must begin with an ISA Segment.
Purpose: To start and identify an interchange of zero or more functional groups and
Interchange-related control segments.
File Delimiters:
1. ISA Segment: This segment is 106 byte fixed length record. Insert trailing spaces after String
type (AN) element values and leading zeroes before Numeric type (Nn) element values as
needed to comply with the length requirement.
2. Data Element Separator: The fourth byte within the ISA record (the first byte after ISA) tells the
receiver what value the sender is using as a data element separator. The value used as the data
element separator must not be present within any data element in the transaction.
a. To BSC: Send the value used as the Data Element Separator in the transaction following
this ISA segment.
b. From BSC: In response to the 278-13 transactions, the value sent to BSC with ISA
record accompanying the 278-13 will be returned on the 278-11 response.
3. Repetition Separator: Byte 83 (ISA11) within the ISA record is a simple or composite data
elements within a segment that can be designated as repeating data elements. Repeating data
elements are adjacent data elements that occur up to a number of times specified in the standard
as number of repeats.
a. To BSC: Send the value used as the Repetition Separator in ISA11 of the transaction.
b. From BSC: In response to the 278-13 transactions, the value sent to BSC with ISA
record accompanying the 278-13 will be returned on the 278-11 response.
4. Component Element Separator: Byte 105 (ISA16) within the ISA record. This delimiter is used
to separate Composite Data Structure which is an intermediate unit of information in a segment.
Composite Data Structures are composed of one or more logically related simple data elements,
each, except the last, followed by a Component Element Separator.
a. To BSC: Send the value used as the Component Element Separator in ISA16 of the
transaction.
b. From BSC: In response to the 278-13 transactions, the value sent to BSC with ISA
record accompanying the 278-13 will be returned on the 278-11 response.
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278-13/278-11 Companion Guide
5. Segment Terminator: Byte 106 within the ISA record. The data segment is a unit of information
in a transaction set. A data segment consists of a segment identifier, one or more composite
data structures or simple data elements each proceeded by a data element separator and
succeeded by a segment terminator.
a. To BSC: Send the value used as Segment Terminator in byte 106 within the ISA record
of the transaction.
b. From BSC: In response to the 278-13 transactions, the value sent to BSC with ISA
record accompanying the 278-13 will be returned on the 278-11 response.
Example: ISA✽ 00✽ ..........✽01✽ SECRET....✽ZZ✽ SUBMITTERS.ID..✽ZZ✽
RECEIVERS.ID...✽ 930602✽1253✽}✽00501✽ 000000905✽ 1✽T✽:~
Table:
Seg
Fld
ISA01
ISA02
ISA03
ISA04
Name
Authorization
Information
Qualifier
Authorization
Information
Security
Information
Qualifier
Security
Information
11
Req
M
M
M
M
Type
ID
AN
ID
AN
Min
Max
(2/2)
(10/10)
(2/2)
(10/10)
Values allowed by
X12 Standards
00=No authorization
info present.
03=Additional data
identification
If ISA01=00, must
be 10 spaces.
If ISA01=03, must
be mutually agreed
upon.
00=No security info
present.
01=Password.
IF ISA03=00, must
be 10 spaces. IF
ISA03-01, must be
mutually agreed
upon.
Values to be used with
BSC
0
10 spaces
0
10 spaces
278-13/278-11 Companion Guide
Seg
Fld
ISA05
Name
Interchange
Sender ID
Qualifier
Req
M
Type
ID
Min
Max
Values allowed by
X12 Standards
(2/2)
01=Duns
14=Duns plus suffix
20=Health
insurance number
(HIN)
27=CMS carrier ID
number
28=CMS fiscal
intermediary ID
number
29=CMS Medicare
provider /supplier ID
30 U.S. federal tax
ID
33=NAIC ID
ZZ=Mutually
defined.
ISA06
Interchange
Sender ID
M
AN
(15/15)
ISA07
Interchange
Receiver ID
Qualifier
M
ID
(2/2)
ISA08
Interchange
Receiver ID
M
AN
(15/15)
ISA09
Interchange Date
M
DT
(6/6)
ISA10
Interchange
Time
12
M
TM
(4/4)
See ISA05 for
values
Values to be used with
BSC
To BSC: Use the value that
best describes the sender ID
in ISA06. If the value in
ISA06 is an ID assigned to
the sender by BSC or
Enumeron LLC, use ZZ.
From BSC: ZZ
To BSC: Send the value
entered as your sender ID
on the Registration or
Settings page, left justified.
From BSC: 940360524, left
justified.
To BSC: ZZ From BSC: In
response to 278-13
transactions, the value sent
to BSC in the ISA05. In
other transactions BSC will
send ZZ.
To BSC: 940360524, left
justified. From BSC: in
responses to 278-13
transactions, the value sent
to BSC in the ISA06.
Format=YYMMDD
Date from sending system.
Format=HHMM
Time from sending system
using 24 hour format. E.G.,
for 1 PM use 1300.
From BSC: this will be EST.
278-13/278-11 Companion Guide
Seg
Fld
ISA11
ISA12
Name
Repetition
Separator
Interchange
Control Version
Number
Req
Type
Min
Max
M
ID
(1/1)
00501
M
ID
(5/5)
ISA13
M
N0
(9/9)
ISA14
Interchange
Acknowledgment
Accepted
M
ID
(1/1)
ISA15
Usage Indicator
M
ID
(1/1)
ISA16
Values to be used with
BSC
{
Interchange
Control Number
Component
Element
Separator (also
referred to as
"sub-element
separator"
Values allowed by
X12 Standards
M
n/a
(1/1)
00501
Must be the same
as the value sent in
the following IEA02
0=No interchange
ACK requested.
1=Interchange ACK
requested
T=Test
P=Production
The value used as
Component
Element Separator
must no be present
for any other reason
within any data
element in the
transaction.
To BSC: Must be a unique
sequential number that does
not repeat within a 180-day
period.
From BSC: In responses to
278-13 transactions, the
value sent to BSC in the
ISA13. Otherwise, an BSC
assigned unique sequential
number that does not repeat
within a 180-day period.
To BSC: in 278-13
transactions: Must be 0.
T=Test
P=Production
To BSC: The value that is
used as the component
element separator in the
transaction following this ISA
segment.
From
BSC: In responses to 27813 transactions, the value
sent to BSC is the ISA16.
There are several things you can use for the sender ID, as outlined in the HIPAA Implementation Guides.
A summary of those guidelines is included here for your perusal.
The qualifier that designates the type of the sender ID is sent in the ISA05 and can be one of the
following:
01=Duns (Dun & Bradstreet)
14=Duns plus suffix
20=Health Industry Number (HIN)
17=Carrier Identification Number as assigned by CMS
29=Fiscal Intermediary Number as assigned by CMS
30=US Federal Tax ID
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278-13/278-11 Companion Guide
33=NAIC Code
ZZ=Mutually Defined
IEA-Interchange Control Trailer
The Interchange Control Trailer (IEA) is the last record of the entire Interchange. Every X12 Interchange
must end with an IEA segment.
Example: IEA*1*000000905~
Purpose: To define the end of the interchange of zero or more functional groups and interchange-related
control segments.
Table:
Seg/Fld
Name
Req
Type
Min/Max
IEA01
Number of
Functional Groups
M
N0
(1/5)
IEA02
Interchange
Control Number
M
N0
(9/9)
Values allowed by
X12 Standards
The total number of
functional groups (GSGE) contained in the
interchange (ISA-IEA)
Must be the same as
the value sent in the
proceeding ISA13.
Values to be used with
BSC
As required by standard.
As required by standard.
6.2 GS-GE-Functional Group Header
The Functional Group Header (GS) is the first record of an entire Functional Group. Every X12
Functional Group must begin with a GS segment.
GS Example: GS*HS*SENDER CODE*RECEIVER CODE*19971001*0802*1*X*005010X217~
GS Purpose: To indicate the beginning of the functional group and to provide control information.
Table
Seg
Fld
GS01
Name
Functional ID Code
14
Req
M
Type
ID
Min
Max
(2/2)
Values allowed by X12
Standards
FA=999 - Functional ACK
HI=278-13 Authorization.
Values to be used with
BSC
Must reflect the transaction
being submitted within the
Functional Group.
278-13/278-11 Companion Guide
Seg
Fld
GS02
Name
Req
Type
Min
Max
M
AN
(2/15)
Application
Sender's Code
Values allowed by X12
Standards
Values to be used with
BSC
To BSC: Send the value
entered as your Submitter Id
on the Registration or
Settings page, left justified.
From BSC: In responses to
278-13 transactions, the
value sent to BSC in the
GS03. Otherwise, the value
entered as your Submitter Id
on the Registration or
Settings page.
To BSC: Must reflect the
transaction being submitted
within the Functional Group
using the values listed
below.
Eligibility: 278-13 is
940360524.
All other transactions: Send
the value 940360524 (the
value also sent in the ISA08,
without trailing spaces).
GS03
Application
Receiver's Code
M
AN
(2/15)
GS04
Date
M
DT
(8/8)
Format=CCYYMMDD
GS05
Time
M
TM
(4/8)
Format=HHMM
GS06
Group Control
Number
M
N0
(1/9)
Must be equal to the value
sent in the following GE02
GS07
Responsible
Agency Code
M
ID
(1/2)
X=ASC X12
(1/12)
005010=999
00501X217=278-13/27811
GS08
Version/Release/In
dustry ID Code
Date from sending system.
Time from sending system
using 24 hour format; e.g.,
for 1 PM, use 1300. From
BSC, this will be EST.
A number assigned by the
sender that is unique to each
functional group within this
interchange.
X
M
AN
Must reflect the transaction
being submitted within the
Functional Group using the
values listed to the left.
GE-Functional Group Trailer
The Functional Group Trailer (GE) is the last record of an entire Functional Group. Every X12 Functional
Group must end with a GE Segment.
Example: GE*1*1~
15
278-13/278-11 Companion Guide
Purpose: To indicate the end of a functional group and to provide control information.
Table:
Seg
Fld
Name
GE01
Number of
Transaction Sets
Included
GE02
Group Control
Number
Req
Type
Min
Max
M
N0
(1/6)
M
N0
(9/9)
Values allowed by
X12 Standards
The total number of
transaction sets (STSE) contained in the
Functional Group (GSGE)
Must be the same as
the value sent in the
preceding GS06.
Values to be used with
BSC
As required by standard
As required by standard
6.3 ST-SE Transaction Set Header
The Transaction Set Header (ST) is the first record of an entire Transaction Set. Every X12 Transaction
set must begin with an ST Segment.
Example: ST*999*1234~
Purpose: To indicate the start of a transaction set and assign a control number.
Set Notes:
1.
These acknowledgments shall not be acknowledged, thereby preventing an endless cycle of
acknowledgments. Nor shall a Functional Acknowledgment be sent to report errors in a
previous Functional Acknowledgment.
2. The Functional Group Header Segment (GS) is used to start the envelope for the Functional
Acknowledgment Transaction Sets. In preparing the functional group of acknowledgments,
the application senders code and the application receiver’s code, take from the functional
group being acknowledged, are exchanged; therefore, one acknowledgment functional group
responds to only those functional groups from one application receivers code to one
application senders code.
3. There is only one Functional Acknowledgment Transaction Set per acknowledged functional
group.
Table
Seg
Fld
Name
Req
Type
Min
Max
ST01
Transaction Set ID
Code
M
ID
(3/3)
16
Values allowed by X12
Standards
999: Functional
Acknowledgment
278-13: Authorization
Review Request
278-11: Authorization
Review
Response/Information
Values to be used
with BSC
As required by
standard
278-13/278-11 Companion Guide
Transaction Set
Control Number
ST01
M
AN
(4/9)
Must be the same as the
value sent in the following
SE02
As required by
standard
SE-Transaction Set Trailer: The Transaction Set Trailer (SE) is the last record of an entire Transaction
Set. Every X12 Transaction Set must end with an SE Segment.
Purpose: To indicate the end of the transaction set and provide the count of the transmitted segments
(including the beginning (ST) and ending (SE) segments).
Example: SE*27*1234~
Table:
Seg/Fld
Name
Req
Type
Min/Max
SE01
Number of
Segments Included
M
N0
(1/10)
SE02
Transaction Set
Control Number
M
AN
(4/9)
Values allowed by
X12 Standards
The total number of
segments contained in
the transaction set
(ST-SE), including the
ST and SE segments.
Must be the same as
the value sent in the
preceding ST02
Values to be used with
BSC
As required by standard
As required by standard
7 Payer Specific Business Rules and Limitations
The purpose of this section is to delineate specific data requirements as they apply to 278-13/278-11
authorization review request. BSC supports processing 278-13 authorization or certification request and
will respond with a 278-11 acknowledging receipt containing a closed pended status (BHT06=18 and
HCR01=A4). Any further status updates are provided outside of the 278 transactions via Blue Shield of
CA Provider Website (www.blueshieldca.com/provider) or Provider Customer Service (see section 5 for
contact information).
8 Acknowledgments and Reports-Reports Inventory
The purpose of this section is to outline the BSC processes for handling the initial processing of incoming
files and electronic acknowledgments.
TA1 Interchange Acknowledgment Transaction
All X12 file submissions are pre-screened upon receipt to determine if the interchange control header
(ISA) or interchange control trailer (IEA) segments are readable. If errors are found, a TA1 response
transaction will be sent to notify the trading partner that the file could not be processed. No TA1 response
transaction will be sent for error-free files.
999 Functional Acknowledgment Transaction
17
278-13/278-11 Companion Guide
If the file submission passes the ISA/IEA pre-screening above, it is then checked for ASCX12 syntax and
HIPAA compliance errors. When the compliance check is completed, a 999 will be sent to the trading
partner informing them if the file has been accepted or rejected. If multiple transaction sets (ST-SE) are
sent within the functional group (GS-GE, the entire functional group (GS-GE) will be rejected when an
ASCX12 or HIPPA compliance error is found.
9 Trading Partner Agreements
Please reference Section 11-Appendices: Trading Partner Agreement.
10 Transaction Specific Information
Please reference Section 11-Appendices: BSC 278-13/278-11 Companion Guides (BSC-278-13-5010
CG/BSC-278-11-5010-CG).
11 Appendices
Additional Attachments:
-
BSC-278-13 -5010-CG
-
BSC-278-11 -5010-CG
-
BS Trading Partner Agreement
-
BSC EDI Enrollment Form
-
BSC Connectivity Detail Form
18
278 Health Care Services
Review Information Request
HIPAA/V5010X217/278: 278 Health Care Services Review Information - Request
Version: 1.0
Company:
Publication:
Blue Shield of California
1/12/2012
1/12/2012
Health Care Services Review Information - Request - 278
Table of Contents
278
. . .
Health Care Services Review Information - Request . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
1
ISA
. . .
Interchange Control Header . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
5
GS
. . .
Functional Group Header . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
9
ST
. .
Transaction Set Header . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
11
BHT
. .
Beginning of Hierarchical Transaction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
12
2000A
. .
Loop Utilization Management Organization (UMO) Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
14
HL
. .
Utilization Management Organization (UMO) Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
15
2010A
. .
Loop Utilization Management Organization (UMO) Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
16
NM1
. .
Utilization Management Organization (UMO) Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
17
2000B
. .
Loop Requester Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
20
HL
. .
Requester Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
21
2010B
. .
Loop Requester Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
23
NM1
. .
Requester Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
24
REF
. .
Requester Supplemental Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
27
N3
. .
Requester Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
29
N4
. .
Requester City, State, ZIP Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
30
PER
. .
Requester Contact Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
32
PRV
. .
Requester Provider Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
35
2000C
. .
Loop Subscriber Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
37
HL
. .
Subscriber Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
38
2010C
. .
Loop Subscriber Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
40
NM1
. .
Subscriber Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
41
REF
. .
Subscriber Supplemental Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
44
N3
. .
Subscriber Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
46
N4
. .
Subscriber City, State, ZIP Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
47
DMG
. .
Subscriber Demographic Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
49
INS
. .
Subscriber Relationship . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
51
2000D
. .
Loop Dependent Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
53
HL
. .
Dependent Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
54
2010D
. .
Loop Dependent Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
56
NM1
. .
Dependent Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
57
REF
. .
Dependent Supplemental Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
59
N3
. .
Dependent Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
60
N4
. .
Dependent City, State, ZIP Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
61
DMG
. .
Dependent Demographic Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
63
INS
. .
Dependent Relationship . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
65
2000E
. .
Loop Patient Event Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
67
HL
. .
Patient Event Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
68
TRN
. .
Patient Event Tracking Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
70
i
For internal use only
1/12/2012
Health Care Services Review Information - Request - 278
UM
. .
Health Care Services Review Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
72
REF
. .
Previous Review Authorization Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
80
REF
. .
Previous Review Administrative Reference Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
81
DTP
. .
Accident Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
82
DTP
. .
Last Menstrual Period Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
83
DTP
. .
Estimated Date of Birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
84
DTP
. .
Onset of Current Symptoms or Illness Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
85
DTP
. .
Event Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
86
DTP
. .
Admission Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
87
DTP
. .
Discharge Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
88
HI
. .
Patient Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
89
HSD
Health Care Services Delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
106
CRC
Ambulance Certification Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
110
CRC
Chiropractic Certification Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
114
CRC
Durable Medical Equipment Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
117
CRC
Oxygen Therapy Certification Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
125
CRC
Functional Limitations Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
128
CRC
Activities Permitted Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
137
CRC
Mental Status Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
142
CL1
Institutional Claim Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
148
CR1
Ambulance Transport Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
150
CR2
Spinal Manipulation Service Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
153
CR5
Home Oxygen Therapy Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
157
CR6
Home Health Care Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
161
PWK
Additional Patient Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
166
MSG
Message Text . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
170
2010EA Loop Patient Event Provider Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
171
NM1
Patient Event Provider Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
172
REF
Patient Event Provider Supplemental Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
175
N3
Patient Event Provider Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
177
N4
Patient Event Provider City, State, Zip Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
178
PER
Patient Event Provider Contact Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
180
PRV
Patient Event Provider Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
183
2010EB Loop Patient Event Transport Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
185
NM1
Patient Event Transport Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
186
N3
Patient Event Transport Location Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
188
N4
Patient Event Transport Location City/State/ZIP Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
189
2010EC Loop Patient Event Other UMO Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
191
NM1
Patient Event Other UMO Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
192
REF
Other UMO Denial Reason . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
194
DTP
Other UMO Denial Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
197
2000F
Loop Service Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
198
HL
Service Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
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Health Care Services Review Information - Request - 278
TRN
199
Service Trace Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
201
UM
Health Care Services Review Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
203
REF
Previous Review Authorization Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
208
REF
Previous Review Administrative Reference Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
209
DTP
Service Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
210
SV1
Professional Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
211
SV2
Institutional Service Line . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
217
SV3
Dental Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
223
TOO
Tooth Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
227
HSD
Health Care Services Delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
230
PWK
Additional Service Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
234
MSG
Message Text . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
238
2010F
Loop Service Provider Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
239
NM1
Service Provider Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
240
REF
Service Provider Supplemental Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
243
N3
Service Provider Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
245
N4
Service Provider City, State, ZIP Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
246
PER
Service Provider Contact Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
248
PRV
Service Provider Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
251
SE
Transaction Set Trailer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
253
GE
Functional Group Trailer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
254
IEA
Interchange Control Trailer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
255
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278
Health Care Services Review Information
- Request
Functional Group= HI
Purpose: This X12 Transaction Set contains the format and establishes the data contents of the Health Care
Services Review Information Transaction Set (278) for use within the context of an Electronic Data Interchange (EDI)
environment. This transaction set can be used to transmit health care service information, such as subscriber,
patient, demographic, diagnosis or treatment data for the purpose of request for review, certification, notification or
reporting the outcome of a health care services review. Expected users of this transaction set are payors, plan
sponsors, providers, utilization management and other entities involved in health care services review.
Not Defined:
Pos
Id
Segment Name
ISA
GS
Interchange Control Header
Functional Group Header
Pos
Id
Segment Name
0100
0200
ST
BHT
Transaction Set Header
Beginning of Hierarchical
Transaction
Id
Segment Name
Req
Max Use
M
M
1
1
Req
Max Use
M
M
1
1
Req
Max Use
Repeat
Notes
Usage
Required
Required
Heading:
Repeat
Notes
Usage
Required
Required
Detail:
Pos
LOOP ID - 2000A
0100
HL
NM1
HL
M
1
Utilization Management
Organization (UMO) Name
O
1
NM1
REF
2000
2100
N3
N4
2200
PER
2400
PRV
Requester Level
M
1
Requester Name
Requester Supplemental
Identification
Requester Address
Requester City, State, ZIP
Code
Requester Contact
Information
Requester Provider
Information
O
O
1
8
Required
Situational
O
O
1
1
Situational
Situational
O
1
Situational
O
1
Situational
HL
Subscriber Level
M
1
NM1
Subscriber Name
O
1
Required
1
1
LOOP ID - 2010C
1700
Required
1
LOOP ID - 2000C
0100
Required
1
LOOP ID - 2010B
1700
1800
Usage
Utilization Management
Organization (UMO) Level
LOOP ID - 2000B
0100
Notes
1
LOOP ID - 2010A
1700
Repeat
Required
1
1
Required
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Pos
1800
Id
REF
2000
2100
N3
N4
2500
DMG
2600
INS
Segment Name
Subscriber Supplemental
Identification
Subscriber Address
Subscriber City, State, ZIP
Code
Subscriber Demographic
Information
Subscriber Relationship
Req
O
Max Use
9
O
O
1
1
Situational
Situational
O
1
Situational
O
1
Situational
LOOP ID - 2000D
0100
HL
NM1
REF
2000
2100
N3
N4
2500
DMG
2600
INS
Dependent Level
O
1
HL
TRN
0400
UM
0600
REF
0600
REF
0700
0700
0700
0700
DTP
DTP
DTP
DTP
0700
0700
0700
0800
0900
DTP
DTP
DTP
HI
HSD
1000
CRC
1000
CRC
1000
CRC
1000
CRC
Usage
Situational
Situational
1
Dependent Name
Dependent Supplemental
Identification
Dependent Address
Dependent City, State, ZIP
Code
Dependent Demographic
Information
Dependent Relationship
O
O
1
3
Required
Situational
O
O
1
1
Situational
Situational
O
1
Situational
O
1
Situational
Patient Event Level
Patient Event Tracking
Number
Health Care Services
Review Information
Previous Review
Authorization Number
Previous Review
Administrative Reference
Number
Accident Date
Last Menstrual Period Date
Estimated Date of Birth
Onset of Current Symptoms
or Illness Date
Event Date
Admission Date
Discharge Date
Patient Diagnosis
Health Care Services
Delivery
Ambulance Certification
Information
Chiropractic Certification
Information
Durable Medical Equipment
Information
Oxygen Therapy
Certification Information
M
O
1
2
Required
Situational
O
1
Required
O
1
Situational
O
1
Situational
O
O
O
O
1
1
1
1
Situational
Situational
Situational
Situational
O
O
O
O
O
1
1
1
1
1
Situational
Situational
Situational
Situational
Situational
O
1
Situational
O
1
Situational
O
1
Situational
O
1
Situational
LOOP ID - 2000E
0100
0200
Notes
1
LOOP ID - 2010D
1700
1800
Repeat
1
2
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Pos
Id
Segment Name
1000
CRC
1000
CRC
1000
1100
1200
CRC
CL1
CR1
1300
CR2
1400
CR5
1500
CR6
1550
PWK
1600
MSG
Functional Limitations
Information
Activities Permitted
Information
Mental Status Information
Institutional Claim Code
Ambulance Transport
Information
Spinal Manipulation Service
Information
Home Oxygen Therapy
Information
Home Health Care
Information
Additional Patient
Information
Message Text
Req
Max Use
O
1
Situational
O
1
Situational
O
O
O
1
1
1
Situational
Situational
Situational
O
1
Situational
O
1
Situational
O
1
Situational
O
10
Situational
O
1
LOOP ID - 2010EA
1700
NM1
1800
REF
2000
N3
2100
N4
2200
PER
2400
PRV
Patient Event Provider
Name
Patient Event Provider
Supplemental Information
Patient Event Provider
Address
Patient Event Provider City,
State, Zip Code
Patient Event Provider
Contact Information
Patient Event Provider
Information
NM1
2000
N3
2100
N4
Patient Event Transport
Information
Patient Event Transport
Location Address
Patient Event Transport
Location City/State/ZIP
Code
NM1
1800
2700
REF
DTP
Patient Event Other UMO
Name
Other UMO Denial Reason
Other UMO Denial Date
HL
TRN
UM
0600
REF
Situational
1
Situational
O
7
Situational
O
1
Situational
O
1
Situational
O
1
Situational
O
1
Situational
O
1
Situational
O
1
Required
O
1
Required
O
1
Situational
O
O
1
1
Required
Required
5
3
LOOP ID - 2000F
0100
0200
0400
Usage
O
LOOP ID - 2010EC
1700
Notes
14
LOOP ID - 2010EB
1700
Repeat
>1
Service Level
Service Trace Number
Health Care Services
Review Information
Previous Review
Authorization Number
O
O
O
1
2
1
Situational
Situational
Situational
O
1
Situational
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Pos
Id
Segment Name
0600
REF
0700
0810
0820
0830
0840
0900
DTP
SV1
SV2
SV3
TOO
HSD
1550
PWK
1600
MSG
Previous Review
Administrative Reference
Number
Service Date
Professional Service
Institutional Service Line
Dental Service
Tooth Information
Health Care Services
Delivery
Additional Service
Information
Message Text
Req
Max Use
Repeat
O
1
Situational
O
O
O
O
O
O
1
1
1
1
32
1
Situational
Situational
Situational
Situational
Situational
Situational
O
10
Situational
O
1
NM1
REF
2000
2100
N3
N4
2200
PER
2400
PRV
2800
SE
Usage
Situational
LOOP ID - 2010F
1700
1800
Notes
10
Service Provider Name
Service Provider
Supplemental Identification
Service Provider Address
Service Provider City, State,
ZIP Code
Service Provider Contact
Information
Service Provider
Information
Transaction Set Trailer
O
O
1
8
Situational
Situational
O
O
1
1
Situational
Situational
O
1
Situational
O
1
Situational
M
1
Required
Req
Max Use
M
M
1
1
Not Defined:
Pos
Id
Segment Name
GE
IEA
Functional Group Trailer
Interchange Control Trailer
Repeat
Notes
Usage
Required
Required
It is required that separate transaction sets be used for different patients.
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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 identifying the type of information in the Authorization Information
CodeList Summary (Total Codes: 7, Included: 2)
Code Name
00
03
ISA02
I02
No Authorization Information Present (No Meaningful Information in I02)
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 identifying the type of information in the Security Information
CodeList Summary (Total Codes: 2, Included: 2)
Code Name
00
01
ISA04
I04
No Security Information Present (No Meaningful Information in I04)
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: Code indicating 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: 41, Included: 9)
Code Name
01
14
20
Duns (Dun & Bradstreet)
Duns Plus Suffix
Health Industry Number (HIN)
CODE SOURCE:
121: Health Industry Identification Number
27
28
Carrier Identification Number as assigned by Health Care Financing Administration
(HCFA)
Fiscal Intermediary Identification Number as assigned by Health Care Financing
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Code Name
Administration (HCFA)
29
Medicare Provider and Supplier Identification Number as assigned by Health Care
Financing Administration (HCFA)
30
U.S. Federal Tax Identification Number
33
National Association of Insurance Commissioners Company Code (NAIC)
ZZ
Mutually Defined
ISA06
I06
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: Code indicating 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: 41, Included: 9)
Code Name
01
14
20
Duns (Dun & Bradstreet)
Duns Plus Suffix
Health Industry Number (HIN)
CODE SOURCE:
121: Health Industry Identification Number
27
28
29
30
33
ZZ
ISA08
I07
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 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
Notes: Blue Shield of CA Receiver Id = 940360524
ISA09
I08
Interchange Date
M
DT
6/6
Required
M
TM
4/4
Required
1/1
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.
ISA11
I65
Repetition Separator
M
Description: Type is not applicable; the repetition separator is a delimiter and not a data
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Ref
Id
Element Name
Req
Type
Min/Max
Usage
element; this field provides the delimiter used to separate repeated occurrences of a
simple data element or a composite data structure; this value must be different than the
data element separator, component element separator, and the segment terminator
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: 20, Included: 1)
Code Name
00501 Standards Approved for Publication by ASC X12 Procedures Review Board
through October 2003
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.
Must be a positive unsigned number and must be identical to the value in IEA02.
ISA14
I13
Acknowledgment Requested
M
ID
1/1
Required
Description: Code indicating sender's request for an interchange acknowledgment
See Section B.1.1.5.1 for interchange acknowledgment information.
CodeList Summary (Total Codes: 2, Included: 2)
Code Name
0
1
ISA15
I14
No Interchange Acknowledgment Requested
Interchange Acknowledgment Requested (TA1)
Interchange Usage Indicator
M
ID
1/1
Required
Description: Code indicating 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
TR3 Notes:
1. All positions within each of the data elements must be filled.
2. For compliant implementations under this implementation guide, ISA13, the interchange Control Number, must
be a positive unsigned number. Therefore, the ISA segment can be considered a fixed record length segment.
3. The first element separator defines the element separator to be used through the entire interchange.
4. The ISA segment terminator defines the segment terminator used throughout the entire interchange.
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5. Spaces in the example interchanges are represented by “.” for clarity.
TR3 Example:
ISA*00*..........*01*SECRET....*ZZ*SUBMITTERS.ID..*ZZ*RECEIVERS.ID...*030101*1253*^*00501*000000905*1
*T*:~
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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
This is the 2-character Functional Identifier Code assigned to each transaction set by X12.
The specific code for a transaction set defined by this implementation guide is presented in
section 1.2, Version Information.
CodeList Summary (Total Codes: 262, Included: 1)
Code Name
HI
GS02
142
Health Care Services Review Information (278)
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
Notes: Blue Shield of CA Receiver Id = 940360524
Use this code to identify the unit receiving the information.
GS04
373
Date
M
DT
8/8
Required
Description: Date expressed as CCYYMMDD where CC represents the first two digits of
the calendar year
Use this date for the functional group creation date.
GS05
337
Time
M
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)
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
For implementations compliant with this guide, GS06 must be unique within a single
transmission (that is, within a single ISA to IEA enveloping structure). The authors
recommend that GS06 be unique within all transmissions over a period of time to be
determined by the sender.
GS07
455
Responsible Agency Code
M
ID
1/2
Required
Description: Code identifying the issuer of the standard; this code is used in conjunction
with Data Element 480
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Health Care Services Review Information - Request - 278
Id
Element Name
Req
Type
Min/Max
Usage
AN
1/12
Required
CodeList Summary (Total Codes: 2, Included: 1)
Code Name
X
GS08
480
Accredited Standards Committee X12
Version / Release / Industry Identifier
Code
M
Description: Code indicating the version, release, subrelease, and industry identifier of the
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
CODE SOURCE: 881: Version / Release / Industry Identifier Code
This is the unique Version/Release/Industry Identifier Code assigned to an implementation
by X12N. The specific code for a transaction set defined by this implementation guide is
presented in section 1.2, Version Information.
CodeList Summary (Total Codes: 65, Included: 1)
Code
Name
005010X21
7
Standards Approved for Publication by ASC X12 Procedures Review Board
through October 2003
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.
TR3 Example:
GS*XX*SENDER CODE*RECEIVERCODE*19991231*0802*1*X*005010X212~
10
For internal use only
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Pos: 0100
ST Transaction Set Header
Max: 1
Heading - Mandatory
Loop: N/A
Elements: 3
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
CodeList Summary (Total Codes: 318, Included: 1)
Code Name
278
ST02
329
Health Care Services Review Information
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
The Transaction Set Control Numbers in ST02 and SE02 must be identical. The number is
assigned by the originator and must be unique within a functional group (GS-GE). For
example, start with the number 0001 and increment from there. The number also aids in
error resolution research. Use the corresponding value in SE02 for this transaction set.
ST03
1705
Implementation Convention Reference
O
AN
1/35
Required
Description: Reference assigned to identify Implementation Convention
IMPLEMENTATION NAME: Implementation Guide Version Name
This element must be populated with the guide identifier named in Section 1.2.
This field contains the same value as GS08.
Some translator products strip off the ISA and GS segments prior to application (STSE)
processing. Providing the information from the GS08 at this level will ensure that the
appropriate application mapping is utilized at translation time.
Semantics:
1. The transaction set identifier (ST01) is used by the translation routines of the interchange partners to select
the appropriate transaction set definition (e.g., 810 selects the Invoice Transaction Set).
2. The implementation convention reference (ST03) is used by the translation routines of the interchange
partners to select the appropriate implementation convention to match the transaction set definition. When
used, this implementation convention reference takes precedence over the implementation reference
specified in the GS08.
TR3 Notes:
1. Use this segment to indicate the start of a health care services review request transaction set with all of the
supporting detail information. This transaction set is the electronic equivalent of a phone, fax, or paper-based
utilization management request.
TR3 Example:
ST*278*0001*005010X217~
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Pos: 0200
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: 81, Included: 1)
Code Name
0007 Information Source, Information Receiver, Subscriber, Dependent, Event, Services
BHT02
353
Transaction Set Purpose Code
M
ID
2/2
Required
Description: Code identifying purpose of transaction set
CodeList Summary (Total Codes: 66, Included: 3)
Code Name
BHT03
127
01
Cancellation
Use this code to cancel a previously submitted 278 transaction. Only 278
transactions that used a BHT06 code of “RU” can be canceled. The cancellation
278 transaction must contain the same BHT06 code as the previously submitted
278 transaction.
13
36
Request
Authority to Deduct (Reply)
Use this code for medical services reservations to reserve or deduct a service with
the health plan. BHT06 must be equal to “RU”.
Reference Identification
O
AN
1/50
Required
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
IMPLEMENTATION NAME: Submitter Transaction Identifier
Use this element to trace the transaction from one point to the next point, such as when the
transaction is passed from one clearinghouse to another clearinghouse. This identifier
must be returned in the corresponding 278 response transaction’s BHT03. This identifier
will only be returned by the last entity to handle the 278. This identifier will not be passed
through the complete life of the transaction. All recipients of 278 request transactions are
required to return the Submitter Transaction Identifier in their 278 response if one is
submitted.
BHT04
373
Date
O
DT
8/8
Required
Description: Date expressed as CCYYMMDD where CC represents the first two digits of
the calendar year
IMPLEMENTATION NAME: Transaction Set Creation Date
BHT05
337
Time
O
12
TM
4/8
Required
For internal use only
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Ref
Id
Element Name
Req
Type
Min/Max
Usage
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)
IMPLEMENTATION NAME: Transaction Set Creation Time
BHT06
640
Transaction Type Code
O
ID
2/2
Situational
Description: Code specifying the type of transaction
Situational Rule: Required when requesting Medical Services Reservation. If not required
by this implementation guide, do not send.
CodeList Summary (Total Codes: 534, Included: 1)
Code Name
RU
Medical Services Reservation
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.
TR3 Example:
BHT*0007*13*200300114000001*20030101*1400~
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Pos: 0100
Loop Utilization Management
Organization (UMO) 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
0100
HL
Utilization Management Organization
(UMO) Level
Loop 2010A
1700
14
Req
Max Use
M
1
O
Repeat
Usage
Required
1
Required
For internal use only
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Pos: 0100
HL Utilization Management
Max: 1
Detail - Mandatory
Organization (UMO) 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
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: 250, 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.
TR3 Notes:
1. This segment indicates the information source hierarchical level. For a request transaction, this segment
corresponds to the identification of the payer, HMO, or other utilization management organization who will be the
source of the decision/response.
TR3 Example:
HL*1**20*1~
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Pos: 1700
Loop Utilization Management
Organization (UMO) Name
Repeat: 1
Optional
Loop:
2010A
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
1700
NM1
Utilization Management Organization
(UMO) Name
16
Req
Max Use
O
1
Repeat
Usage
Required
For internal use only
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Pos: 1700
NM1 Utilization Management
Max: 1
Detail - Optional
Organization (UMO) Name
Loop:
2010A
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: 1500, Included: 4)
Code Name
NM102
1065
2B
36
PR
Third-Party Administrator
Employer
Payer
Use only when the organization receiving the request is a health plan but is not the
entity rendering the medical decision, as in plan to plan communication or
communication from the health plan to the medical review organization.
X3
Utilization Management Organization
Entity Type Qualifier
M
ID
1/1
Required
Description: Code qualifying the type of entity
CodeList Summary (Total Codes: 16, Included: 2)
Code Name
NM103
1035
1
Person
Use this code only if the reviewing entity is an individual, such as an individual
primary care physician.
2
Non-Person Entity
Name Last or Organization Name
X
AN
1/60
Situational
Description: Individual last name or organizational name
Situational Rule: Required when name information is needed to identify the UMO. If not
required by this implementation guide, do not send.
IMPLEMENTATION NAME: Utilization Management Organization (UMO) Last or
Organization Name
NM104
1036
Name First
O
AN
1/35
Situational
Description: Individual first name
Situational Rule: Required when NM103 is valued and the reviewing entity is an individual
(NM102 = 1), such as a primary care provider. If not required by this implementation guide,
do not send.
IMPLEMENTATION NAME: Utilization Management Organization (UMO) First Name
NM105
1037
Name Middle
O
AN
1/25
Situational
Description: Individual middle name or initial
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Id
Element Name
Req
Type
Min/Max
Usage
Situational Rule: Required when NM104 is present and the middle name/initial of the
person is known. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Utilization Management Organization (UMO) Middle Name
NM107
1039
Name Suffix
O
AN
1/10
Situational
Description: Suffix to individual name
Situational Rule: Required when NM104 is present and the suffix of the individual’s name
is known; e.g. Sr., Jr., or III. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Utilization Management Organization (UMO) Name Suffix
NM108
66
Identification Code Qualifier
X
ID
1/2
Required
Description: Code designating the system/method of code structure used for Identification
Code (67)
CodeList Summary (Total Codes: 241, Included: 5)
Code Name
24
34
46
PI
Employer's Identification Number
Social Security Number
Electronic Transmitter Identification Number (ETIN)
Payor Identification
Use until the National PlanID is mandated if the UMO is a payer.
XV
Centers for Medicare and Medicaid Services PlanID
Required on or after the mandated HIPAA National Plan ID implementation date
when the UMO is the payer.
CODE SOURCE:
540: Centers for Medicare and Medicaid Services PlanID
NM109
67
Identification Code
X
AN
2/80
Required
Description: Code identifying a party or other code
IMPLEMENTATION NAME: Utilization Management Organization (UMO) Identifier
ExternalCodeList
Name: 537
Description: Centers for Medicare and Medicaid Services National Provider Identifier
ExternalCodeList
Name: 540
Description: Centers for Medicare and Medicaid Services 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.
3. C1203 - If NM112 is present, then NM103 is required.
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
2. NM112 can identify a second surname.
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TR3 Notes:
1. This segment identifies the source of information. In the case of a request transaction, the source of
information would normally be the payer or utilization review organization making the decision on the request.
TR3 Example:
NM1*X3*2*ABC PAYER*****46*123450000~
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Pos: 0100
Loop Requester Level
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
Req
Max Use
0100
1700
HL
Requester Level
Loop 2010B
M
O
1
20
Repeat
Usage
1
Required
Required
For internal use only
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Pos: 0100
HL Requester Level
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: 250, Included: 1)
Code Name
21
HL04
736
Information Receiver
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.
TR3 Notes:
1. This segment indicates the health care services review information receiver. For request transactions, this
segment corresponds to the identification of the provider initiating the request for review.
TR3 Example:
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HL*2*1*21*1~
22
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Pos: 1700
Loop Requester Name
Repeat: 1
Optional
Loop:
2010B
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
1700
1800
2000
2100
2200
2400
NM1
REF
N3
N4
PER
PRV
Requester Name
Requester Supplemental Identification
Requester Address
Requester City, State, ZIP Code
Requester Contact Information
Requester Provider Information
23
Req
Max Use
O
O
O
O
O
O
1
8
1
1
1
1
Repeat
Usage
Required
Situational
Situational
Situational
Situational
Situational
For internal use only
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Pos: 1700
NM1 Requester Name
Max: 1
Detail - Optional
Loop:
2010B
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: 1500, Included: 5)
Code Name
NM102
1065
1P
Provider
Use when the requester is an individual provider.
2B
36
FA
Third-Party Administrator
Employer
Facility
Use when the requester is a facility, such as a clinic or hospital.
PR
Payer
Use only when the organization sending the request is a health plan, as in plan to
plan communication or communication from the health plan to the medical review
organization.
Entity Type Qualifier
M
ID
1/1
Required
AN
1/60
Situational
Description: Code qualifying the type of entity
CodeList Summary (Total Codes: 16, Included: 2)
Code Name
1
2
NM103
1035
Person
Non-Person Entity
Name Last or Organization Name
X
Description: Individual last name or organizational name
Situational Rule: Required when name information is needed by the UMO to identify the
requester. If not required by this implementation guide, may be provided at the sender’s
discretion but cannot be required by the receiver.
IMPLEMENTATION NAME: Requester Last or Organization Name
NM104
1036
Name First
O
AN
1/35
Situational
Description: Individual first name
Situational Rule: Required when NM103 is present and NM102=1. If not required by this
implementation guide, do not send.
IMPLEMENTATION NAME: Requester First Name
NM105
1037
Name Middle
O
AN
1/25
Situational
Description: Individual middle name or initial
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Id
Element Name
Req
Type
Min/Max
Usage
Situational Rule: Required when NM104 is present and the middle name/initial of the
person is known. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Requester Middle Name
NM107
1039
Name Suffix
O
AN
1/10
Situational
Description: Suffix to individual name
Situational Rule: Required when NM104 is present and the suffix of the individual’s name
is known; e.g. Sr., Jr., or III. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Requester Name Suffix
NM108
66
Identification Code Qualifier
X
ID
1/2
Required
Description: Code designating the system/method of code structure used for Identification
Code (67)
CodeList Summary (Total Codes: 241, Included: 5)
Code Name
24
34
46
XV
Employer's Identification Number
Social Security Number
Electronic Transmitter Identification Number (ETIN)
Centers for Medicare and Medicaid Services PlanID
CODE SOURCE:
540: Centers for Medicare and Medicaid Services
PlanID
XX
Centers for Medicare and Medicaid Services National Provider Identifier
Required for providers in the United States or its
territories on or after the mandated HIPAA National Provider Identifier (NPI)
implementation date when the provider is eligible to receive an NPI;
OR
Required for providers not in the United States or its territories on or after the
mandated HIPAA National Provider Identifier (NPI) implementation date when the
provider has received an NPI;
OR
Required for providers prior to the mandated NPI
implementation date when the provider has received an NPI and the submitter has
the capability to send it;
If not required by this implementation guide, do not send.
CODE SOURCE:
537: Centers for Medicare and Medicaid Services National Provider Identifier
NM109
67
Identification Code
X
AN
2/80
Required
Description: Code identifying a party or other code
IMPLEMENTATION NAME: Requester Identifier
ExternalCodeList
Name: 537
Description: Centers for Medicare and Medicaid Services 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.
3. C1203 - If NM112 is present, then NM103 is required.
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Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
2. NM112 can identify a second surname.
TR3 Notes:
1. This segment identifies the receiver of information. In the case of a request transaction, the receiver would
normally be the provider who will ultimately be receiving the decision.
TR3 Example:
NM1*1P*1*GARDENER*JAMES****24*000012345~
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Pos: 1800
REF Requester Supplemental
Max: 8
Detail - Optional
Identification
Loop:
2010B
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: 1731, Included: 8)
Code Name
REF02
127
1G
1J
EI
Provider UPIN Number
Facility ID Number
Employer's Identification Number
Not used if NM108 = 24.
G5
Provider Site Number
Required when needed to identify the physician, clinic, or group practice
associated with the requester identified in this NM1 loop. If not required, do not
send.
N5
N7
SY
Provider Plan Network Identification Number
Facility Network Identification Number
Social Security Number
The social security number may not be used for Medicare. Not used if NM108 =
34.
ZH
Carrier Assigned Reference Number
Required when necessary to provide the requester/provider ID as assigned by the
UMO identified in Loop 2000A. If not required, do not end.
Reference Identification
X
AN
1/50
Required
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
IMPLEMENTATION NAME: Requester 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.
Situational Rule:
Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an
identification number other than the NPI is necessary for the UMO to identify the provider;
OR
Required after the mandated NPI implementation date, when the entity is a non-health care provider, and an
identifier is necessary for the UMO to identify the entity. If not required by this implementation guide, do not send.
TR3 Example:
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REF*1G*123456~
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Pos: 2000
N3 Requester Address
Max: 1
Detail - Optional
Loop:
2010B
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
1/55
Situational
Description: Address information
IMPLEMENTATION NAME: Requester Address Line
Use this element for the first line of the requester’s address.
N302
166
Address Information
O
AN
Description: Address information
Situational Rule: Required when a second address line exists. If not required by this
implementation guide, do not send.
IMPLEMENTATION NAME: Requester Address Line
Situational Rule:
Required when necessary to identify the requester by location. If not required by this implementation guide, do
not send.
TR3 Notes:
1. Use to identify a specific location when the requester has multiple locations and authority varies based on
location.
TR3 Example:
N3*43 SUNRISE BLVD*SUITE 234~
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Pos: 2100
N4 Requester City, State, ZIP
Max: 1
Detail - Optional
Code
Loop:
2010B
Elements: 5
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
ID
2/2
Situational
Description: Free-form text for city name
IMPLEMENTATION NAME: Requester City Name
N402
156
State or Province Code
X
Description: Code (Standard State/Province) as defined by appropriate government
agency
Situational Rule: Required when the address is in the United States of America, including
its territories, or Canada. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Requester State or Province Code
CODE SOURCE: 22: States and Provinces
ExternalCodeList
Name: 22C
Description: States and Provinces
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)
Situational Rule: Required when the address is in the United States of America, including
its territories, or Canada, or when a postal code exists for the country in N404. If not
required by this implementation guide, do not send.
IMPLEMENTATION NAME: Requester Postal Zone or ZIP Code
CODE SOURCE: 51: ZIP Code
932: Universal Postal Codes
ExternalCodeList
Name: 932
Description:
ExternalCodeList
Name: 51
Description: ZIP Code
N404
26
Country Code
X
ID
2/3
Situational
Description: Code identifying the country
Situational Rule: Required when the address is outside the United States of America. If
not required by this implementation guide, do not send.
CODE SOURCE: 5: Countries, Currencies and Funds
Use the alpha-2 country codes from Part 1 of ISO 3166.
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Id
Element Name
Req
Type
Min/Max
Usage
ID
1/3
Situational
ExternalCodeList
Name: 5
Description: Countries, Currencies and Funds
N407
1715
Country Subdivision Code
X
Description: Code identifying the country subdivision
Situational Rule: Required when the address is not in the United States of America,
including its territories, or Canada, and the country in N404 has administrative subdivisions
such as but not limited to states, provinces, cantons, etc. If not required by this
implementation guide, do not send.
CODE SOURCE: 5: Countries, Currencies and Funds
Use the country subdivision codes from Part 2 of ISO 3166.
ExternalCodeList
Name: 5
Description: Countries, Currencies and Funds
Syntax Rules:
1. E0207 - Only one of N402 or N407 may be present.
2. C0605 - If N406 is present, then N405 is required.
3. C0704 - If N407 is present, then N404 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.
Situational Rule:
Required when necessary to identify the requester by location. If not required by this implementation guide, do
not send.
TR3 Example:
N4*KANSAS CITY*MO*64108~
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Pos: 2200
PER Requester Contact
Max: 1
Detail - Optional
Information
Loop:
2010B
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: 238, Included: 1)
Code Name
IC
PER02
93
Information Contact
Name
O
AN
1/60
Situational
Description: Free-form name
Situational Rule: Required when the response must be directed to a particular contact
and the name of the entity to contact is not already defined or is different than the name
supplied in the NM1 segment of this loop. If not required by this implementation guide, do
not send.
IMPLEMENTATION NAME: Requester Contact Name
PER03
365
Communication Number Qualifier
X
ID
2/2
Situational
Description: Code identifying the type of communication number
Situational Rule: Required when PER02 is not valued to transmit a contact
communication number. If not required by this implementation guide, do not send.
CodeList Summary (Total Codes: 42, Included: 4)
Code Name
EM
FX
TE
UR
PER04
364
Electronic Mail
Facsimile
Telephone
Uniform Resource Locator (URL)
Must not contain any characters used as delimiters in this transaction.
Communication Number
X
AN
1/256
Situational
Description: Complete communications number including country or area code when
applicable
Situational Rule: Required when PER02 is not valued to transmit a contact
communication number. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Requester Contact Communication Number
PER05
365
Communication Number Qualifier
X
ID
2/2
Situational
Description: Code identifying the type of communication number
Situational Rule: Required when the telephone extension or multiple communication
numbers are available. If not required by this implementation guide, do not send.
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Id
Element Name
Req
Type
Min/Max
Usage
CodeList Summary (Total Codes: 42, Included: 5)
Code Name
EM
EX
FX
TE
UR
PER06
364
Electronic Mail
Telephone Extension
Facsimile
Telephone
Uniform Resource Locator (URL)
Must not contain any characters used as delimiters in this transaction.
Communication Number
X
AN
1/256
Situational
Description: Complete communications number including country or area code when
applicable
Situational Rule: Required when the telephone extension or multiple communication
numbers are available. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Requester Contact Communication Number
PER07
365
Communication Number Qualifier
X
ID
2/2
Situational
Description: Code identifying the type of communication number
Situational Rule: Required when the telephone extension or multiple communication
numbers are available. If not required by this implementation guide, do not send.
CodeList Summary (Total Codes: 42, Included: 5)
Code Name
EM
EX
FX
TE
UR
PER08
364
Electronic Mail
Telephone Extension
Facsimile
Telephone
Uniform Resource Locator (URL)
Must not contain any characters used as delimiters in this transaction.
Communication Number
X
AN
1/256
Situational
Description: Complete communications number including country or area code when
applicable
Situational Rule: Required when the telephone extension or multiple communication
numbers are available. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Requester Contact Communication Number
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.
Situational Rule:
Required when the UMO must direct requests for additional information to a specific requester contact, electronic
mail, facsimile, or telephone number. If not required by this implementation guide, do not send.
TR3 Notes:
1. When the communication number represents a telephone number in the United States and other countries
using the North American Dialing Plan (for voice, data, fax, etc.), the communication number should always
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include the area code and telephone 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.
TR3 Example:
PER*IC*WILBER*TE*8189991234*FX*8188769304~
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Pos: 2400
PRV Requester Provider
Max: 1
Detail - Optional
Information
Loop:
2010B
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
Situational
Description: Code identifying the type of provider
CodeList Summary (Total Codes: 26, Included: 11)
Code Name
AD
AS
AT
CO
CV
OP
OR
OT
PC
PE
RF
PRV02
128
Admitting
Assistant Surgeon
Attending
Consulting
Covering
Operating
Ordering
Other Physician
Primary Care Physician
Performing
Referring
Reference Identification Qualifier
X
Description: Code qualifying the Reference Identification
Situational Rule: Required when necessary to identify the requesting provider’s specialty.
If not required by this implementation guide, may be provided at the sender’s discretion but
cannot be required by the receiver.
CodeList Summary (Total Codes: 1731, Included: 1)
Code Name
PXC
Health Care Provider Taxonomy Code
CODE SOURCE:
682: Health Care Provider Taxonomy
PRV03
127
Reference Identification
X
AN
1/50
Situational
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Situational Rule: Required when necessary to identify the requesting provider’s specialty.
If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Provider Taxonomy Code
ExternalCodeList
Name: 682
Description: Health Care Provider Taxonomy
Syntax Rules:
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1. P0203 - If either PRV02 or PRV03 is present, then the other is required.
Situational Rule:
Required when needed to indicate the requester’s role in the care of the patient and the requesting provider’s
specialty. If not required by this implementation guide, may be provided at the sender’s discretion but cannot be
required by the receiver.
TR3 Example:
PRV*CO*PXC*203BS0133X~
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Pos: 0100
Loop Subscriber Level
Repeat: 1
Mandatory
Loop:
2000C
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
Req
Max Use
0100
1700
HL
Subscriber Level
Loop 2010C
M
O
1
37
Repeat
Usage
1
Required
Required
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Pos: 0100
HL Subscriber Level
Max: 1
Detail - Mandatory
Loop:
2000C
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: 250, 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
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.
TR3 Notes:
1. This segment indicates the subscriber hierarchical level. This segment corresponds to the identification of the
subscriber or individual insured member. The subscriber could also be the patient. If the subscriber is the patient
or the patient has a unique insurance identifier, the dependent hierarchical level (Loop 2000D) is not used.
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TR3 Example:
HL*3*2*22*1~
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Pos: 1700
Loop Subscriber Name
Repeat: 1
Optional
Loop:
2010C
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
1700
1800
2000
2100
2500
2600
NM1
REF
N3
N4
DMG
INS
Subscriber
Subscriber
Subscriber
Subscriber
Subscriber
Subscriber
Name
Supplemental Identification
Address
City, State, ZIP Code
Demographic Information
Relationship
40
Req
Max Use
O
O
O
O
O
O
1
9
1
1
1
1
Repeat
Usage
Required
Situational
Situational
Situational
Situational
Situational
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Pos: 1700
NM1 Subscriber Name
Max: 1
Detail - Optional
Loop:
2010C
Elements: 9
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: 1500, Included: 1)
Code Name
IL
NM102
1065
Insured or Subscriber
Entity Type Qualifier
M
ID
1/1
Required
AN
1/60
Situational
Description: Code qualifying the type of entity
CodeList Summary (Total Codes: 16, Included: 1)
Code Name
1
NM103
1035
Person
Name Last or Organization Name
X
Description: Individual last name or organizational name
Situational Rule: Required when name information is needed by the UMO to identify the
Subscriber. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Subscriber Last Name
NM104
1036
Name First
O
AN
1/35
Situational
Description: Individual first name
Situational Rule: Required when name information is needed by the UMO to identify the
Subscriber. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Subscriber First Name
NM105
1037
Name Middle
O
AN
1/25
Situational
Description: Individual middle name or initial
Situational Rule: Required when name information is needed by the UMO to identify the
Subscriber and the middle name/initial of the person is known. If not required by this
implementation guide, do not send.
IMPLEMENTATION NAME: Subscriber Middle Name or Initial
NM106
1038
Name Prefix
O
AN
1/10
Situational
Description: Prefix to individual name
Situational Rule: Required when military title or rank is needed by the UMO to determine
the approriate benefit/level of care. If not required by this implementation guide, do not
send.
IMPLEMENTATION NAME: Subscriber Name Prefix
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Ref
Id
Element Name
NM107
1039
Name Suffix
Req
Type
Min/Max
Usage
O
AN
1/10
Situational
Description: Suffix to individual name
Situational Rule: Required when the suffix is needed to further identify the patient; e.g.
Sr., Jr., or III. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Subscriber Name Suffix
NM108
66
Identification Code Qualifier
X
ID
1/2
Required
Description: Code designating the system/method of code structure used for Identification
Code (67)
CodeList Summary (Total Codes: 241, Included: 2)
Code Name
NM109
67
II
Standard Unique Health Identifier for each Individual in the United States
The value “II” when used in this data element, shall be defined as “HIPAA
Individual Identifier” if this identifier has been adopted. Under the Health Insurance
Portability and Accountability Act of 1996, the Secretary of Health and Human
Services must adopt a standard individual identifier for use in this transaction.
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. Use
MI - Member Identification Number to convey the following terms: Insured’s ID,
Subscriber’s ID, Health Insurance Claim Number (HIC), etc.
Identification Code
X
AN
2/80
Required
Description: Code identifying a party or other code
IMPLEMENTATION NAME: Subscriber Primary 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.
3. C1203 - If NM112 is present, then NM103 is required.
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
2. NM112 can identify a second surname.
TR3 Notes:
1. This segment conveys the name and identification number of the subscriber (who may also be the patient).
2. The Member Identification Number (NM108/NM109) is required and may be adequate to identify the subscriber
to the UMO. However, the UMO can require additional information. The maximum data elements that the UMO
can require to identify the subscriber, in addition to the member ID are as follows:
Subscriber Last Name (NM103)
Subscriber First Name (NM104)
Subscriber Birth Date (DMG01 and DMG02)
3. Refer to Section 2.2.2.1 Identifying the Patient for specific information on how to identify an individual to a
UMO.
TR3 Example:
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NM1*IL*1*SMITH*JOE****MI*12345678901~
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Pos: 1800
REF Subscriber Supplemental
Max: 9
Detail - Optional
Identification
Loop:
2010C
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: 1731, Included: 11)
Code Name
REF02
127
1L
Group or Policy Number
Use this code only if you cannot determine if the number is a Group Number (6P)
or a Policy Number (IG).
3L
6P
DP
EJ
Branch Identifier
Group Number
Department Number
Patient Account Number
The maximum number of characters to be supported for this qualifier is ‘20’.
Characters beyond the maximum are not required to be stored nor returned by
any receiving system. Use this code only if the subscriber is the patient.
F6
Health Insurance Claim (HIC) Number
Use the NM1 (Subscriber Name) segment if the subscriber’s HIC number is the
primary identifier for his or her coverage. Use this code only in a REF segment
when the payer has a different member number, and there is also a need to pass
the subscriber’s HIC number. This might occur in a Medicare HMO situation.
HJ
Identity Card Number
Use this code when the Identity Card Number differs from the Member
Identification Number. This is particularly prevalent in the Medicaid environment.
IG
N6
NQ
SY
Insurance Policy Number
Plan Network Identification Number
Medicaid Recipient Identification Number
Social Security Number
Use this code only if the Social Security Number was not used by the payer as its
primary method of identifying the subscriber. The social security number may not
be used for Medicare.
Reference Identification
X
AN
1/50
Required
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
IMPLEMENTATION NAME: Subscriber Supplemental Identifier
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
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1. REF04 contains data relating to the value cited in REF02.
Situational Rule:
Required when needed to provide a supplemental identifier for the subscriber. If not required by this
implementation guide, do not send.
TR3 Notes:
1. The primary identifier is the Member Identification Number in the NM1 segment.
2. Health Insurance Claim (HIC) Number or Medicaid Recipient Identification Number are to be provided in the
NM1 segment as a Member Identification Number when it is the primary number a UMO knows a member by
(such as for Medicare or Medicaid). Do not use this segment for the Health Insurance Claim (HIC) Number or
Medicaid Recipient Identification Number unless they are different from the Member Identification Number
provided in the NM1 segment.
3. If the requester values this segment with the Patient Account Number (REF01="EJ") on the request, the UMO
is required to return the same value in this segment on the response.
TR3 Example:
REF*SY*123456789~
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Pos: 2000
N3 Subscriber Address
Max: 1
Detail - Optional
Loop:
2010C
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
Description: Address information
IMPLEMENTATION NAME: Subscriber Address Line
Use this element for the first line of the Subscriber mailing address.
N302
166
Address Information
O
AN
1/55
Situational
Description: Address information
Situational Rule: Required when a second address line exists. If not required by this
implementation guide, do not send.
IMPLEMENTATION NAME: Subscriber Address Line
Situational Rule:
Required when the subscriber is the patient and the current address of the patient is used to determine the
appropriate location or network of service. If not required by this implementation guide, do not send.
TR3 Example:
N3*PO Box 171021~
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Pos: 2100
N4 Subscriber City, State, ZIP
Max: 1
Detail - Optional
Code
Loop:
2010C
Elements: 5
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
ID
2/2
Situational
Description: Free-form text for city name
IMPLEMENTATION NAME: Subscriber City Name
N402
156
State or Province Code
X
Description: Code (Standard State/Province) as defined by appropriate government
agency
Situational Rule: Required when the address is in the United States of America, including
its territories, or Canada. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Subscriber State Code
CODE SOURCE: 22: States and Provinces
ExternalCodeList
Name: 22C
Description: States and Provinces
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)
Situational Rule: Required when the address is in the United States of America, including
its territories, or Canada, or when a postal code exists for the country in N404. If not
required by this implementation guide, do not send.
IMPLEMENTATION NAME: Payer Postal Zone or ZIP Code
CODE SOURCE: 51: ZIP Code
932: Universal Postal Codes
ExternalCodeList
Name: 932
Description:
ExternalCodeList
Name: 51
Description: ZIP Code
N404
26
Country Code
X
ID
2/3
Situational
Description: Code identifying the country
Situational Rule: Required when the address is outside the United States of America. If
not required by this implementation guide, do not send.
CODE SOURCE: 5: Countries, Currencies and Funds
Use the alpha-2 country codes from Part 1 of ISO 3166.
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Id
Element Name
Req
Type
Min/Max
Usage
ID
1/3
Situational
ExternalCodeList
Name: 5
Description: Countries, Currencies and Funds
N407
1715
Country Subdivision Code
X
Description: Code identifying the country subdivision
Situational Rule: Required when the address is not in the United States of America,
including its territories, or Canada, and the country in N404 has administrative subdivisions
such as but not limited to states, provinces, cantons, etc. If not required by this
implementation guide, do not send.
CODE SOURCE: 5: Countries, Currencies and Funds
Use the country subdivision codes from Part 2 of ISO 3166.
ExternalCodeList
Name: 5
Description: Countries, Currencies and Funds
Syntax Rules:
1. E0207 - Only one of N402 or N407 may be present.
2. C0605 - If N406 is present, then N405 is required.
3. C0704 - If N407 is present, then N404 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.
Situational Rule:
Required when the subscriber is the patient and the current address of the patient is used to determine the
appropriate location or network of service. If not required by this implementation guide, do not send.
TR3 Example:
N4*KANSAS CITY*MO*64108~
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Pos: 2500
DMG Subscriber Demographic
Max: 1
Detail - Optional
Information
Loop:
2010C
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
X
ID
2/3
Required
Description: Code indicating the date format, time format, or date and time format
CodeList Summary (Total Codes: 42, Included: 1)
Code Name
D8
DMG02
1251
Date Expressed in Format CCYYMMDD
Date Time Period
X
AN
1/35
Required
Description: Expression of a date, a time, or range of dates, times or dates and times
IMPLEMENTATION NAME: Subscriber Birth Date
DMG03
1068
Gender Code
O
ID
1/1
Situational
Description: Code indicating the sex of the individual
Situational Rule: Required when gender code (DMG03) is needed to determine medical
necessity. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Subscriber Gender Code
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.
2. P1011 - If either DMG10 or DMG11 is present, then the other is required.
3. C1105 - If DMG11 is present, then DMG05 is required.
Semantics:
1.
2.
3.
4.
DMG02 is the date of birth.
DMG07 is the country of citizenship.
DMG09 is the age in years.
DMG11 is used to specify how the information in DMG05, including repeats of C056, was collected.
Situational Rule:
Required when birth date is needed to identify the patient or when gender information is used by the UMO to
render a medical decision. If not required by this implementation guide, do not send.
TR3 Notes:
1. Refer to Section 1.12.2 Identifying the Patient for specific information on how to identify an individual to a UMO.
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TR3 Example:
DMG*D8*19580322*M~
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Pos: 2600
INS Subscriber Relationship
Max: 1
Detail - Optional
Loop:
2010C
Elements: 3
User Option (Usage): Situational
Purpose: To provide benefit information on insured entities
Element Summary:
Ref
Id
Element Name
INS01
1073
Yes/No Condition or Response Code
Req
Type
Min/Max
Usage
M
ID
1/1
Required
2/2
Required
Description: Code indicating a Yes or No condition or response
IMPLEMENTATION NAME: Insured Indicator
CodeList Summary (Total Codes: 4, Included: 1)
Code Name
Y
INS02
1069
Yes
Individual Relationship Code
M
ID
Description: Code indicating the relationship between two individuals or entities
CodeList Summary (Total Codes: 154, Included: 1)
Code Name
18
INS08
584
Self
Employment Status Code
O
ID
2/2
Required
Description: Code showing the general employment status of an employee/claimant
Use to qualify the patient’s relationship to the military.
CodeList Summary (Total Codes: 91, Included: 5)
Code Name
AO
AU
DI
PV
RU
Active Military - Overseas
Active Military - USA
Deceased
Previous
Retired Military - USA
Syntax Rules:
1. P1112 - If either INS11 or INS12 is present, then the other is required.
Semantics:
1. INS01 indicates status of the insured. A "Y" value indicates the insured is a subscriber: an "N" value indicates
the insured is a dependent.
2. INS10 is the handicapped status indicator. A "Y" value indicates an individual is handicapped; an "N" value
indicates an individual is not handicapped.
3. INS12 is the date of death.
4. INS14, INS15, and INS16 identify where the employee works.
5. INS17 is the number assigned to each family member born with the same birth date. This number identifies
birth sequence for multiple births allowing proper tracking and response of benefits for each dependent (i.e.,
twins, triplets, etc.).
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Situational Rule:
Required when the subscriber’s role in the military is necessary to determine the appropriate benefit/level of care.
If not required by this implementation guide, do not send.
TR3 Example:
NS*Y*18******AO~
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Pos: 0100
Loop Dependent Level
Repeat: 1
Optional
Loop:
2000D
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
Req
Max Use
0100
1700
HL
Dependent Level
Loop 2010D
O
O
1
53
Repeat
Usage
1
Situational
Required
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Pos: 0100
HL Dependent Level
Max: 1
Detail - Optional
Loop:
2000D
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: 250, Included: 1)
Code Name
23
HL04
736
Dependent
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.
Situational Rule:
Required when the patient is someone other than the subscriber and the patient does not have a unique (different
from the subscriber) member ID. If not required by this implementation guide, do not send.
TR3 Notes:
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1. If the patient has a unique member ID, use Loop 2000C to identify the patient.
2. Required segments in this loop are required only when this loop is used.
TR3 Example:
HL*4*3*23*1~
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Pos: 1700
Loop Dependent Name
Repeat: 1
Optional
Loop:
2010D
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
1700
1800
2000
2100
2500
2600
NM1
REF
N3
N4
DMG
INS
Dependent Name
Dependent Supplemental Identification
Dependent Address
Dependent City, State, ZIP Code
Dependent Demographic Information
Dependent Relationship
56
Req
Max Use
O
O
O
O
O
O
1
3
1
1
1
1
Repeat
Usage
Required
Situational
Situational
Situational
Situational
Situational
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Pos: 1700
NM1 Dependent Name
Max: 1
Detail - Optional
Loop:
2010D
Elements: 6
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: 1500, Included: 1)
Code Name
QC
NM102
1065
Patient
Entity Type Qualifier
M
ID
1/1
Required
AN
1/60
Situational
Description: Code qualifying the type of entity
CodeList Summary (Total Codes: 16, Included: 1)
Code Name
1
NM103
1035
Person
Name Last or Organization Name
X
Description: Individual last name or organizational name
Situational Rule: Required when name information is needed by the UMO to identify the
Dependent. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Dependent Last Name
NM104
1036
Name First
O
AN
1/35
Situational
Description: Individual first name
Situational Rule: Required when name information is needed by the UMO to identify the
Dependent. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Dependent First Name
NM105
1037
Name Middle
O
AN
1/25
Situational
Description: Individual middle name or initial
Situational Rule: Required when name information is needed by the UMO to identify the
Dependent and the middle name/initial of the dependent is known. If not required by this
implementation guide, do not send.
IMPLEMENTATION NAME: Dependent Middle Name
NM107
1039
Name Suffix
O
AN
1/10
Situational
Description: Suffix to individual name
Situational Rule: Required when name information is needed to identify the Dependent
and the suffix of an individual’s name; e.g. Sr., Jr., or III of the dependent is known. If not
required by this implementation guide, do not send.
IMPLEMENTATION NAME: Dependent Name Suffix
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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.
3. C1203 - If NM112 is present, then NM103 is required.
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
2. NM112 can identify a second surname.
TR3 Notes:
1. This segment conveys the name of the dependent who is the patient.
2. The maximum data elements in Loop 2010D that can be required by a UMO to identify a dependent are as
follows:
Dependent Last Name (NM103)
Dependent First Name (NM104)
Dependent Birth Date (DMG01 and DMG02)
3. Refer to Section 1.12.2 Identifying the Patient for specific information on how to identify an individual to a UMO.
TR3 Example:
NM1*QC*1*SMITH*MARY~
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Pos: 1800
REF Dependent Supplemental
Max: 3
Detail - Optional
Identification
Loop:
2010D
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: 1731, Included: 2)
Code Name
REF02
127
EJ
Patient Account Number
The maximum number of characters to be supported for this qualifier is ‘20’.
Characters beyond the maximum are not required to be stored nor returned by
any receiving system.
SY
Social Security Number
The social security number may not be used for Medicare.
Reference Identification
X
AN
1/50
Required
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
IMPLEMENTATION NAME: Dependent 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.
Situational Rule:
Required when needed to provide a supplemental identifier for the dependent. If not required by this
implementation guide, do not send.
TR3 Notes:
1. Use the Subscriber Supplemental Identifier (REF) segment in Loop 2010C for supplemental identifiers related
to the subscriber’s policy or group number.
2. If the requester values this segment with the Patient Account Number (REF01 = “EJ”) on the request, the UMO
is required to return the same value in this segment on the response.
TR3 Example:
REF*SY*123456789~
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Pos: 2000
N3 Dependent Address
Max: 1
Detail - Optional
Loop:
2010D
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
1/55
Situational
Description: Address information
IMPLEMENTATION NAME: Dependent Address Line
Use this element for the first line of the Dependent address.
N302
166
Address Information
O
AN
Description: Address information
Situational Rule: Required when a second address line exists. If not required by this
implementation guide, do not send.
IMPLEMENTATION NAME: Dependent Address Line
Situational Rule:
Required when the current address of the patient is used to determine the appropriate location or network of
service. If not required by this implementation guide, do not send.
TR3 Example:
N3*PO Box 171021~
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Pos: 2100
N4 Dependent City, State, ZIP
Max: 1
Detail - Optional
Code
Loop:
2010D
Elements: 5
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
ID
2/2
Situational
Description: Free-form text for city name
IMPLEMENTATION NAME: Dependent City Name
N402
156
State or Province Code
X
Description: Code (Standard State/Province) as defined by appropriate government
agency
Situational Rule: Required when the address is in the United States of America, including
its territories, or Canada. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Dependent State Code
CODE SOURCE: 22: States and Provinces
ExternalCodeList
Name: 22C
Description: States and Provinces
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)
Situational Rule: Required when the address is in the United States of America, including
its territories, or Canada, or when a postal code exists for the country in N404. If not
required by this implementation guide, do not send.
IMPLEMENTATION NAME: Dependent Postal Zone or ZIP Code
CODE SOURCE: 51: ZIP Code
932: Universal Postal Codes
ExternalCodeList
Name: 932
Description:
ExternalCodeList
Name: 51
Description: ZIP Code
N404
26
Country Code
X
ID
2/3
Situational
Description: Code identifying the country
Situational Rule: Required when the address is outside the United States of America. If
not required by this implementation guide, do not send.
CODE SOURCE: 5: Countries, Currencies and Funds
Use the alpha-2 country codes from Part 1 of ISO 3166.
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Id
Element Name
Req
Type
Min/Max
Usage
ID
1/3
Situational
ExternalCodeList
Name: 5
Description: Countries, Currencies and Funds
N407
1715
Country Subdivision Code
X
Description: Code identifying the country subdivision
Situational Rule: Required when the address is not in the United States of America,
including its territories, or Canada, and the country in N404 has administrative subdivisions
such as but not limited to states, provinces, cantons, etc. If not required by this
implementation guide, do not send.
CODE SOURCE: 5: Countries, Currencies and Funds
Use the country subdivision codes from Part 2 of ISO 3166.
ExternalCodeList
Name: 5
Description: Countries, Currencies and Funds
Syntax Rules:
1. E0207 - Only one of N402 or N407 may be present.
2. C0605 - If N406 is present, then N405 is required.
3. C0704 - If N407 is present, then N404 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.
Situational Rule:
Required when the current address of the patient is used to determine the appropriate location or network of
service. If not required by this implementation guide, do not send.
TR3 Example:
N4*KANSAS CITY*MO*64108~
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Pos: 2500
DMG Dependent Demographic
Max: 1
Detail - Optional
Information
Loop:
2010D
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
X
ID
2/3
Required
Description: Code indicating the date format, time format, or date and time format
CodeList Summary (Total Codes: 42, Included: 1)
Code Name
D8
DMG02
1251
Date Expressed in Format CCYYMMDD
Date Time Period
X
AN
1/35
Required
Description: Expression of a date, a time, or range of dates, times or dates and times
IMPLEMENTATION NAME: Dependent Birth Date
DMG03
1068
Gender Code
O
ID
1/1
Situational
Description: Code indicating the sex of the individual
Situational Rule: Required when gender code (DMG03) is needed to determine medical
necessity. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Dependent Gender Code
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.
2. P1011 - If either DMG10 or DMG11 is present, then the other is required.
3. C1105 - If DMG11 is present, then DMG05 is required.
Semantics:
1.
2.
3.
4.
DMG02 is the date of birth.
DMG07 is the country of citizenship.
DMG09 is the age in years.
DMG11 is used to specify how the information in DMG05, including repeats of C056, was collected.
Situational Rule:
Required when birth date is needed to identify the patient or when gender information is used by the UMO to
render a medical decision. If not required by this implementation guide, do not send.
TR3 Notes:
1. Refer to Section 1.12.2 Identifying the Patient for specific information on how to identify an individual to a UMO.
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TR3 Example:
DMG*D8*19580322*M~
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Pos: 2600
INS Dependent Relationship
Max: 1
Detail - Optional
Loop:
2010D
Elements: 3
User Option (Usage): Situational
Purpose: To provide benefit information on insured entities
Element Summary:
Ref
Id
Element Name
INS01
1073
Yes/No Condition or Response Code
Req
Type
Min/Max
Usage
M
ID
1/1
Required
2/2
Required
Description: Code indicating a Yes or No condition or response
IMPLEMENTATION NAME: Insured Indicator
CodeList Summary (Total Codes: 4, Included: 1)
Code Name
N
INS02
1069
No
Individual Relationship Code
M
ID
Description: Code indicating the relationship between two individuals or entities
CodeList Summary (Total Codes: 154, Included: 3)
Code Name
01
19
G8
INS17
1470
Spouse
Child
Other Relationship
Number
O
N0
1/9
Situational
Description: A generic number
Situational Rule: Required when the dependent is a child from a multiple birth. If not
required, do not send.
IMPLEMENTATION NAME: Birth Sequence Number
Syntax Rules:
1. P1112 - If either INS11 or INS12 is present, then the other is required.
Semantics:
1. INS01 indicates status of the insured. A "Y" value indicates the insured is a subscriber: an "N" value indicates
the insured is a dependent.
2. INS10 is the handicapped status indicator. A "Y" value indicates an individual is handicapped; an "N" value
indicates an individual is not handicapped.
3. INS12 is the date of death.
4. INS14, INS15, and INS16 identify where the employee works.
5. INS17 is the number assigned to each family member born with the same birth date. This number identifies
birth sequence for multiple births allowing proper tracking and response of benefits for each dependent (i.e.,
twins, triplets, etc.).
Situational Rule:
Required when patient relationship to insured or birth sequence is needed by the UMO to determine the
appropriate benefit/level of care. If not required by this implementation guide, do not send.
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TR3 Notes:
1. This segment may be used to further identify the patient. Examples include identifying a patient in a multiple
birth or differentiating dependents with the same name.
TR3 Example:
INS*N*19~
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Pos: 0100
Loop Patient Event Level
Repeat: 1
Mandatory
Loop:
2000E
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
0100
0200
0400
0600
0600
HL
TRN
UM
REF
REF
0700
0700
0700
0700
0700
0700
0700
0800
0900
1000
1000
1000
1000
1000
1000
1000
1100
1200
1300
1400
1500
1550
1600
1700
1700
1700
DTP
DTP
DTP
DTP
DTP
DTP
DTP
HI
HSD
CRC
CRC
CRC
CRC
CRC
CRC
CRC
CL1
CR1
CR2
CR5
CR6
PWK
MSG
Patient Event Level
Patient Event Tracking Number
Health Care Services Review Information
Previous Review Authorization Number
Previous Review Administrative Reference
Number
Accident Date
Last Menstrual Period Date
Estimated Date of Birth
Onset of Current Symptoms or Illness Date
Event Date
Admission Date
Discharge Date
Patient Diagnosis
Health Care Services Delivery
Ambulance Certification Information
Chiropractic Certification Information
Durable Medical Equipment Information
Oxygen Therapy Certification Information
Functional Limitations Information
Activities Permitted Information
Mental Status Information
Institutional Claim Code
Ambulance Transport Information
Spinal Manipulation Service Information
Home Oxygen Therapy Information
Home Health Care Information
Additional Patient Information
Message Text
Loop 2010EA
Loop 2010EB
Loop 2010EC
67
Req
Max Use
Repeat
M
O
O
O
O
1
2
1
1
1
Required
Situational
Required
Situational
Situational
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
10
1
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
14
5
3
Usage
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Pos: 0100
HL Patient Event Level
Max: 1
Detail - Mandatory
Loop:
2000E
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: 250, Included: 1)
Code Name
EV
HL04
736
Event
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: 2)
Code Name
0
1
No Subordinate HL Segment in This Hierarchical Structure.
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.
TR3 Notes:
1. Loop 2000E to provide information on the patient event associated with this health care services review.
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TR3 Example:
HL*5*4*EV*1~
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Pos: 0200
TRN Patient Event Tracking
Max: 2
Detail - Optional
Number
Loop:
2000E
Elements: 4
User Option (Usage): Situational
Purpose: To uniquely identify a transaction to an application
Element Summary:
Ref
Id
Element Name
TRN01
481
Trace Type Code
Req
Type
Min/Max
Usage
M
ID
1/2
Required
Description: Code identifying which transaction is being referenced
CodeList Summary (Total Codes: 3, Included: 1)
Code Name
1
TRN02
127
Current Transaction Trace Numbers
Reference Identification
M
AN
1/50
Required
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
IMPLEMENTATION NAME: Patient Event Trace Number
TRN03
509
Originating Company Identifier
O
AN
10/10
Required
Description: A unique identifier designating the company initiating the funds transfer
instructions, business transaction or assigning tracking reference identification.
IMPLEMENTATION NAME: Trace Assigning Entity Identifier
Use this element to identify the organization that assigned this trace number. TRN03 must
be completed to aid requesters and clearinghouses in identifying their TRN in the 278
response.
The first position must be either a “1" if an EIN is used, a ”3" if a DUNS is used or a “9" if a
user assigned identifier is used.
TRN04
127
Reference Identification
O
AN
1/50
Situational
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Situational Rule: Required when a specific division or group, of the company identified in
the previous data element (TRN03) is needed by the requester to further identify a specific
component of the entity. If not required by this implementation guide, may be provided at
the sender’s discretion but cannot be required by the receiver.
IMPLEMENTATION NAME: Trace Assigning Entity Additional Identifier
Semantics:
1. TRN02 provides unique identification for the transaction.
2. TRN03 identifies an organization.
3. TRN04 identifies a further subdivision within the organization.
Situational Rule:
Required when the requester needs to assign a unique trace number to the patient event request. If not required
by this implementation guide, may be provided at the sender’s discretion but cannot be required by the receiver.
TR3 Notes:
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1. This enables the requester to
• uniquely identify this patient event request
• trace the request
• match the response to the request
• reference this request in any associated attachments containing additional patient information related to this
patient event request.
2. If the transaction is routed through a clearinghouse, the clearinghouse may add their own TRN segment. If the
transaction passes through multiple clearinghouses, and the second clearinghouse needs to assign their own
TRN segment, they must replace the TRN from the first clearinghouse and retain it to be returned in the 278
response. If the second clearinghouse does not need to assign a TRN segment, they should pass all received
TRN segments.
3. Each trace number provided in the TRN segment at this level on the request must be returned by the UMO in
the TRN segment at the corresponding level of the response.
TR3 Example:
TRN*1*2001042801*9012345678*CARDIOLOGY~
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UM Health Care Services Review
Information
Pos: 0400
Max: 1
Detail - Optional
Loop:
2000E
Elements: 10
User Option (Usage): Required
Purpose: To specify health care services review information
Element Summary:
Ref
Id
Element Name
UM01
1525
Request Category Code
Req
Type
Min/Max
Usage
M
ID
1/2
Required
Description: Code indicating a type of request
CodeList Summary (Total Codes: 7, Included: 4)
Code Name
UM02
1322
AR
Admission Review
Required if requesting an admission to a facility.
HS
Health Services Review
Required if requesting a review of services related to an episode of care.
IN
Individual
Required when BHT06 is equal to “RU”.
SC
Specialty Care Review
Required if requesting a referral to a specialty provider.
Certification Type Code
O
ID
1/1
Required
Description: Code indicating the type of certification
CodeList Summary (Total Codes: 15, Included: 8)
Code Name
1
Appeal - Immediate
Use this value only for appeals of review decisions where the level of service
required is emergency or urgent. If UM02 = 1 then UM06 must be valued.
2
Appeal - Standard
Use this value for appeals of review decisions where the level of service required
is not emergency or urgent.
3
4
Cancel
Extension
Indicates that this is an extension request to a prior approved service.
I
N
R
Initial
Reconsideration
Renewal
Various services, such as physical therapy, spinal manipulation, and allergy
treatment, have both a delivery pattern and a time span of authorization. Many
UMOs place time limits - as in will not authorize anything for more than 30 days at
a time. For example, blanket authorization for allergy treatments as required for 30
days. At the end of the 30 days, the provider must request to renew the
certification - not extend it - because the UMO authorizes for 30 day intervals, one
interval at a time.
S
Revised
Use if the requester is revising the specifics of a certification for which services
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Code Name
have not been rendered. For example, the requester may be requesting additional
procedures or other procedures for the same patient event.
UM03
1365
Service Type Code
O
ID
1/2
Situational
Description: Code identifying the classification of service
Situational Rule: Required when Loop 2000F is not valued. If not required by this
implementation guide, may be provided at sender’s discretion but cannot be required by
the receiver.
CodeList Summary (Total Codes: 190, Included: 103)
Code Name
1
2
3
4
5
6
7
8
11
12
14
15
16
17
18
20
21
23
24
25
Medical Care
Surgical
Consultation
Diagnostic X-Ray
Diagnostic Lab
Radiation Therapy
Anesthesia
Surgical Assistance
Used Durable Medical Equipment
Durable Medical Equipment Purchase
Renal Supplies in the Home
Alternate Method Dialysis
Chronic Renal Disease (CRD) Equipment
Pre-Admission Testing
Durable Medical Equipment Rental
Second Surgical Opinion
Third Surgical Opinion
Diagnostic Dental
Periodontics
Restorative
Use for restorative dental.
26
27
28
33
35
36
37
38
39
40
42
44
45
46
54
56
Endodontics
Maxillofacial Prosthetics
Adjunctive Dental Services
Chiropractic
Dental Care
Dental Crowns
Dental Accident
Orthodontics
Prosthodontics
Oral Surgery
Home Health Care
Home Health Visits
Hospice
Respite Care
Long Term Care
Medically Related Transportation
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Code Name
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
82
83
84
85
86
87
88
93
A4
A6
A9
AD
AE
AF
AG
AI
AJ
AK
AL
AR
B1
BB
BC
BD
BE
BF
BG
In-vitro Fertilization
MRI/CAT Scan
Donor Procedures
Acupuncture
Newborn Care
Pathology
Smoking Cessation
Well Baby Care
Maternity
Transplants
Audiology Exam
Inhalation Therapy
Diagnostic Medical
Private Duty Nursing
Prosthetic Device
Dialysis
Otological Exam
Chemotherapy
Allergy Testing
Immunizations
Family Planning
Infertility
Abortion
AIDS
Emergency Services
Cancer
Pharmacy
Podiatry
Psychiatric
Psychotherapy
Rehabilitation
Occupational Therapy
Physical Medicine
Speech Therapy
Skilled Nursing Care
Substance Abuse
Alcoholism
Drug Addiction
Vision (Optometry)
Experimental Drug Therapy
Burn Care
Partial Hospitalization (Psychiatric)
Day Care (Psychiatric)
Cognitive Therapy
Massage Therapy
Pulmonary Rehabilitation
Cardiac Rehabilitation
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Code Name
BL
BN
BP
BQ
BS
BY
BZ
C1
CQ
GY
IC
MH
NI
ON
PT
PU
RN
RT
TC
TN
UM04
C023
Cardiac
Gastrointestinal
Endocrine
Neurology
Invasive Procedures
Physician Visit - Office: Sick
Physician Visit - Office: Well
Coronary Care
Case Management
Allergy
Intensive Care
Mental Health
Neonatal Intensive Care
Oncology
Physical Therapy
Pulmonary
Renal
Residential Psychiatric Treatment
Transitional Care
Transitional Nursery Care
Health Care Service Location
Information
O
Comp
Situational
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
Situational Rule: Required when UM04 is not valued at 2000F. If not required by this
implementation guide, may be provided at the sender’s discretion, but cannot be required
by the receiver.
Value at 2000F, Service Level, overrides the patient event for that service only.
UM04-01
1331
Facility Code Value
M
AN
1/2
Required
Description: Code identifying where services were, or may be, performed; the first and
second positions of the Uniform Bill Type Code for Institutional Services or the Place of
Service Codes for Professional or Dental Services.
IMPLEMENTATION NAME: Facility Type Code
Use to indicate a facility code value from the code source referenced in UM04-2.
ExternalCodeList
Name: 236
Description: Uniform Billing Claim Form Bill Type
ExternalCodeList
Name: 237
Description: Place of Service Codes for Professional Claims
UM04-02
1332
Facility Code Qualifier
O
ID
1/2
Required
Description: Code identifying the type of facility referenced
CodeList Summary (Total Codes: 2, Included: 2)
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Code Name
A
Uniform Billing Claim Form Bill Type
CODE SOURCE:
B
Place of Service Codes for Professional or Dental Services
CODE SOURCE:
236: Uniform Billing Claim Form Bill Type
237: Place of Service Codes for Professional Claims
UM05
C024
Related Causes Information
O
Comp
Situational
Description: To identify one or more related causes and associated state or country
information
Situational Rule: Required when the patient’s condition is accident or employment related.
If not required by this implementation guide, do not send.
UM05-01
1362
Related-Causes Code
M
ID
2/3
Required
Description: Code identifying an accompanying cause of an illness, injury or an accident
IMPLEMENTATION NAME: Related Causes Code
Always use this data element if the related cause is an auto accident.
CodeList Summary (Total Codes: 6, Included: 3)
Code Name
AA
AP
EM
UM05-02
1362
Auto Accident
Another Party Responsible
Employment
Related-Causes Code
O
ID
2/3
Situational
Description: Code identifying an accompanying cause of an illness, injury or an accident
Situational Rule: Required when there is greater than 1 related cause for this certification.
If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Related Causes Code
CodeList Summary (Total Codes: 6, Included: 2)
Code Name
AP
EM
UM05-03
1362
Another Party Responsible
Employment
Related-Causes Code
O
ID
2/3
Situational
Description: Code identifying an accompanying cause of an illness, injury or an accident
Situational Rule: Required when UM05 -1 and UM05-2 are not equal “AP” and “AP”
applies to this patient event. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Related Causes Code
CodeList Summary (Total Codes: 6, Included: 1)
Code Name
AP
UM05-04
156
Another Party Responsible
State or Province Code
O
ID
2/2
Situational
Description: Code (Standard State/Province) as defined by appropriate government
agency
Situational Rule: Required when UM05-1 = “AA” and the accident occurred out of the
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Id
Element Name
Req
Type
Min/Max
Usage
services provider’s state. If not required by this implementation guide, may be provided at
the sender’s discretion but cannot be required by the receiver.
CODE SOURCE: 22: States and Provinces
ExternalCodeList
Name: 22C
Description: States and Provinces
UM05-05
26
Country Code
O
ID
2/3
Situational
Description: Code identifying the country
Situational Rule: Required when the automobile accident occurred out of the United
States to identify the country in which the accident occurred. If not required by this
implementation guide, do not send.
CODE SOURCE: 5: Countries, Currencies and Funds
ExternalCodeList
Name: 5
Description: Countries, Currencies and Funds
UM06
1338
Level of Service Code
O
ID
1/3
Situational
Description: Code specifying the level of service rendered
Situational Rule: Required when the patient event represents an emergency or otherwise
urgent need for care. If not required by this implementation guide, do not send.
CodeList Summary (Total Codes: 18, Included: 3)
Code Name
E
U
03
UM07
1213
Elective
Urgent
Emergency
Current Health Condition Code
O
ID
1/1
Situational
Description: Code indicating current health condition of the individual
Situational Rule: Required when the patient’s condition, as expressed by the codes in this
data element, is a factor in the provider’s determination of services to be performed that are
not typically requested for the patient’s diagnosis and proposed treatment. If not required
by this implementation guide, do not send.
CodeList Summary (Total Codes: 13, Included: 13)
Code Name
1
2
3
4
5
6
7
8
9
E
F
Acute
Stable
Chronic
Systemic
Localized
Mild Disease
Normal, Healthy
Severe Systemic disease
Severe Systemic Disease that is a Constant Threat to Life
Excellent
Fair
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Code Name
G
P
UM08
923
Good
Poor
Prognosis Code
O
ID
1/1
Situational
Description: Code indicating physician's prognosis for the patient
Situational Rule: Required when the patient’s prognosis, as expressed by the codes in
this data element, is a factor in the provider’s determination of services to be performed
that are not typically requested for the patient’s diagnosis and proposed treatment. If not
required by this implementation guide, do not send.
CodeList Summary (Total Codes: 8, Included: 8)
Code Name
1
2
3
4
5
6
7
8
UM09
1363
Poor
Guarded
Fair
Good
Very Good
Excellent
Less than 6 Months to Live
Terminal
Release of Information Code
O
ID
1/1
Situational
Description: Code indicating whether the provider has on file a signed statement by the
patient authorizing the release of medical data to other organizations
Situational Rule: Required when applicable legislation requires that a signature be
collected and reported on this Health Care Services Review. If not required by this
implementation guide, may be provided at the sender’s discretion but cannot be required
by the receiver.
The Release of Information response is limited to the information carried in this service
review.
CodeList Summary (Total Codes: 6, Included: 2)
Code Name
UM10
1514
M
The Provider has Limited or Restricted Ability to Release Data Related to a Claim
For professional service, this value is only used when state or federal laws
supersede the HIPAA privacy rule by requiring that the provider collect a signature
and the patient is either not present or physically unable to sign at the time the
provider submits the request.
Y
Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data
Related to a Claim
Delay Reason Code
O
ID
1/2
Situational
Description: Code indicating the reason why a request was delayed
Situational Rule: Required when the request is not submitted within the normal timeframe
of the UMO. If not required by this implementation guide, do not send.
CodeList Summary (Total Codes: 14, Included: 11)
Code Name
1
2
3
Proof of Eligibility Unknown or Unavailable
Litigation
Authorization Delays
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Code Name
4
7
8
10
11
15
16
17
Delay in Certifying Provider
Third Party Processing Delay
Delay in Eligibility Determination
Administration Delay in the Prior Approval Process
Other
Natural Disaster
Lack of Information
No response to initial request
TR3 Notes:
1. This segment identifies the type of health care services review request.
TR3 Example:
UM*SC*I*3******Y~
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Pos: 0600
REF Previous Review
Max: 1
Detail - Optional
Authorization Number
Loop:
2000E
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
1/50
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1731, Included: 1)
Code Name
BB
REF02
127
Authorization Number
Reference Identification
X
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
IMPLEMENTATION NAME: Previous Review 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.
Situational Rule:
Required when submitting an additional health care services review request associated with a request already
processed by the UMO. If not required by this implementation guide, do not send.
TR3 Notes:
1. This is the authorization number assigned by the UMO to the original service review outcome associated with
this service review. This is not the trace number assigned by the requester.
TR3 Example:
REF*BB*A123~
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Pos: 0600
REF Previous Review
Max: 1
Detail - Optional
Administrative Reference
Number
Loop:
2000E
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
1/50
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1731, Included: 1)
Code Name
NT
REF02
127
Administrator's Reference Number
Reference Identification
X
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
IMPLEMENTATION NAME: Previous Administrative 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.
Situational Rule:
Required when submitting a follow-up to a previous health care services review request for which the UMO has
returned a response that contained an administrative reference number in the REF segment where REF01 = NT
and did not return a certification number in HCR02. If not required by this implementation guide, do not send.
TR3 Example:
REF*NT*Z123~
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Pos: 0700
DTP Accident Date
Max: 1
Detail - Optional
Loop:
2000E
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
IMPLEMENTATION NAME: Date Time Qualifier
CodeList Summary (Total Codes: 1280, 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: 42, 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
IMPLEMENTATION NAME: Accident Date
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
Situational Rule:
Required when the patient’s condition is accident related and the date of the accident is known. If not required by
this implementation guide, do not send.
TR3 Example:
DTP*439*D8*20050430~
82
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DTP Last Menstrual Period Date
Pos: 0700
Max: 1
Detail - Optional
Loop:
2000E
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
IMPLEMENTATION NAME: Date Time Qualifier
CodeList Summary (Total Codes: 1280, 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: 42, 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
IMPLEMENTATION NAME: Last Menstrual Period Date
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
Situational Rule:
Required when the certification is pregnancy related. If not required by this implementation guide, do not send.
TR3 Example:
DTP*484*D8*20050312~
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Pos: 0700
DTP Estimated Date of Birth
Max: 1
Detail - Optional
Loop:
2000E
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
IMPLEMENTATION NAME: Date Time Qualifier
CodeList Summary (Total Codes: 1280, Included: 1)
Code Name
ABC
DTP02
1250
Estimated Date of Birth
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: 42, 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
IMPLEMENTATION NAME: Estimated Birth Date
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
Situational Rule:
Required when the certification is related to the estimated date of delivery. If not required by this implementation
guide, do not send.
TR3 Example:
DTP*ABC*D8*20051130~
84
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DTP Onset of Current Symptoms
or Illness Date
Pos: 0700
Max: 1
Detail - Optional
Loop:
2000E
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
IMPLEMENTATION NAME: Date Time Qualifier
CodeList Summary (Total Codes: 1280, 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: 42, 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
IMPLEMENTATION NAME: Onset Date
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
Situational Rule:
Required when the date of onset of the patient’s condition is different from the diagnosis date, and not accident or
pregnancy related. If not required by this implementation guide, do not send.
TR3 Example:
DTP*431*D8*20050415~
85
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Pos: 0700
DTP Event Date
Max: 1
Detail - Optional
Loop:
2000E
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
IMPLEMENTATION NAME: Date Time Qualifier
CodeList Summary (Total Codes: 1280, Included: 1)
Code Name
AAH
DTP02
1250
Event
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: 42, Included: 2)
Code Name
D8
RD8
DTP03
1251
Date Expressed in Format CCYYMMDD
Range of Dates Expressed in Format CCYYMMDD-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
IMPLEMENTATION NAME: Proposed or Actual Event Date
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
Situational Rule:
Required when the proposed or actual date or range of dates of this patient event are known and UM01 does not
equal AR. If not required by this implementation guide, do not send.
TR3 Notes:
1. If UM01 = AR use Admit Date.
TR3 Example:
DTP*AAH*D8*20050516~
86
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Pos: 0700
DTP Admission Date
Max: 1
Detail - Optional
Loop:
2000E
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
IMPLEMENTATION NAME: Date Time Qualifier
CodeList Summary (Total Codes: 1280, 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: 42, Included: 2)
Code Name
D8
RD8
DTP03
1251
Date Expressed in Format CCYYMMDD
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
Use this for the range of dates when admission can occur. Use the HSD segment
for the length of stay.
Date Time Period
M
AN
1/35
Required
Description: Expression of a date, a time, or range of dates, times or dates and times
IMPLEMENTATION NAME: Proposed or Actual Admission Date
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
Situational Rule:
Required when requesting an admission review (UM01 = “AR”) to identify the proposed or actual date of
admission. If not required by this implementation guide, do not send.
TR3 Example:
DTP*435*D8*20050505~
87
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Pos: 0700
DTP Discharge Date
Max: 1
Detail - Optional
Loop:
2000E
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
IMPLEMENTATION NAME: Date Time Qualifier
CodeList Summary (Total Codes: 1280, 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: 42, 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
IMPLEMENTATION NAME: Proposed or Actual Discharge Date
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
Situational Rule:
Required when requesting an admission review (UM01 = “AR”) and the proposed or actual date of discharge from
a facility is known. If not required by this implementation guide, do not send.
TR3 Example:
DTP*096*D8*20050509~
88
For internal use only
1/12/2012
Health Care Services Review Information - Request - 278
Pos: 0800
HI Patient Diagnosis
Max: 1
Detail - Optional
Loop:
2000E
Elements: 12
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
HI01-01
1270
Code List Qualifier Code
M
ID
1/3
Required
Description: Code identifying a specific industry code list
IMPLEMENTATION NAME: Diagnosis Type Code
CodeList Summary (Total Codes: 948, Included: 9)
Code Name
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
CODE SOURCE:
131: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
BJ
International Classification of Diseases Clinical Modification (ICD-9-CM) Admitting
Diagnosis
CODE SOURCE:
131: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
BK
International Classification of Diseases Clinical Modification (ICD-9-CM) Principal
Diagnosis
CODE SOURCE:
131: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
DR
Diagnosis Related Group (DRG)
CODE SOURCE:
229: Diagnosis Related Group Number (DRG)
PR
International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's
Reason for Visit
CODE SOURCE:
131: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
CODE SOURCE:
897: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
ABJ
International Classification of Diseases Clinical Modification (ICD-10-CM) Admitting
Diagnosis
CODE SOURCE:
897: International Classification of Diseases, 10th Revision, Clinical Modification
89
For internal use only
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Code Name
(ICD-10-CM)
ABK
International Classification of Diseases Clinical Modification (ICD-10-CM) Principal
Diagnosis
CODE SOURCE:
897: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
APR
International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's
Reason for Visit
CODE SOURCE:
897: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
HI01-02
1271
Industry Code
M
AN
1/30
Required
Description: Code indicating a code from a specific industry code list
IMPLEMENTATION NAME: Diagnosis Code
ExternalCodeList
Name: 131D
Description: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
ExternalCodeList
Name: 229
Description: Diagnosis Related Group Number (DRG)
ExternalCodeList
Name: 897
Description: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
HI01-03
1250
Date Time Period Format Qualifier
X
ID
2/3
Situational
Description: Code indicating the date format, time format, or date and time format
Situational Rule: Required when the date diagnosed is known.
If not required by this implementation guide, do not send.
CodeList Summary (Total Codes: 42, Included: 1)
Code Name
D8
HI01-04
1251
Date Expressed in Format CCYYMMDD
Date Time Period
X
AN
1/35
Situational
Description: Expression of a date, a time, or range of dates, times or dates and times
Situational Rule: Required when the date diagnosed is known.
If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Diagnosis Date
HI02
C022
Health Care Code Information
O
Comp
Situational
Description: To send health care codes and their associated dates, amounts and
quantities
Situational Rule: Required when there are additional diagnoses to communicate. If not
required by this implementation guide, do not send.
90
For internal use only
1/12/2012
Health Care Services Review Information - Request - 278
Ref
Id
Element Name
HI02-01
1270
Code List Qualifier Code
Req
Type
Min/Max
Usage
M
ID
1/3
Required
Description: Code identifying a specific industry code list
IMPLEMENTATION NAME: Diagnosis Type Code
CodeList Summary (Total Codes: 948, Included: 7)
Code Name
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
CODE SOURCE:
131: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
BJ
International Classification of Diseases Clinical Modification (ICD-9-CM) Admitting
Diagnosis
CODE SOURCE:
131: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
DR
Diagnosis Related Group (DRG)
CODE SOURCE:
PR
International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's
Reason for Visit
CODE SOURCE:
229: Diagnosis Related Group Number (DRG)
131: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
CODE SOURCE:
897: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
ABJ
International Classification of Diseases Clinical Modification (ICD-10-CM) Admitting
Diagnosis
CODE SOURCE:
897: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
APR
International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's
Reason for Visit
CODE SOURCE:
897: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
HI02-02
1271
Industry Code
M
AN
1/30
Required
Description: Code indicating a code from a specific industry code list
IMPLEMENTATION NAME: Diagnosis Code
ExternalCodeList
Name: 131D
Description: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
ExternalCodeList
Name: 229
91
For internal use only
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Description: Diagnosis Related Group Number (DRG)
ExternalCodeList
Name: 897
Description: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
HI02-03
1250
Date Time Period Format Qualifier
X
ID
2/3
Situational
Description: Code indicating the date format, time format, or date and time format
Situational Rule: Required when the date diagnosed is known.
If not required by this implementation guide, do not send.
CodeList Summary (Total Codes: 42, Included: 1)
Code Name
D8
HI02-04
1251
Date Expressed in Format CCYYMMDD
Date Time Period
X
AN
1/35
Situational
Description: Expression of a date, a time, or range of dates, times or dates and times
Situational Rule: Required when the date diagnosed is known.
If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Diagnosis Date
HI03
C022
Health Care Code Information
O
Comp
Situational
Description: To send health care codes and their associated dates, amounts and
quantities
Situational Rule: Required when there are additional diagnoses to communicate. If not
required by this implementation guide, do not send.
HI03-01
1270
Code List Qualifier Code
M
ID
1/3
Required
Description: Code identifying a specific industry code list
IMPLEMENTATION NAME: Diagnosis Type Code
CodeList Summary (Total Codes: 948, Included: 5)
Code Name
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
CODE SOURCE:
131: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
DR
Diagnosis Related Group (DRG)
CODE SOURCE:
PR
International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's
Reason for Visit
CODE SOURCE:
229: Diagnosis Related Group Number (DRG)
131: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
CODE SOURCE:
897: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
92
For internal use only
1/12/2012
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Code Name
APR
International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's
Reason for Visit
CODE SOURCE:
897: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
HI03-02
1271
Industry Code
M
AN
1/30
Required
Description: Code indicating a code from a specific industry code list
IMPLEMENTATION NAME: Diagnosis Code
ExternalCodeList
Name: 131D
Description: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
ExternalCodeList
Name: 229
Description: Diagnosis Related Group Number (DRG)
ExternalCodeList
Name: 897
Description: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
HI03-03
1250
Date Time Period Format Qualifier
X
ID
2/3
Situational
Description: Code indicating the date format, time format, or date and time format
Situational Rule: Required when the date diagnosed is known.
If not required by this implementation guide, do not send.
CodeList Summary (Total Codes: 42, Included: 1)
Code Name
D8
HI03-04
1251
Date Expressed in Format CCYYMMDD
Date Time Period
X
AN
1/35
Situational
Description: Expression of a date, a time, or range of dates, times or dates and times
Situational Rule: Required when the date diagnosed is known.
If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Diagnosis Date
HI04
C022
Health Care Code Information
O
Comp
Situational
Description: To send health care codes and their associated dates, amounts and
quantities
Situational Rule: Required when there are additional diagnoses to communicate. If not
required by this implementation guide, do not send.
HI04-01
1270
Code List Qualifier Code
M
ID
1/3
Required
Description: Code identifying a specific industry code list
IMPLEMENTATION NAME: Diagnosis Type Code
CodeList Summary (Total Codes: 948, Included: 5)
93
For internal use only
1/12/2012
Health Care Services Review Information - Request - 278
Code Name
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
CODE SOURCE:
131: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
DR
Diagnosis Related Group (DRG)
CODE SOURCE:
229: Diagnosis Related Group Number (DRG)
PR
International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's
Reason for Visit
CODE SOURCE:
131: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
CODE SOURCE:
897: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
APR
International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's
Reason for Visit
CODE SOURCE:
897: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
HI04-02
1271
Industry Code
M
AN
1/30
Required
Description: Code indicating a code from a specific industry code list
IMPLEMENTATION NAME: Diagnosis Code
ExternalCodeList
Name: 131D
Description: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
ExternalCodeList
Name: 229
Description: Diagnosis Related Group Number (DRG)
ExternalCodeList
Name: 897
Description: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
HI04-03
1250
Date Time Period Format Qualifier
X
ID
2/3
Situational
Description: Code indicating the date format, time format, or date and time format
Situational Rule: Required when the date diagnosed is known.
If not required by this implementation guide, do not send.
CodeList Summary (Total Codes: 42, Included: 1)
Code Name
D8
HI04-04
1251
Date Expressed in Format CCYYMMDD
Date Time Period
X
94
AN
1/35
Situational
For internal use only
1/12/2012
Ref
Health Care Services Review Information - Request - 278
Id
Element Name
Req
Type
Min/Max
Usage
Description: Expression of a date, a time, or range of dates, times or dates and times
Situational Rule: Required when the date diagnosed is known.
If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Diagnosis Date
HI05
C022
Health Care Code Information
O
Comp
Situational
Description: To send health care codes and their associated dates, amounts and
quantities
Situational Rule: Required when there are additional diagnoses to communicate. If not
required by this implementation guide, do not send.
HI05-01
1270
Code List Qualifier Code
M
ID
1/3
Required
Description: Code identifying a specific industry code list
IMPLEMENTATION NAME: Diagnosis Type Code
CodeList Summary (Total Codes: 948, Included: 5)
Code Name
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
CODE SOURCE:
131: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
DR
Diagnosis Related Group (DRG)
CODE SOURCE:
229: Diagnosis Related Group Number (DRG)
PR
International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's
Reason for Visit
CODE SOURCE:
131: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
CODE SOURCE:
897: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
APR
International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's
Reason for Visit
CODE SOURCE:
897: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
HI05-02
1271
Industry Code
M
AN
1/30
Required
Description: Code indicating a code from a specific industry code list
IMPLEMENTATION NAME: Diagnosis Code
ExternalCodeList
Name: 131D
Description: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
ExternalCodeList
Name: 229
95
For internal use only
1/12/2012
Health Care Services Review Information - Request - 278
Description: Diagnosis Related Group Number (DRG)
ExternalCodeList
Name: 897
Description: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
HI05-03
1250
Date Time Period Format Qualifier
X
ID
2/3
Situational
Description: Code indicating the date format, time format, or date and time format
Situational Rule: Required when used by the UMO to render a
medical decision. If not required by this implementation guide, do not send.
CodeList Summary (Total Codes: 42, Included: 1)
Code Name
D8
HI05-04
1251
Date Expressed in Format CCYYMMDD
Date Time Period
X
AN
1/35
Situational
Description: Expression of a date, a time, or range of dates, times or dates and times
Situational Rule: Required when the date diagnosed is known.
If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Diagnosis Date
HI06
C022
Health Care Code Information
O
Comp
Situational
Description: To send health care codes and their associated dates, amounts and
quantities
Situational Rule: Required when there are additional diagnoses to communicate. If not
required by this implementation guide, do not send.
HI06-01
1270
Code List Qualifier Code
M
ID
1/3
Required
Description: Code identifying a specific industry code list
IMPLEMENTATION NAME: Diagnosis Type Code
CodeList Summary (Total Codes: 948, Included: 5)
Code Name
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
CODE SOURCE:
131: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
DR
Diagnosis Related Group (DRG)
CODE SOURCE:
PR
International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's
Reason for Visit
CODE SOURCE:
229: Diagnosis Related Group Number (DRG)
131: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
CODE SOURCE:
897: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
96
For internal use only
1/12/2012
Health Care Services Review Information - Request - 278
Code Name
APR
International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's
Reason for Visit
CODE SOURCE:
897: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
HI06-02
1271
Industry Code
M
AN
1/30
Required
Description: Code indicating a code from a specific industry code list
IMPLEMENTATION NAME: Diagnosis Code
ExternalCodeList
Name: 131D
Description: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
ExternalCodeList
Name: 229
Description: Diagnosis Related Group Number (DRG)
ExternalCodeList
Name: 897
Description: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
HI06-03
1250
Date Time Period Format Qualifier
X
ID
2/3
Situational
Description: Code indicating the date format, time format, or date and time format
Situational Rule: Required when the date diagnosed is known.
If not required by this implementation guide, do not send.
CodeList Summary (Total Codes: 42, Included: 1)
Code Name
D8
HI06-04
1251
Date Expressed in Format CCYYMMDD
Date Time Period
X
AN
1/35
Situational
Description: Expression of a date, a time, or range of dates, times or dates and times
Situational Rule: Required when the date diagnosed is known.
If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Diagnosis Date
HI07
C022
Health Care Code Information
O
Comp
Situational
Description: To send health care codes and their associated dates, amounts and
quantities
Situational Rule: Required when there are additional diagnoses to communicate. If not
required by this implementation guide, do not send.
HI07-01
1270
Code List Qualifier Code
M
ID
1/3
Required
Description: Code identifying a specific industry code list
IMPLEMENTATION NAME: Diagnosis Type Code
CodeList Summary (Total Codes: 948, Included: 5)
97
For internal use only
1/12/2012
Health Care Services Review Information - Request - 278
Code Name
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
CODE SOURCE:
131: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
DR
Diagnosis Related Group (DRG)
CODE SOURCE:
229: Diagnosis Related Group Number (DRG)
PR
International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's
Reason for Visit
CODE SOURCE:
131: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
CODE SOURCE:
897: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
APR
International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's
Reason for Visit
CODE SOURCE:
897: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
HI07-02
1271
Industry Code
M
AN
1/30
Required
Description: Code indicating a code from a specific industry code list
IMPLEMENTATION NAME: Diagnosis Code
ExternalCodeList
Name: 131D
Description: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
ExternalCodeList
Name: 229
Description: Diagnosis Related Group Number (DRG)
ExternalCodeList
Name: 897
Description: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
HI07-03
1250
Date Time Period Format Qualifier
X
ID
2/3
Situational
Description: Code indicating the date format, time format, or date and time format
Situational Rule: Required when the date diagnosed is known.
If not required by this implementation guide, do not send.
CodeList Summary (Total Codes: 42, Included: 1)
Code Name
D8
HI07-04
1251
Date Expressed in Format CCYYMMDD
Date Time Period
X
98
AN
1/35
Situational
For internal use only
1/12/2012
Ref
Health Care Services Review Information - Request - 278
Id
Element Name
Req
Type
Min/Max
Usage
Description: Expression of a date, a time, or range of dates, times or dates and times
Situational Rule: Required when the date diagnosed is known.
If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Diagnosis Date
HI08
C022
Health Care Code Information
O
Comp
Situational
Description: To send health care codes and their associated dates, amounts and
quantities
Situational Rule: Required when there are additional diagnoses to communicate. If not
required by this implementation guide, do not send.
HI08-01
1270
Code List Qualifier Code
M
ID
1/3
Required
Description: Code identifying a specific industry code list
IMPLEMENTATION NAME: Diagnosis Type Code
CodeList Summary (Total Codes: 948, Included: 5)
Code Name
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
CODE SOURCE:
131: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
DR
Diagnosis Related Group (DRG)
CODE SOURCE:
229: Diagnosis Related Group Number (DRG)
PR
International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's
Reason for Visit
CODE SOURCE:
131: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
CODE SOURCE:
897: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
APR
International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's
Reason for Visit
CODE SOURCE:
897: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
HI08-02
1271
Industry Code
M
AN
1/30
Required
Description: Code indicating a code from a specific industry code list
IMPLEMENTATION NAME: Diagnosis Code
ExternalCodeList
Name: 131D
Description: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
ExternalCodeList
Name: 229
99
For internal use only
1/12/2012
Health Care Services Review Information - Request - 278
Description: Diagnosis Related Group Number (DRG)
ExternalCodeList
Name: 897
Description: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
HI08-03
1250
Date Time Period Format Qualifier
X
ID
2/3
Situational
Description: Code indicating the date format, time format, or date and time format
Situational Rule: Required when the date diagnosed is known.
If not required by this implementation guide, do not send.
CodeList Summary (Total Codes: 42, Included: 1)
Code Name
D8
HI08-04
1251
Date Expressed in Format CCYYMMDD
Date Time Period
X
AN
1/35
Situational
Description: Expression of a date, a time, or range of dates, times or dates and times
Situational Rule: Required when the date diagnosed is known.
If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Diagnosis Date
HI09
C022
Health Care Code Information
O
Comp
Situational
Description: To send health care codes and their associated dates, amounts and
quantities
Situational Rule: Required when there are additional diagnoses to communicate. If not
required by this implementation guide, do not send.
HI09-01
1270
Code List Qualifier Code
M
ID
1/3
Required
Description: Code identifying a specific industry code list
IMPLEMENTATION NAME: Diagnosis Type Code
CodeList Summary (Total Codes: 948, Included: 5)
Code Name
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
CODE SOURCE:
131: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
DR
Diagnosis Related Group (DRG)
CODE SOURCE:
PR
International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's
Reason for Visit
CODE SOURCE:
229: Diagnosis Related Group Number (DRG)
131: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
CODE SOURCE:
897: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
100
For internal use only
1/12/2012
Health Care Services Review Information - Request - 278
Code Name
APR
International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's
Reason for Visit
CODE SOURCE:
897: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
HI09-02
1271
Industry Code
M
AN
1/30
Required
Description: Code indicating a code from a specific industry code list
IMPLEMENTATION NAME: Diagnosis Code
ExternalCodeList
Name: 131D
Description: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
ExternalCodeList
Name: 229
Description: Diagnosis Related Group Number (DRG)
ExternalCodeList
Name: 897
Description: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
HI09-03
1250
Date Time Period Format Qualifier
X
ID
2/3
Situational
Description: Code indicating the date format, time format, or date and time format
Situational Rule: Required when the date diagnosed is known.
If not required by this implementation guide, do not send.
CodeList Summary (Total Codes: 42, Included: 1)
Code Name
D8
HI09-04
1251
Date Expressed in Format CCYYMMDD
Date Time Period
X
AN
1/35
Situational
Description: Expression of a date, a time, or range of dates, times or dates and times
Situational Rule: Required when the date diagnosed is known.
If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Diagnosis Date
HI10
C022
Health Care Code Information
O
Comp
Situational
Description: To send health care codes and their associated dates, amounts and
quantities
Situational Rule: Required when there are additional diagnoses to communicate. If not
required by this implementation guide, do not send.
HI10-01
1270
Code List Qualifier Code
M
ID
1/3
Required
Description: Code identifying a specific industry code list
IMPLEMENTATION NAME: Diagnosis Type Code
CodeList Summary (Total Codes: 948, Included: 5)
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Code Name
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
CODE SOURCE:
131: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
DR
Diagnosis Related Group (DRG)
CODE SOURCE:
229: Diagnosis Related Group Number (DRG)
PR
International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's
Reason for Visit
CODE SOURCE:
131: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
CODE SOURCE:
897: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
APR
International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's
Reason for Visit
CODE SOURCE:
897: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
HI10-02
1271
Industry Code
M
AN
1/30
Required
Description: Code indicating a code from a specific industry code list
IMPLEMENTATION NAME: Diagnosis Code
ExternalCodeList
Name: 131D
Description: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
ExternalCodeList
Name: 229
Description: Diagnosis Related Group Number (DRG)
ExternalCodeList
Name: 897
Description: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
HI10-03
1250
Date Time Period Format Qualifier
X
ID
2/3
Situational
Description: Code indicating the date format, time format, or date and time format
Situational Rule: Required when the date diagnosed is known.
If not required by this implementation guide, do not send.
CodeList Summary (Total Codes: 42, Included: 1)
Code Name
D8
HI10-04
1251
Date Expressed in Format CCYYMMDD
Date Time Period
X
102
AN
1/35
Situational
For internal use only
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Id
Element Name
Req
Type
Min/Max
Usage
Description: Expression of a date, a time, or range of dates, times or dates and times
Situational Rule: Required when the date diagnosed is known.
If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Diagnosis Date
HI11
C022
Health Care Code Information
O
Comp
Situational
Description: To send health care codes and their associated dates, amounts and
quantities
Situational Rule: Required when there are additional diagnoses to communicate. If not
required by this implementation guide, do not send.
HI11-01
1270
Code List Qualifier Code
M
ID
1/3
Required
Description: Code identifying a specific industry code list
IMPLEMENTATION NAME: Diagnosis Type Code
CodeList Summary (Total Codes: 948, Included: 5)
Code Name
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
CODE SOURCE:
131: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
DR
Diagnosis Related Group (DRG)
CODE SOURCE:
229: Diagnosis Related Group Number (DRG)
PR
International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's
Reason for Visit
CODE SOURCE:
131: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
CODE SOURCE:
897: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
APR
International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's
Reason for Visit
CODE SOURCE:
897: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
HI11-02
1271
Industry Code
M
AN
1/30
Required
Description: Code indicating a code from a specific industry code list
IMPLEMENTATION NAME: Diagnosis Code
ExternalCodeList
Name: 131D
Description: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
ExternalCodeList
Name: 229
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Description: Diagnosis Related Group Number (DRG)
ExternalCodeList
Name: 897
Description: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
HI11-03
1250
Date Time Period Format Qualifier
X
ID
2/3
Situational
Description: Code indicating the date format, time format, or date and time format
Situational Rule: Required when the date diagnosed is known.
If not required by this implementation guide, do not send.
CodeList Summary (Total Codes: 42, Included: 1)
Code Name
D8
HI11-04
1251
Date Expressed in Format CCYYMMDD
Date Time Period
X
AN
1/35
Situational
Description: Expression of a date, a time, or range of dates, times or dates and times
Situational Rule: Required when the date diagnosed is known.
If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Diagnosis Date
HI12
C022
Health Care Code Information
O
Comp
Situational
Description: To send health care codes and their associated dates, amounts and
quantities
Situational Rule: Required when there are additional diagnoses to communicate. If not
required by this implementation guide, do not send.
HI12-01
1270
Code List Qualifier Code
M
ID
1/3
Required
Description: Code identifying a specific industry code list
IMPLEMENTATION NAME: Diagnosis Type Code
CodeList Summary (Total Codes: 948, Included: 5)
Code Name
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
CODE SOURCE:
131: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
DR
Diagnosis Related Group (DRG)
CODE SOURCE:
PR
International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's
Reason for Visit
CODE SOURCE:
229: Diagnosis Related Group Number (DRG)
131: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
CODE SOURCE:
897: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
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Code Name
APR
International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's
Reason for Visit
CODE SOURCE:
897: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
HI12-02
1271
Industry Code
M
AN
1/30
Required
Description: Code indicating a code from a specific industry code list
IMPLEMENTATION NAME: Diagnosis Code
ExternalCodeList
Name: 131D
Description: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
ExternalCodeList
Name: 229
Description: Diagnosis Related Group Number (DRG)
ExternalCodeList
Name: 897
Description: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
HI12-03
1250
Date Time Period Format Qualifier
X
ID
2/3
Situational
Description: Code indicating the date format, time format, or date and time format
Situational Rule: Required when the date diagnosed is known.
If not required by this implementation guide, do not send.
CodeList Summary (Total Codes: 42, Included: 1)
Code Name
D8
HI12-04
1251
Date Expressed in Format CCYYMMDD
Date Time Period
X
AN
1/35
Situational
Description: Expression of a date, a time, or range of dates, times or dates and times
Situational Rule: Required when the date diagnosed is known.
If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Diagnosis Date
Situational Rule:
Required when known by the requester to convey diagnosis information. If not required by this implementation
guide, do not send.
TR3 Example:
HI*BF:41090:D8:20050415~
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Pos: 0900
HSD Health Care Services
Max: 1
Detail - Optional
Delivery
Loop:
2000E
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
X
ID
2/2
Situational
Description: Code specifying the type of quantity
Situational Rule: Required when HSD02 is valued to qualify the type of service count for
this patient event. If not required by this implementation guide, do not send.
CodeList Summary (Total Codes: 1123, Included: 5)
Code Name
DY
FL
HS
MN
VS
HSD02
380
Days
Units
Hours
Month
Visits
Quantity
X
R
1/15
Situational
Description: Numeric value of quantity
Situational Rule: Required when HSD01 is valued to indicate the service quantity. If not
required by this implementation guide, do not send
IMPLEMENTATION NAME: Service Unit Count
If this is a request for an extension to an existing certification (UM02 = 4), then HSD02
represents the number of visits by which the certification is extended. If this is a request to
revise an existing certification (UM02 = S), then HSD02 represents the new total.
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
Situational Rule: Required when HSD04 is valued to qualify the time frame in which the
quantity of services (HSD02) will be rendered. If not required by this implementation guide,
do not send.
CodeList Summary (Total Codes: 844, Included: 3)
Code Name
DA
MO
WK
HSD04
1167
Days
Months
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
Situational Rule: Required when needed to indicate the frequency for the service. If not
required by this implementation guide, do not send.
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Ref
Id
Element Name
HSD05
615
Time Period Qualifier
Req
Type
Min/Max
Usage
X
ID
1/2
Situational
Description: Code defining periods
Situational Rule: Required when patient events must be rendered within a specific
timeframe. If not required by this implementation guide, do not send.
CodeList Summary (Total Codes: 38, Included: 7)
Code Name
6
7
21
26
27
34
35
HSD06
616
Hour
Day
Years
Episode
Visit
Month
Week
Number of Periods
O
N0
1/3
Situational
Description: Total number of periods
Situational Rule: Required when patient events must be rendered within a specific
timeframe. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Period Count
HSD07
678
Ship/Delivery or Calendar Pattern Code
O
ID
1/2
Situational
Description: Code which specifies the routine shipments, deliveries, or calendar pattern
Situational Rule: Required when the patient event must be rendered within a specific
calendar delivery pattern. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Delivery Frequency Code
CodeList Summary (Total Codes: 45, Included: 43)
Code Name
1
2
3
4
5
6
7
8
9
A
B
C
D
E
F
G
H
J
K
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
1st Working Day of Period
Last Working Day of Period
Monday through Friday
Monday through Saturday
Monday through Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
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Code Name
L
M
N
O
P
Q
R
S
T
U
V
W
X
Y
SA
SB
SC
SD
SG
SL
SP
SX
SY
SZ
HSD08
679
Monday through Thursday
Immediately
As Directed
Daily Mon. through Fri.
1/2 Mon. & 1/2 Thurs.
1/2 Tues. & 1/2 Thurs.
1/2 Wed. & 1/2 Fri.
Once Anytime Mon. through Fri.
1/2 Tue. & 1/2 Fri.
1/2 Mon. & 1/2 Wed.
1/3 Mon., 1/3 Wed., 1/3 Fri.
Whenever Necessary
1/2 By Wed., Bal. By Fri.
None (Also Used to Cancel or Override a Previous Pattern)
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
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
Situational Rule: Required when a specific time delivery pattern for the services in this
patient event must be identified. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Delivery Pattern Time Code
CodeList Summary (Total Codes: 9, Included: 8)
Code Name
A
B
C
D
E
F
G
Y
1st Shift (Normal Working Hours)
2nd Shift
3rd Shift
A.M.
P.M.
As Directed
Any Shift
None (Also Used to Cancel or Override a Previous Pattern)
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.
Situational Rule:
Required when requesting services that have a specific pattern of delivery or usage. If not required by this
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implementation guide, do not send.
TR3 Notes:
1. An explanation of the uses of this segment follows.
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”.
TR3 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”.)
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Pos: 1000
CRC Ambulance Certification
Max: 1
Detail - Optional
Information
Loop:
2000E
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: 426, Included: 1)
Code Name
07
CRC02
1073
Ambulance Certification
Yes/No Condition or Response Code
M
ID
1/1
Required
2/3
Required
Description: Code indicating a Yes or No condition or response
IMPLEMENTATION NAME: Certification Condition 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
IMPLEMENTATION NAME: Condition Code
CodeList Summary (Total Codes: 1316, Included: 14)
Code Name
01
02
03
04
05
06
07
08
09
41
43
5A
60
9D
CRC04
1321
Patient was admitted to a hospital
Patient was bed confined before the ambulance service
Patient was bed confined after the ambulance service
Patient was moved by stretcher
Patient was unconscious or in shock
Patient was transported in an emergency situation
Patient had to be physically restrained
Patient had visible hemorrhaging
Ambulance service was medically necessary
Patient or Caregiver is Unable to Propel or Lift a Standard Weight Wheelchair
Patient Weight or Usage Needs Necessitate a Heavy Duty Wheelchair
Treatment is rendered related to the terminal illness
Transportation Was To the Nearest Facility
Lack of Appropriate Facility within Reasonable Distance to Treat Patient in the
Event of Complications
Condition Indicator
O
ID
2/3
Situational
Description: Code indicating a condition
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Id
Element Name
Req
Type
Min/Max
Usage
Situational Rule: Required when multiple conditions apply to the certification. If not
required by this implementation guide, do not send.
IMPLEMENTATION NAME: Condition Code
Use codes listed in CRC03.
CodeList Summary (Total Codes: 1316, Included: 14)
Code Name
01
02
03
04
05
06
07
08
09
41
43
5A
60
9D
CRC05
1321
Patient was admitted to a hospital
Patient was bed confined before the ambulance service
Patient was bed confined after the ambulance service
Patient was moved by stretcher
Patient was unconscious or in shock
Patient was transported in an emergency situation
Patient had to be physically restrained
Patient had visible hemorrhaging
Ambulance service was medically necessary
Patient or Caregiver is Unable to Propel or Lift a Standard Weight Wheelchair
Patient Weight or Usage Needs Necessitate a Heavy Duty Wheelchair
Treatment is rendered related to the terminal illness
Transportation Was To the Nearest Facility
Lack of Appropriate Facility within Reasonable Distance to Treat Patient in the
Event of Complications
Condition Indicator
O
ID
2/3
Situational
Description: Code indicating a condition
Situational Rule: Required when multiple conditions apply to the certification. If not
required by this implementation guide, do not send.
IMPLEMENTATION NAME: Condition Code
Use codes listed in CRC03.
CodeList Summary (Total Codes: 1316, Included: 14)
Code Name
01
02
03
04
05
06
07
08
09
41
43
5A
60
9D
CRC06
1321
Patient was admitted to a hospital
Patient was bed confined before the ambulance service
Patient was bed confined after the ambulance service
Patient was moved by stretcher
Patient was unconscious or in shock
Patient was transported in an emergency situation
Patient had to be physically restrained
Patient had visible hemorrhaging
Ambulance service was medically necessary
Patient or Caregiver is Unable to Propel or Lift a Standard Weight Wheelchair
Patient Weight or Usage Needs Necessitate a Heavy Duty Wheelchair
Treatment is rendered related to the terminal illness
Transportation Was To the Nearest Facility
Lack of Appropriate Facility within Reasonable Distance to Treat Patient in the
Event of Complications
Condition Indicator
O
111
ID
2/3
Situational
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Id
Element Name
Req
Type
Min/Max
Usage
Description: Code indicating a condition
Situational Rule: Required when multiple conditions apply to the certification. If not
required by this implementation guide, do not send.
IMPLEMENTATION NAME: Condition Code
Use codes listed in CRC03.
CodeList Summary (Total Codes: 1316, Included: 14)
Code Name
01
02
03
04
05
06
07
08
09
41
43
5A
60
9D
CRC07
1321
Patient was admitted to a hospital
Patient was bed confined before the ambulance service
Patient was bed confined after the ambulance service
Patient was moved by stretcher
Patient was unconscious or in shock
Patient was transported in an emergency situation
Patient had to be physically restrained
Patient had visible hemorrhaging
Ambulance service was medically necessary
Patient or Caregiver is Unable to Propel or Lift a Standard Weight Wheelchair
Patient Weight or Usage Needs Necessitate a Heavy Duty Wheelchair
Treatment is rendered related to the terminal illness
Transportation Was To the Nearest Facility
Lack of Appropriate Facility within Reasonable Distance to Treat Patient in the
Event of Complications
Condition Indicator
O
ID
2/3
Situational
Description: Code indicating a condition
Situational Rule: Required when multiple conditions apply to the certification. If not
required by this implementation guide, do not send.
IMPLEMENTATION NAME: Condition Code
Use codes listed in CRC03.
CodeList Summary (Total Codes: 1316, Included: 14)
Code Name
01
02
03
04
05
06
07
08
09
41
43
5A
60
9D
Patient was admitted to a hospital
Patient was bed confined before the ambulance service
Patient was bed confined after the ambulance service
Patient was moved by stretcher
Patient was unconscious or in shock
Patient was transported in an emergency situation
Patient had to be physically restrained
Patient had visible hemorrhaging
Ambulance service was medically necessary
Patient or Caregiver is Unable to Propel or Lift a Standard Weight Wheelchair
Patient Weight or Usage Needs Necessitate a Heavy Duty Wheelchair
Treatment is rendered related to the terminal illness
Transportation Was To the Nearest Facility
Lack of Appropriate Facility within Reasonable Distance to Treat Patient in the
Event of Complications
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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.
Situational Rule:
Required when health care services review is requesting ambulance certification. If not required by this
implementation guide, do not send.
TR3 Example:
CRC*07*Y*01~
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Pos: 1000
CRC Chiropractic Certification
Max: 1
Detail - Optional
Information
Loop:
2000E
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: 426, Included: 1)
Code Name
08
CRC02
1073
Chiropractic Certification
Yes/No Condition or Response Code
M
ID
1/1
Required
2/3
Required
Description: Code indicating a Yes or No condition or response
IMPLEMENTATION NAME: Certification Condition 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
IMPLEMENTATION NAME: Condition Code
CodeList Summary (Total Codes: 1316, Included: 7)
Code Name
11
12
14
24
25
27
30
CRC04
1321
Ambulation is Impaired and Walking Aid is Used for Therapy or Mobility
Patient is confined to a bed or chair
Ambulation is Impaired and Walking Aid is Used for Mobility
Patient has an orthopedic impairment requiring traction equipment which prevents
ambulation during period of use
Item has been prescribed as part of a planned regimen of treatment in patient home
Patient or a care-giver has been instructed in use of equipment
Without the equipment, the patient would require surgery
Condition Indicator
O
ID
2/3
Situational
Description: Code indicating a condition
Situational Rule: Required when multiple conditions apply to the certification. If not
required by this implementation guide, do not send.
IMPLEMENTATION NAME: Condition Code
Use codes listed in CRC03.
CodeList Summary (Total Codes: 1316, Included: 7)
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Code Name
11
12
14
24
25
27
30
CRC05
1321
Ambulation is Impaired and Walking Aid is Used for Therapy or Mobility
Patient is confined to a bed or chair
Ambulation is Impaired and Walking Aid is Used for Mobility
Patient has an orthopedic impairment requiring traction equipment which prevents
ambulation during period of use
Item has been prescribed as part of a planned regimen of treatment in patient home
Patient or a care-giver has been instructed in use of equipment
Without the equipment, the patient would require surgery
Condition Indicator
O
ID
2/3
Situational
Description: Code indicating a condition
Situational Rule: Required when multiple conditions apply to the certification. If not
required by this implementation guide, do not send.
IMPLEMENTATION NAME: Condition Code
Use codes listed in CRC03.
CodeList Summary (Total Codes: 1316, Included: 7)
Code Name
11
12
14
24
25
27
30
CRC06
1321
Ambulation is Impaired and Walking Aid is Used for Therapy or Mobility
Patient is confined to a bed or chair
Ambulation is Impaired and Walking Aid is Used for Mobility
Patient has an orthopedic impairment requiring traction equipment which prevents
ambulation during period of use
Item has been prescribed as part of a planned regimen of treatment in patient home
Patient or a care-giver has been instructed in use of equipment
Without the equipment, the patient would require surgery
Condition Indicator
O
ID
2/3
Situational
Description: Code indicating a condition
Situational Rule: Required when multiple conditions apply to the certification. If not
required by this implementation guide, do not send.
IMPLEMENTATION NAME: Condition Code
Use codes listed in CRC03.
CodeList Summary (Total Codes: 1316, Included: 7)
Code Name
11
12
14
24
25
27
30
CRC07
1321
Ambulation is Impaired and Walking Aid is Used for Therapy or Mobility
Patient is confined to a bed or chair
Ambulation is Impaired and Walking Aid is Used for Mobility
Patient has an orthopedic impairment requiring traction equipment which prevents
ambulation during period of use
Item has been prescribed as part of a planned regimen of treatment in patient home
Patient or a care-giver has been instructed in use of equipment
Without the equipment, the patient would require surgery
Condition Indicator
O
ID
2/3
Situational
Description: Code indicating a condition
Situational Rule: Required when multiple conditions apply to the certification. If not
required by this implementation guide, do not send.
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Id
Element Name
Req
Type
Min/Max
Usage
IMPLEMENTATION NAME: Condition Code
Use codes listed in CRC03.
CodeList Summary (Total Codes: 1316, Included: 7)
Code Name
11
12
14
24
25
27
30
Ambulation is Impaired and Walking Aid is Used for Therapy or Mobility
Patient is confined to a bed or chair
Ambulation is Impaired and Walking Aid is Used for Mobility
Patient has an orthopedic impairment requiring traction equipment which prevents
ambulation during period of use
Item has been prescribed as part of a planned regimen of treatment in patient home
Patient or a care-giver has been instructed in use of equipment
Without the equipment, the patient would require surgery
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.
Situational Rule:
Required when health care services review is requesting chiropractic certification. If not required by this
implementation guide, do not send.
TR3 Example:
CRC*08*Y*14~
116
For internal use only
1/12/2012
Health Care Services Review Information - Request - 278
CRC Durable Medical Equipment
Information
Pos: 1000
Max: 1
Detail - Optional
Loop:
2000E
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: 426, Included: 1)
Code Name
09
CRC02
1073
Durable Medical Equipment Certification
Yes/No Condition or Response Code
M
ID
1/1
Required
2/3
Required
Description: Code indicating a Yes or No condition or response
IMPLEMENTATION NAME: Certification Condition 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
IMPLEMENTATION NAME: Condition Code
CodeList Summary (Total Codes: 1316, Included: 52)
Code Name
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
Patient was admitted to a hospital
Patient was bed confined before the ambulance service
Patient was bed confined after the ambulance service
Patient was moved by stretcher
Patient was unconscious or in shock
Patient was transported in an emergency situation
Patient had to be physically restrained
Patient had visible hemorrhaging
Ambulance service was medically necessary
Patient is ambulatory
Ambulation is Impaired and Walking Aid is Used for Therapy or Mobility
Patient is confined to a bed or chair
Patient is Confined to a Room or an Area Without Bathroom Facilities
Ambulation is Impaired and Walking Aid is Used for Mobility
Patient Condition Requires Positioning of the Body or Attachments Which Would
Not be Feasible With the Use of an Ordinary Bed
Patient needs a trapeze bar to sit up due to respiratory condition or change body
positions for other medical reasons
117
For internal use only
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Code Name
17
18
19
20
21
22
23
24
25
26
27
29
30
31
32
33
35
37
38
40
41
42
43
44
45
46
58
59
60
9D
9H
9J
9K
IH
LB
SL
CRC04
1321
Patient's Ability to Breathe is Severely Impaired
Patient condition requires frequent and/or immediate changes in body positions
Patient can operate controls
Siderails Are to be Attached to a Hospital Bed Owned by the Beneficiary
Patient owns equipment
Mattress or Siderails are Being Used with Prescribed Medically Necessary Hospital
Bed Owned by the Beneficiary
Patient Needs Lift to Get In or Out of Bed or to Assist in Transfer from Bed to
Wheelchair
Patient has an orthopedic impairment requiring traction equipment which prevents
ambulation during period of use
Item has been prescribed as part of a planned regimen of treatment in patient home
Patient is highly susceptible to decubitus ulcers
Patient or a care-giver has been instructed in use of equipment
A 6-7 hour nocturnal study documents 30 episodes of apnea each lasting more
than 10 seconds
Without the equipment, the patient would require surgery
Patient has had a total knee replacement
Patient has intractable lymphedema of the extremities
Patient is in a nursing home
This Feeding is the Only Form of Nutritional Intake for This Patient
Oxygen delivery equipment is stationary
Certification signed by the physician is on file at the supplier's office
Patient or Caregiver is Capable of Using the Equipment Without Technical or
Professional Supervision
Patient or Caregiver is Unable to Propel or Lift a Standard Weight Wheelchair
Patient Requires Leg Elevation for Edema or Body Alignment
Patient Weight or Usage Needs Necessitate a Heavy Duty Wheelchair
Patient Requires Reclining Function of a Wheelchair
Patient is Unable to Operate a Wheelchair Manually
Patient or Caregiver Requires Side Transfer into Wheelchair, Commode or Other
Durable Medical Equipment (DME) Purchased New
Durable Medical Equipment (DME) Is Under Warranty
Transportation Was To the Nearest Facility
Lack of Appropriate Facility within Reasonable Distance to Treat Patient in the
Event of Complications
Patient Requires Intensive IV Therapy
Patient Requires Protective Isolation
Patient Requires Frequent Monitoring
Independent at Home
Legally Blind
Speech Limitations
Condition Indicator
O
ID
2/3
Situational
Description: Code indicating a condition
Situational Rule: Required when multiple conditions apply to the certification. If not
required by this implementation guide, do not send.
IMPLEMENTATION NAME: Condition Code
118
For internal use only
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Ref
Health Care Services Review Information - Request - 278
Id
Element Name
Req
Type
Min/Max
Usage
Use codes listed in CRC03.
CodeList Summary (Total Codes: 1316, Included: 52)
Code Name
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
29
30
31
32
33
35
37
38
40
41
42
Patient was admitted to a hospital
Patient was bed confined before the ambulance service
Patient was bed confined after the ambulance service
Patient was moved by stretcher
Patient was unconscious or in shock
Patient was transported in an emergency situation
Patient had to be physically restrained
Patient had visible hemorrhaging
Ambulance service was medically necessary
Patient is ambulatory
Ambulation is Impaired and Walking Aid is Used for Therapy or Mobility
Patient is confined to a bed or chair
Patient is Confined to a Room or an Area Without Bathroom Facilities
Ambulation is Impaired and Walking Aid is Used for Mobility
Patient Condition Requires Positioning of the Body or Attachments Which Would
Not be Feasible With the Use of an Ordinary Bed
Patient needs a trapeze bar to sit up due to respiratory condition or change body
positions for other medical reasons
Patient's Ability to Breathe is Severely Impaired
Patient condition requires frequent and/or immediate changes in body positions
Patient can operate controls
Siderails Are to be Attached to a Hospital Bed Owned by the Beneficiary
Patient owns equipment
Mattress or Siderails are Being Used with Prescribed Medically Necessary Hospital
Bed Owned by the Beneficiary
Patient Needs Lift to Get In or Out of Bed or to Assist in Transfer from Bed to
Wheelchair
Patient has an orthopedic impairment requiring traction equipment which prevents
ambulation during period of use
Item has been prescribed as part of a planned regimen of treatment in patient home
Patient is highly susceptible to decubitus ulcers
Patient or a care-giver has been instructed in use of equipment
A 6-7 hour nocturnal study documents 30 episodes of apnea each lasting more
than 10 seconds
Without the equipment, the patient would require surgery
Patient has had a total knee replacement
Patient has intractable lymphedema of the extremities
Patient is in a nursing home
This Feeding is the Only Form of Nutritional Intake for This Patient
Oxygen delivery equipment is stationary
Certification signed by the physician is on file at the supplier's office
Patient or Caregiver is Capable of Using the Equipment Without Technical or
Professional Supervision
Patient or Caregiver is Unable to Propel or Lift a Standard Weight Wheelchair
Patient Requires Leg Elevation for Edema or Body Alignment
119
For internal use only
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Code Name
43
44
45
46
58
59
60
9D
9H
9J
9K
IH
LB
SL
CRC05
1321
Patient Weight or Usage Needs Necessitate a Heavy Duty Wheelchair
Patient Requires Reclining Function of a Wheelchair
Patient is Unable to Operate a Wheelchair Manually
Patient or Caregiver Requires Side Transfer into Wheelchair, Commode or Other
Durable Medical Equipment (DME) Purchased New
Durable Medical Equipment (DME) Is Under Warranty
Transportation Was To the Nearest Facility
Lack of Appropriate Facility within Reasonable Distance to Treat Patient in the
Event of Complications
Patient Requires Intensive IV Therapy
Patient Requires Protective Isolation
Patient Requires Frequent Monitoring
Independent at Home
Legally Blind
Speech Limitations
Condition Indicator
O
ID
2/3
Situational
Description: Code indicating a condition
Situational Rule: Required when multiple conditions apply to the certification. If not
required by this implementation guide, do not send.
IMPLEMENTATION NAME: Condition Code
Use codes listed in CRC03.
CodeList Summary (Total Codes: 1316, Included: 52)
Code Name
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
Patient was admitted to a hospital
Patient was bed confined before the ambulance service
Patient was bed confined after the ambulance service
Patient was moved by stretcher
Patient was unconscious or in shock
Patient was transported in an emergency situation
Patient had to be physically restrained
Patient had visible hemorrhaging
Ambulance service was medically necessary
Patient is ambulatory
Ambulation is Impaired and Walking Aid is Used for Therapy or Mobility
Patient is confined to a bed or chair
Patient is Confined to a Room or an Area Without Bathroom Facilities
Ambulation is Impaired and Walking Aid is Used for Mobility
Patient Condition Requires Positioning of the Body or Attachments Which Would
Not be Feasible With the Use of an Ordinary Bed
Patient needs a trapeze bar to sit up due to respiratory condition or change body
positions for other medical reasons
Patient's Ability to Breathe is Severely Impaired
Patient condition requires frequent and/or immediate changes in body positions
Patient can operate controls
Siderails Are to be Attached to a Hospital Bed Owned by the Beneficiary
Patient owns equipment
120
For internal use only
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Code Name
22
23
24
25
26
27
29
30
31
32
33
35
37
38
40
41
42
43
44
45
46
58
59
60
9D
9H
9J
9K
IH
LB
SL
CRC06
1321
Mattress or Siderails are Being Used with Prescribed Medically Necessary Hospital
Bed Owned by the Beneficiary
Patient Needs Lift to Get In or Out of Bed or to Assist in Transfer from Bed to
Wheelchair
Patient has an orthopedic impairment requiring traction equipment which prevents
ambulation during period of use
Item has been prescribed as part of a planned regimen of treatment in patient home
Patient is highly susceptible to decubitus ulcers
Patient or a care-giver has been instructed in use of equipment
A 6-7 hour nocturnal study documents 30 episodes of apnea each lasting more
than 10 seconds
Without the equipment, the patient would require surgery
Patient has had a total knee replacement
Patient has intractable lymphedema of the extremities
Patient is in a nursing home
This Feeding is the Only Form of Nutritional Intake for This Patient
Oxygen delivery equipment is stationary
Certification signed by the physician is on file at the supplier's office
Patient or Caregiver is Capable of Using the Equipment Without Technical or
Professional Supervision
Patient or Caregiver is Unable to Propel or Lift a Standard Weight Wheelchair
Patient Requires Leg Elevation for Edema or Body Alignment
Patient Weight or Usage Needs Necessitate a Heavy Duty Wheelchair
Patient Requires Reclining Function of a Wheelchair
Patient is Unable to Operate a Wheelchair Manually
Patient or Caregiver Requires Side Transfer into Wheelchair, Commode or Other
Durable Medical Equipment (DME) Purchased New
Durable Medical Equipment (DME) Is Under Warranty
Transportation Was To the Nearest Facility
Lack of Appropriate Facility within Reasonable Distance to Treat Patient in the
Event of Complications
Patient Requires Intensive IV Therapy
Patient Requires Protective Isolation
Patient Requires Frequent Monitoring
Independent at Home
Legally Blind
Speech Limitations
Condition Indicator
O
ID
2/3
Situational
Description: Code indicating a condition
Situational Rule: Required when multiple conditions apply to the certification. If not
required by this implementation guide, do not send.
IMPLEMENTATION NAME: Condition Code
Use codes listed in CRC03.
CodeList Summary (Total Codes: 1316, Included: 52)
Code Name
01
02
Patient was admitted to a hospital
Patient was bed confined before the ambulance service
121
For internal use only
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Code Name
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
29
30
31
32
33
35
37
38
40
41
42
43
44
45
46
58
Patient was bed confined after the ambulance service
Patient was moved by stretcher
Patient was unconscious or in shock
Patient was transported in an emergency situation
Patient had to be physically restrained
Patient had visible hemorrhaging
Ambulance service was medically necessary
Patient is ambulatory
Ambulation is Impaired and Walking Aid is Used for Therapy or Mobility
Patient is confined to a bed or chair
Patient is Confined to a Room or an Area Without Bathroom Facilities
Ambulation is Impaired and Walking Aid is Used for Mobility
Patient Condition Requires Positioning of the Body or Attachments Which Would
Not be Feasible With the Use of an Ordinary Bed
Patient needs a trapeze bar to sit up due to respiratory condition or change body
positions for other medical reasons
Patient's Ability to Breathe is Severely Impaired
Patient condition requires frequent and/or immediate changes in body positions
Patient can operate controls
Siderails Are to be Attached to a Hospital Bed Owned by the Beneficiary
Patient owns equipment
Mattress or Siderails are Being Used with Prescribed Medically Necessary Hospital
Bed Owned by the Beneficiary
Patient Needs Lift to Get In or Out of Bed or to Assist in Transfer from Bed to
Wheelchair
Patient has an orthopedic impairment requiring traction equipment which prevents
ambulation during period of use
Item has been prescribed as part of a planned regimen of treatment in patient home
Patient is highly susceptible to decubitus ulcers
Patient or a care-giver has been instructed in use of equipment
A 6-7 hour nocturnal study documents 30 episodes of apnea each lasting more
than 10 seconds
Without the equipment, the patient would require surgery
Patient has had a total knee replacement
Patient has intractable lymphedema of the extremities
Patient is in a nursing home
This Feeding is the Only Form of Nutritional Intake for This Patient
Oxygen delivery equipment is stationary
Certification signed by the physician is on file at the supplier's office
Patient or Caregiver is Capable of Using the Equipment Without Technical or
Professional Supervision
Patient or Caregiver is Unable to Propel or Lift a Standard Weight Wheelchair
Patient Requires Leg Elevation for Edema or Body Alignment
Patient Weight or Usage Needs Necessitate a Heavy Duty Wheelchair
Patient Requires Reclining Function of a Wheelchair
Patient is Unable to Operate a Wheelchair Manually
Patient or Caregiver Requires Side Transfer into Wheelchair, Commode or Other
Durable Medical Equipment (DME) Purchased New
122
For internal use only
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Health Care Services Review Information - Request - 278
Code
59
60
9D
9H
9J
9K
IH
LB
SL
CRC07
1321
Name
Durable Medical Equipment (DME) Is Under Warranty
Transportation Was To the Nearest Facility
Lack of Appropriate Facility within Reasonable Distance to Treat Patient in the
Event of Complications
Patient Requires Intensive IV Therapy
Patient Requires Protective Isolation
Patient Requires Frequent Monitoring
Independent at Home
Legally Blind
Speech Limitations
Condition Indicator
O
ID
2/3
Situational
Description: Code indicating a condition
Situational Rule: Required when multiple conditions apply to the certification. If not
required by this implementation guide, do not send.
IMPLEMENTATION NAME: Condition Code
Use codes listed in CRC03.
CodeList Summary (Total Codes: 1316, Included: 52)
Code Name
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
Patient was admitted to a hospital
Patient was bed confined before the ambulance service
Patient was bed confined after the ambulance service
Patient was moved by stretcher
Patient was unconscious or in shock
Patient was transported in an emergency situation
Patient had to be physically restrained
Patient had visible hemorrhaging
Ambulance service was medically necessary
Patient is ambulatory
Ambulation is Impaired and Walking Aid is Used for Therapy or Mobility
Patient is confined to a bed or chair
Patient is Confined to a Room or an Area Without Bathroom Facilities
Ambulation is Impaired and Walking Aid is Used for Mobility
Patient Condition Requires Positioning of the Body or Attachments Which Would
Not be Feasible With the Use of an Ordinary Bed
Patient needs a trapeze bar to sit up due to respiratory condition or change body
positions for other medical reasons
Patient's Ability to Breathe is Severely Impaired
Patient condition requires frequent and/or immediate changes in body positions
Patient can operate controls
Siderails Are to be Attached to a Hospital Bed Owned by the Beneficiary
Patient owns equipment
Mattress or Siderails are Being Used with Prescribed Medically Necessary Hospital
Bed Owned by the Beneficiary
Patient Needs Lift to Get In or Out of Bed or to Assist in Transfer from Bed to
Wheelchair
Patient has an orthopedic impairment requiring traction equipment which prevents
ambulation during period of use
123
For internal use only
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Code Name
25
26
27
29
30
31
32
33
35
37
38
40
41
42
43
44
45
46
58
59
60
9D
9H
9J
9K
IH
LB
SL
Item has been prescribed as part of a planned regimen of treatment in patient home
Patient is highly susceptible to decubitus ulcers
Patient or a care-giver has been instructed in use of equipment
A 6-7 hour nocturnal study documents 30 episodes of apnea each lasting more
than 10 seconds
Without the equipment, the patient would require surgery
Patient has had a total knee replacement
Patient has intractable lymphedema of the extremities
Patient is in a nursing home
This Feeding is the Only Form of Nutritional Intake for This Patient
Oxygen delivery equipment is stationary
Certification signed by the physician is on file at the supplier's office
Patient or Caregiver is Capable of Using the Equipment Without Technical or
Professional Supervision
Patient or Caregiver is Unable to Propel or Lift a Standard Weight Wheelchair
Patient Requires Leg Elevation for Edema or Body Alignment
Patient Weight or Usage Needs Necessitate a Heavy Duty Wheelchair
Patient Requires Reclining Function of a Wheelchair
Patient is Unable to Operate a Wheelchair Manually
Patient or Caregiver Requires Side Transfer into Wheelchair, Commode or Other
Durable Medical Equipment (DME) Purchased New
Durable Medical Equipment (DME) Is Under Warranty
Transportation Was To the Nearest Facility
Lack of Appropriate Facility within Reasonable Distance to Treat Patient in the
Event of Complications
Patient Requires Intensive IV Therapy
Patient Requires Protective Isolation
Patient Requires Frequent Monitoring
Independent at Home
Legally Blind
Speech Limitations
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.
Situational Rule:
Required when health care services is requesting durable medical equipment. If not required by this
implementation guide, do not send.
TR3 Example:
CRC*09*Y*29~
124
For internal use only
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Pos: 1000
CRC Oxygen Therapy
Max: 1
Detail - Optional
Certification Information
Loop:
2000E
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: 426, Included: 1)
Code Name
11
CRC02
1073
Oxygen Therapy Certification
Yes/No Condition or Response Code
M
ID
1/1
Required
2/3
Required
Description: Code indicating a Yes or No condition or response
IMPLEMENTATION NAME: Certification Condition 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
IMPLEMENTATION NAME: Condition Code
CodeList Summary (Total Codes: 1316, Included: 11)
Code Name
06
16
17
25
33
37
39
5A
9J
9K
DY
CRC04
1321
Patient was transported in an emergency situation
Patient needs a trapeze bar to sit up due to respiratory condition or change body
positions for other medical reasons
Patient's Ability to Breathe is Severely Impaired
Item has been prescribed as part of a planned regimen of treatment in patient home
Patient is in a nursing home
Oxygen delivery equipment is stationary
Patient Has Mobilizing Respiratory Tract Secretions
Treatment is rendered related to the terminal illness
Patient Requires Protective Isolation
Patient Requires Frequent Monitoring
Dyspnea with Minimal Exertion
Condition Indicator
O
ID
2/3
Situational
Description: Code indicating a condition
Situational Rule: Required when multiple conditions apply to the certification. If not
required by this implementation guide, do not send.
IMPLEMENTATION NAME: Condition Code
125
For internal use only
1/12/2012
Ref
Health Care Services Review Information - Request - 278
Id
Element Name
Req
Type
Min/Max
Usage
Use codes listed in CRC03.
CodeList Summary (Total Codes: 1316, Included: 11)
Code Name
06
16
17
25
33
37
39
5A
9J
9K
DY
CRC05
1321
Patient was transported in an emergency situation
Patient needs a trapeze bar to sit up due to respiratory condition or change body
positions for other medical reasons
Patient's Ability to Breathe is Severely Impaired
Item has been prescribed as part of a planned regimen of treatment in patient home
Patient is in a nursing home
Oxygen delivery equipment is stationary
Patient Has Mobilizing Respiratory Tract Secretions
Treatment is rendered related to the terminal illness
Patient Requires Protective Isolation
Patient Requires Frequent Monitoring
Dyspnea with Minimal Exertion
Condition Indicator
O
ID
2/3
Situational
Description: Code indicating a condition
Situational Rule: Required when multiple conditions apply to the certification. If not
required by this implementation guide, do not send.
IMPLEMENTATION NAME: Condition Code
Use codes listed in CRC03.
CodeList Summary (Total Codes: 1316, Included: 11)
Code Name
06
16
17
25
33
37
39
5A
9J
9K
DY
CRC06
1321
Patient was transported in an emergency situation
Patient needs a trapeze bar to sit up due to respiratory condition or change body
positions for other medical reasons
Patient's Ability to Breathe is Severely Impaired
Item has been prescribed as part of a planned regimen of treatment in patient home
Patient is in a nursing home
Oxygen delivery equipment is stationary
Patient Has Mobilizing Respiratory Tract Secretions
Treatment is rendered related to the terminal illness
Patient Requires Protective Isolation
Patient Requires Frequent Monitoring
Dyspnea with Minimal Exertion
Condition Indicator
O
ID
2/3
Situational
Description: Code indicating a condition
Situational Rule: Required when multiple conditions apply to the certification. If not
required by this implementation guide, do not send.
IMPLEMENTATION NAME: Condition Code
Use codes listed in CRC03.
CodeList Summary (Total Codes: 1316, Included: 11)
Code Name
06
Patient was transported in an emergency situation
126
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Code Name
16
17
25
33
37
39
5A
9J
9K
DY
CRC07
1321
Patient needs a trapeze bar to sit up due to respiratory condition or change body
positions for other medical reasons
Patient's Ability to Breathe is Severely Impaired
Item has been prescribed as part of a planned regimen of treatment in patient home
Patient is in a nursing home
Oxygen delivery equipment is stationary
Patient Has Mobilizing Respiratory Tract Secretions
Treatment is rendered related to the terminal illness
Patient Requires Protective Isolation
Patient Requires Frequent Monitoring
Dyspnea with Minimal Exertion
Condition Indicator
O
ID
2/3
Situational
Description: Code indicating a condition
Situational Rule: Required when multiple conditions apply to the certification. If not
required by this implementation guide, do not send.
IMPLEMENTATION NAME: Condition Code
Use codes listed in CRC03.
CodeList Summary (Total Codes: 1316, Included: 11)
Code Name
06
16
17
25
33
37
39
5A
9J
9K
DY
Patient was transported in an emergency situation
Patient needs a trapeze bar to sit up due to respiratory condition or change body
positions for other medical reasons
Patient's Ability to Breathe is Severely Impaired
Item has been prescribed as part of a planned regimen of treatment in patient home
Patient is in a nursing home
Oxygen delivery equipment is stationary
Patient Has Mobilizing Respiratory Tract Secretions
Treatment is rendered related to the terminal illness
Patient Requires Protective Isolation
Patient Requires Frequent Monitoring
Dyspnea with Minimal Exertion
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.
Situational Rule:
Required when health care services review is requesting oxygen therapy certification. If not required by this
implementation guide, do not send.
TR3 Example:
CRC*11*Y*25~
127
For internal use only
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Pos: 1000
CRC Functional Limitations
Max: 1
Detail - Optional
Information
Loop:
2000E
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: 426, Included: 1)
Code Name
75
CRC02
1073
Functional Limitations
Yes/No Condition or Response Code
M
ID
1/1
Required
2/3
Required
Description: Code indicating a Yes or No condition or response
IMPLEMENTATION NAME: Certification Condition 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
IMPLEMENTATION NAME: Condition Code
CodeList Summary (Total Codes: 1316, Included: 63)
Code Name
02
03
04
05
06
11
12
14
15
16
17
18
19
20
21
22
Patient was bed confined before the ambulance service
Patient was bed confined after the ambulance service
Patient was moved by stretcher
Patient was unconscious or in shock
Patient was transported in an emergency situation
Ambulation is Impaired and Walking Aid is Used for Therapy or Mobility
Patient is confined to a bed or chair
Ambulation is Impaired and Walking Aid is Used for Mobility
Patient Condition Requires Positioning of the Body or Attachments Which Would
Not be Feasible With the Use of an Ordinary Bed
Patient needs a trapeze bar to sit up due to respiratory condition or change body
positions for other medical reasons
Patient's Ability to Breathe is Severely Impaired
Patient condition requires frequent and/or immediate changes in body positions
Patient can operate controls
Siderails Are to be Attached to a Hospital Bed Owned by the Beneficiary
Patient owns equipment
Mattress or Siderails are Being Used with Prescribed Medically Necessary Hospital
128
For internal use only
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Code Name
Bed Owned by the Beneficiary
23
Patient Needs Lift to Get In or Out of Bed or to Assist in Transfer from Bed to
Wheelchair
24
Patient has an orthopedic impairment requiring traction equipment which prevents
ambulation during period of use
25
Item has been prescribed as part of a planned regimen of treatment in patient home
26
Patient is highly susceptible to decubitus ulcers
27
Patient or a care-giver has been instructed in use of equipment
28
Patient has poor diabetic control
30
Without the equipment, the patient would require surgery
31
Patient has had a total knee replacement
32
Patient has intractable lymphedema of the extremities
35
This Feeding is the Only Form of Nutritional Intake for This Patient
37
Oxygen delivery equipment is stationary
39
Patient Has Mobilizing Respiratory Tract Secretions
40
Patient or Caregiver is Capable of Using the Equipment Without Technical or
Professional Supervision
41
Patient or Caregiver is Unable to Propel or Lift a Standard Weight Wheelchair
42
Patient Requires Leg Elevation for Edema or Body Alignment
43
Patient Weight or Usage Needs Necessitate a Heavy Duty Wheelchair
44
Patient Requires Reclining Function of a Wheelchair
45
Patient is Unable to Operate a Wheelchair Manually
46
Patient or Caregiver Requires Side Transfer into Wheelchair, Commode or Other
5A
Treatment is rendered related to the terminal illness
68
Severe
69
Moderate
9E
Sudden Onset of Disorientation
9F
Sudden Onset of Severe, Incapacitating Pain
9H
Patient Requires Intensive IV Therapy
AA
Amputation
AL
Ambulation Limitations
BL
Bowel Limitations, Bladder Limitations, or both (Incontinence)
CA
Cane Required
CB
Complete Bedrest
CO
Contracture
DY
Dyspnea with Minimal Exertion
EL
Endurance Limitations
EP
Exercises Prescribed
HL
Hearing Limitations
LB
Legally Blind
LE
Lethargic
OL
Other Limitation
PA
Paralysis
PW
Partial Weight Bearing
SL
Speech Limitations
WA
Walker Required
WR Wheelchair Required
BPD Beneficiary is Partially Dependent
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Code Name
BTD
CNJ
TNJ
CRC04
1321
Beneficiary is Totally Dependent
Cumulative Injury
Traumatic Injury
Condition Indicator
O
ID
2/3
Situational
Description: Code indicating a condition
Situational Rule: Required when multiple conditions apply to the certification. If not
required by this implementation guide, do not send.
IMPLEMENTATION NAME: Condition Code
Use codes listed in CRC03.
CodeList Summary (Total Codes: 1316, Included: 63)
Code Name
02
03
04
05
06
11
12
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
30
31
32
35
37
39
40
41
Patient was bed confined before the ambulance service
Patient was bed confined after the ambulance service
Patient was moved by stretcher
Patient was unconscious or in shock
Patient was transported in an emergency situation
Ambulation is Impaired and Walking Aid is Used for Therapy or Mobility
Patient is confined to a bed or chair
Ambulation is Impaired and Walking Aid is Used for Mobility
Patient Condition Requires Positioning of the Body or Attachments Which Would
Not be Feasible With the Use of an Ordinary Bed
Patient needs a trapeze bar to sit up due to respiratory condition or change body
positions for other medical reasons
Patient's Ability to Breathe is Severely Impaired
Patient condition requires frequent and/or immediate changes in body positions
Patient can operate controls
Siderails Are to be Attached to a Hospital Bed Owned by the Beneficiary
Patient owns equipment
Mattress or Siderails are Being Used with Prescribed Medically Necessary Hospital
Bed Owned by the Beneficiary
Patient Needs Lift to Get In or Out of Bed or to Assist in Transfer from Bed to
Wheelchair
Patient has an orthopedic impairment requiring traction equipment which prevents
ambulation during period of use
Item has been prescribed as part of a planned regimen of treatment in patient home
Patient is highly susceptible to decubitus ulcers
Patient or a care-giver has been instructed in use of equipment
Patient has poor diabetic control
Without the equipment, the patient would require surgery
Patient has had a total knee replacement
Patient has intractable lymphedema of the extremities
This Feeding is the Only Form of Nutritional Intake for This Patient
Oxygen delivery equipment is stationary
Patient Has Mobilizing Respiratory Tract Secretions
Patient or Caregiver is Capable of Using the Equipment Without Technical or
Professional Supervision
Patient or Caregiver is Unable to Propel or Lift a Standard Weight Wheelchair
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Code Name
42
43
44
45
46
5A
68
69
9E
9F
9H
AA
AL
BL
CA
CB
CO
DY
EL
EP
HL
LB
LE
OL
PA
PW
SL
WA
WR
BPD
BTD
CNJ
TNJ
CRC05
1321
Patient Requires Leg Elevation for Edema or Body Alignment
Patient Weight or Usage Needs Necessitate a Heavy Duty Wheelchair
Patient Requires Reclining Function of a Wheelchair
Patient is Unable to Operate a Wheelchair Manually
Patient or Caregiver Requires Side Transfer into Wheelchair, Commode or Other
Treatment is rendered related to the terminal illness
Severe
Moderate
Sudden Onset of Disorientation
Sudden Onset of Severe, Incapacitating Pain
Patient Requires Intensive IV Therapy
Amputation
Ambulation Limitations
Bowel Limitations, Bladder Limitations, or both (Incontinence)
Cane Required
Complete Bedrest
Contracture
Dyspnea with Minimal Exertion
Endurance Limitations
Exercises Prescribed
Hearing Limitations
Legally Blind
Lethargic
Other Limitation
Paralysis
Partial Weight Bearing
Speech Limitations
Walker Required
Wheelchair Required
Beneficiary is Partially Dependent
Beneficiary is Totally Dependent
Cumulative Injury
Traumatic Injury
Condition Indicator
O
ID
2/3
Situational
Description: Code indicating a condition
Situational Rule: Required when multiple conditions apply to the certification. If not
required by this implementation guide, do not send.
IMPLEMENTATION NAME: Condition Code
Use codes listed in CRC03.
CodeList Summary (Total Codes: 1316, Included: 63)
Code Name
02
03
04
05
Patient was bed confined before the ambulance service
Patient was bed confined after the ambulance service
Patient was moved by stretcher
Patient was unconscious or in shock
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Code Name
06
11
12
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
30
31
32
35
37
39
40
41
42
43
44
45
46
5A
68
69
9E
9F
9H
AA
AL
BL
CA
CB
Patient was transported in an emergency situation
Ambulation is Impaired and Walking Aid is Used for Therapy or Mobility
Patient is confined to a bed or chair
Ambulation is Impaired and Walking Aid is Used for Mobility
Patient Condition Requires Positioning of the Body or Attachments Which Would
Not be Feasible With the Use of an Ordinary Bed
Patient needs a trapeze bar to sit up due to respiratory condition or change body
positions for other medical reasons
Patient's Ability to Breathe is Severely Impaired
Patient condition requires frequent and/or immediate changes in body positions
Patient can operate controls
Siderails Are to be Attached to a Hospital Bed Owned by the Beneficiary
Patient owns equipment
Mattress or Siderails are Being Used with Prescribed Medically Necessary Hospital
Bed Owned by the Beneficiary
Patient Needs Lift to Get In or Out of Bed or to Assist in Transfer from Bed to
Wheelchair
Patient has an orthopedic impairment requiring traction equipment which prevents
ambulation during period of use
Item has been prescribed as part of a planned regimen of treatment in patient home
Patient is highly susceptible to decubitus ulcers
Patient or a care-giver has been instructed in use of equipment
Patient has poor diabetic control
Without the equipment, the patient would require surgery
Patient has had a total knee replacement
Patient has intractable lymphedema of the extremities
This Feeding is the Only Form of Nutritional Intake for This Patient
Oxygen delivery equipment is stationary
Patient Has Mobilizing Respiratory Tract Secretions
Patient or Caregiver is Capable of Using the Equipment Without Technical or
Professional Supervision
Patient or Caregiver is Unable to Propel or Lift a Standard Weight Wheelchair
Patient Requires Leg Elevation for Edema or Body Alignment
Patient Weight or Usage Needs Necessitate a Heavy Duty Wheelchair
Patient Requires Reclining Function of a Wheelchair
Patient is Unable to Operate a Wheelchair Manually
Patient or Caregiver Requires Side Transfer into Wheelchair, Commode or Other
Treatment is rendered related to the terminal illness
Severe
Moderate
Sudden Onset of Disorientation
Sudden Onset of Severe, Incapacitating Pain
Patient Requires Intensive IV Therapy
Amputation
Ambulation Limitations
Bowel Limitations, Bladder Limitations, or both (Incontinence)
Cane Required
Complete Bedrest
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Code Name
CO
DY
EL
EP
HL
LB
LE
OL
PA
PW
SL
WA
WR
BPD
BTD
CNJ
TNJ
CRC06
1321
Contracture
Dyspnea with Minimal Exertion
Endurance Limitations
Exercises Prescribed
Hearing Limitations
Legally Blind
Lethargic
Other Limitation
Paralysis
Partial Weight Bearing
Speech Limitations
Walker Required
Wheelchair Required
Beneficiary is Partially Dependent
Beneficiary is Totally Dependent
Cumulative Injury
Traumatic Injury
Condition Indicator
O
ID
2/3
Situational
Description: Code indicating a condition
Situational Rule: Required when multiple conditions apply to the certification. If not
required by this implementation guide, do not send.
IMPLEMENTATION NAME: Condition Code
Use codes listed in CRC03.
CodeList Summary (Total Codes: 1316, Included: 63)
Code Name
02
03
04
05
06
11
12
14
15
16
17
18
19
20
21
22
23
Patient was bed confined before the ambulance service
Patient was bed confined after the ambulance service
Patient was moved by stretcher
Patient was unconscious or in shock
Patient was transported in an emergency situation
Ambulation is Impaired and Walking Aid is Used for Therapy or Mobility
Patient is confined to a bed or chair
Ambulation is Impaired and Walking Aid is Used for Mobility
Patient Condition Requires Positioning of the Body or Attachments Which Would
Not be Feasible With the Use of an Ordinary Bed
Patient needs a trapeze bar to sit up due to respiratory condition or change body
positions for other medical reasons
Patient's Ability to Breathe is Severely Impaired
Patient condition requires frequent and/or immediate changes in body positions
Patient can operate controls
Siderails Are to be Attached to a Hospital Bed Owned by the Beneficiary
Patient owns equipment
Mattress or Siderails are Being Used with Prescribed Medically Necessary Hospital
Bed Owned by the Beneficiary
Patient Needs Lift to Get In or Out of Bed or to Assist in Transfer from Bed to
Wheelchair
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Code Name
24
25
26
27
28
30
31
32
35
37
39
40
41
42
43
44
45
46
5A
68
69
9E
9F
9H
AA
AL
BL
CA
CB
CO
DY
EL
EP
HL
LB
LE
OL
PA
PW
SL
WA
WR
BPD
BTD
CNJ
Patient has an orthopedic impairment requiring traction equipment which prevents
ambulation during period of use
Item has been prescribed as part of a planned regimen of treatment in patient home
Patient is highly susceptible to decubitus ulcers
Patient or a care-giver has been instructed in use of equipment
Patient has poor diabetic control
Without the equipment, the patient would require surgery
Patient has had a total knee replacement
Patient has intractable lymphedema of the extremities
This Feeding is the Only Form of Nutritional Intake for This Patient
Oxygen delivery equipment is stationary
Patient Has Mobilizing Respiratory Tract Secretions
Patient or Caregiver is Capable of Using the Equipment Without Technical or
Professional Supervision
Patient or Caregiver is Unable to Propel or Lift a Standard Weight Wheelchair
Patient Requires Leg Elevation for Edema or Body Alignment
Patient Weight or Usage Needs Necessitate a Heavy Duty Wheelchair
Patient Requires Reclining Function of a Wheelchair
Patient is Unable to Operate a Wheelchair Manually
Patient or Caregiver Requires Side Transfer into Wheelchair, Commode or Other
Treatment is rendered related to the terminal illness
Severe
Moderate
Sudden Onset of Disorientation
Sudden Onset of Severe, Incapacitating Pain
Patient Requires Intensive IV Therapy
Amputation
Ambulation Limitations
Bowel Limitations, Bladder Limitations, or both (Incontinence)
Cane Required
Complete Bedrest
Contracture
Dyspnea with Minimal Exertion
Endurance Limitations
Exercises Prescribed
Hearing Limitations
Legally Blind
Lethargic
Other Limitation
Paralysis
Partial Weight Bearing
Speech Limitations
Walker Required
Wheelchair Required
Beneficiary is Partially Dependent
Beneficiary is Totally Dependent
Cumulative Injury
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Code Name
TNJ
CRC07
1321
Traumatic Injury
Condition Indicator
O
ID
2/3
Situational
Description: Code indicating a condition
Situational Rule: Required when multiple conditions apply to the certification. If not
required by this implementation guide, do not send.
IMPLEMENTATION NAME: Condition Code
Use codes listed in CRC03.
CodeList Summary (Total Codes: 1316, Included: 63)
Code Name
02
03
04
05
06
11
12
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
30
31
32
35
37
39
40
41
42
43
Patient was bed confined before the ambulance service
Patient was bed confined after the ambulance service
Patient was moved by stretcher
Patient was unconscious or in shock
Patient was transported in an emergency situation
Ambulation is Impaired and Walking Aid is Used for Therapy or Mobility
Patient is confined to a bed or chair
Ambulation is Impaired and Walking Aid is Used for Mobility
Patient Condition Requires Positioning of the Body or Attachments Which Would
Not be Feasible With the Use of an Ordinary Bed
Patient needs a trapeze bar to sit up due to respiratory condition or change body
positions for other medical reasons
Patient's Ability to Breathe is Severely Impaired
Patient condition requires frequent and/or immediate changes in body positions
Patient can operate controls
Siderails Are to be Attached to a Hospital Bed Owned by the Beneficiary
Patient owns equipment
Mattress or Siderails are Being Used with Prescribed Medically Necessary Hospital
Bed Owned by the Beneficiary
Patient Needs Lift to Get In or Out of Bed or to Assist in Transfer from Bed to
Wheelchair
Patient has an orthopedic impairment requiring traction equipment which prevents
ambulation during period of use
Item has been prescribed as part of a planned regimen of treatment in patient home
Patient is highly susceptible to decubitus ulcers
Patient or a care-giver has been instructed in use of equipment
Patient has poor diabetic control
Without the equipment, the patient would require surgery
Patient has had a total knee replacement
Patient has intractable lymphedema of the extremities
This Feeding is the Only Form of Nutritional Intake for This Patient
Oxygen delivery equipment is stationary
Patient Has Mobilizing Respiratory Tract Secretions
Patient or Caregiver is Capable of Using the Equipment Without Technical or
Professional Supervision
Patient or Caregiver is Unable to Propel or Lift a Standard Weight Wheelchair
Patient Requires Leg Elevation for Edema or Body Alignment
Patient Weight or Usage Needs Necessitate a Heavy Duty Wheelchair
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Code Name
44
45
46
5A
68
69
9E
9F
9H
AA
AL
BL
CA
CB
CO
DY
EL
EP
HL
LB
LE
OL
PA
PW
SL
WA
WR
BPD
BTD
CNJ
TNJ
Patient Requires Reclining Function of a Wheelchair
Patient is Unable to Operate a Wheelchair Manually
Patient or Caregiver Requires Side Transfer into Wheelchair, Commode or Other
Treatment is rendered related to the terminal illness
Severe
Moderate
Sudden Onset of Disorientation
Sudden Onset of Severe, Incapacitating Pain
Patient Requires Intensive IV Therapy
Amputation
Ambulation Limitations
Bowel Limitations, Bladder Limitations, or both (Incontinence)
Cane Required
Complete Bedrest
Contracture
Dyspnea with Minimal Exertion
Endurance Limitations
Exercises Prescribed
Hearing Limitations
Legally Blind
Lethargic
Other Limitation
Paralysis
Partial Weight Bearing
Speech Limitations
Walker Required
Wheelchair Required
Beneficiary is Partially Dependent
Beneficiary is Totally Dependent
Cumulative Injury
Traumatic Injury
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.
Situational Rule:
Required when the assessing provider has defined function limitation for the patient. If not required by this
implementation guide, do not send.
TR3 Example:
CRC*75*Y*02~
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Pos: 1000
CRC Activities Permitted
Max: 1
Detail - Optional
Information
Loop:
2000E
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: 426, Included: 1)
Code Name
76
CRC02
1073
Activities Permitted
Yes/No Condition or Response Code
M
ID
1/1
Required
2/3
Required
Description: Code indicating a Yes or No condition or response
IMPLEMENTATION NAME: Certification Condition 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
IMPLEMENTATION NAME: Condition Code
CodeList Summary (Total Codes: 1316, Included: 22)
Code Name
10
13
19
21
22
27
31
40
BR
CA
CB
CR
EL
EP
IH
NR
Patient is ambulatory
Patient is Confined to a Room or an Area Without Bathroom Facilities
Patient can operate controls
Patient owns equipment
Mattress or Siderails are Being Used with Prescribed Medically Necessary Hospital
Bed Owned by the Beneficiary
Patient or a care-giver has been instructed in use of equipment
Patient has had a total knee replacement
Patient or Caregiver is Capable of Using the Equipment Without Technical or
Professional Supervision
Bedrest BRP (Bathroom Privileges)
Cane Required
Complete Bedrest
Crutches Required
Endurance Limitations
Exercises Prescribed
Independent at Home
No Restrictions
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Code Name
PA
PW
TR
UT
WA
WR
CRC04
1321
Paralysis
Partial Weight Bearing
Transfer to Bed, or Chair, or Both
Up as Tolerated
Walker Required
Wheelchair Required
Condition Indicator
O
ID
2/3
Situational
Description: Code indicating a condition
Situational Rule: Required when multiple conditions apply to the certification. If not
required by this implementation guide, do not send.
IMPLEMENTATION NAME: Condition Code
Use codes listed in CRC03.
CodeList Summary (Total Codes: 1316, Included: 22)
Code Name
10
13
19
21
22
27
31
40
BR
CA
CB
CR
EL
EP
IH
NR
PA
PW
TR
UT
WA
WR
CRC05
1321
Patient is ambulatory
Patient is Confined to a Room or an Area Without Bathroom Facilities
Patient can operate controls
Patient owns equipment
Mattress or Siderails are Being Used with Prescribed Medically Necessary Hospital
Bed Owned by the Beneficiary
Patient or a care-giver has been instructed in use of equipment
Patient has had a total knee replacement
Patient or Caregiver is Capable of Using the Equipment Without Technical or
Professional Supervision
Bedrest BRP (Bathroom Privileges)
Cane Required
Complete Bedrest
Crutches Required
Endurance Limitations
Exercises Prescribed
Independent at Home
No Restrictions
Paralysis
Partial Weight Bearing
Transfer to Bed, or Chair, or Both
Up as Tolerated
Walker Required
Wheelchair Required
Condition Indicator
O
ID
2/3
Situational
Description: Code indicating a condition
Situational Rule: Required when multiple conditions apply to the certification. If not
required by this implementation guide, do not send.
IMPLEMENTATION NAME: Condition Code
Use codes listed in CRC03.
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CodeList Summary (Total Codes: 1316, Included: 22)
Code Name
10
13
19
21
22
27
31
40
BR
CA
CB
CR
EL
EP
IH
NR
PA
PW
TR
UT
WA
WR
CRC06
1321
Patient is ambulatory
Patient is Confined to a Room or an Area Without Bathroom Facilities
Patient can operate controls
Patient owns equipment
Mattress or Siderails are Being Used with Prescribed Medically Necessary Hospital
Bed Owned by the Beneficiary
Patient or a care-giver has been instructed in use of equipment
Patient has had a total knee replacement
Patient or Caregiver is Capable of Using the Equipment Without Technical or
Professional Supervision
Bedrest BRP (Bathroom Privileges)
Cane Required
Complete Bedrest
Crutches Required
Endurance Limitations
Exercises Prescribed
Independent at Home
No Restrictions
Paralysis
Partial Weight Bearing
Transfer to Bed, or Chair, or Both
Up as Tolerated
Walker Required
Wheelchair Required
Condition Indicator
O
ID
2/3
Situational
Description: Code indicating a condition
Situational Rule: Required when multiple conditions apply to the certification. If not
required by this implementation guide, do not send.
IMPLEMENTATION NAME: Condition Code
Use codes listed in CRC03.
CodeList Summary (Total Codes: 1316, Included: 22)
Code Name
10
13
19
21
22
27
31
40
BR
CA
CB
Patient is ambulatory
Patient is Confined to a Room or an Area Without Bathroom Facilities
Patient can operate controls
Patient owns equipment
Mattress or Siderails are Being Used with Prescribed Medically Necessary Hospital
Bed Owned by the Beneficiary
Patient or a care-giver has been instructed in use of equipment
Patient has had a total knee replacement
Patient or Caregiver is Capable of Using the Equipment Without Technical or
Professional Supervision
Bedrest BRP (Bathroom Privileges)
Cane Required
Complete Bedrest
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Code Name
CR
EL
EP
IH
NR
PA
PW
TR
UT
WA
WR
CRC07
1321
Crutches Required
Endurance Limitations
Exercises Prescribed
Independent at Home
No Restrictions
Paralysis
Partial Weight Bearing
Transfer to Bed, or Chair, or Both
Up as Tolerated
Walker Required
Wheelchair Required
Condition Indicator
O
ID
2/3
Situational
Description: Code indicating a condition
Situational Rule: Required when multiple conditions apply to the certification. If not
required by this implementation guide, do not send.
IMPLEMENTATION NAME: Condition Code
Use codes listed in CRC03.
CodeList Summary (Total Codes: 1316, Included: 22)
Code Name
10
13
19
21
22
27
31
40
BR
CA
CB
CR
EL
EP
IH
NR
PA
PW
TR
UT
WA
WR
Patient is ambulatory
Patient is Confined to a Room or an Area Without Bathroom Facilities
Patient can operate controls
Patient owns equipment
Mattress or Siderails are Being Used with Prescribed Medically Necessary Hospital
Bed Owned by the Beneficiary
Patient or a care-giver has been instructed in use of equipment
Patient has had a total knee replacement
Patient or Caregiver is Capable of Using the Equipment Without Technical or
Professional Supervision
Bedrest BRP (Bathroom Privileges)
Cane Required
Complete Bedrest
Crutches Required
Endurance Limitations
Exercises Prescribed
Independent at Home
No Restrictions
Paralysis
Partial Weight Bearing
Transfer to Bed, or Chair, or Both
Up as Tolerated
Walker Required
Wheelchair Required
Semantics:
1. CRC01 qualifies CRC03 through CRC07.
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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.
Situational Rule:
Required when the assessing provider has defined activities permitted for the patient. If not required by this
implementation guide, do not send.
TR3 Example:
CRC*76*Y*10~
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CRC Mental Status Information
Pos: 1000
Max: 1
Detail - Optional
Loop:
2000E
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: 426, Included: 1)
Code Name
77
CRC02
1073
Mental Status
Yes/No Condition or Response Code
M
ID
1/1
Required
2/3
Required
Description: Code indicating a Yes or No condition or response
IMPLEMENTATION NAME: Certification Condition 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
IMPLEMENTATION NAME: Condition Code
CodeList Summary (Total Codes: 1316, Included: 30)
Code Name
01
05
07
13
20
22
23
26
33
34
5A
68
69
9E
9F
9J
Patient was admitted to a hospital
Patient was unconscious or in shock
Patient had to be physically restrained
Patient is Confined to a Room or an Area Without Bathroom Facilities
Siderails Are to be Attached to a Hospital Bed Owned by the Beneficiary
Mattress or Siderails are Being Used with Prescribed Medically Necessary Hospital
Bed Owned by the Beneficiary
Patient Needs Lift to Get In or Out of Bed or to Assist in Transfer from Bed to
Wheelchair
Patient is highly susceptible to decubitus ulcers
Patient is in a nursing home
Patient is conscious
Treatment is rendered related to the terminal illness
Severe
Moderate
Sudden Onset of Disorientation
Sudden Onset of Severe, Incapacitating Pain
Patient Requires Protective Isolation
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Code Name
9K
AG
CB
CM
DI
DP
FO
HO
LE
MC
OT
UN
BPD
BTD
CRC04
1321
Patient Requires Frequent Monitoring
Agitated
Complete Bedrest
Comatose
Disoriented
Depressed
Forgetful
Hostile
Lethargic
Other Mental Condition
Oriented
Uncooperative
Beneficiary is Partially Dependent
Beneficiary is Totally Dependent
Condition Indicator
O
ID
2/3
Situational
Description: Code indicating a condition
Situational Rule: Required when multiple conditions apply to the certification. If not
required by this implementation guide, do not send.
IMPLEMENTATION NAME: Condition Code
Use codes listed in CRC03.
CodeList Summary (Total Codes: 1316, Included: 30)
Code Name
01
05
07
13
20
22
23
26
33
34
5A
68
69
9E
9F
9J
9K
AG
CB
CM
DI
DP
Patient was admitted to a hospital
Patient was unconscious or in shock
Patient had to be physically restrained
Patient is Confined to a Room or an Area Without Bathroom Facilities
Siderails Are to be Attached to a Hospital Bed Owned by the Beneficiary
Mattress or Siderails are Being Used with Prescribed Medically Necessary Hospital
Bed Owned by the Beneficiary
Patient Needs Lift to Get In or Out of Bed or to Assist in Transfer from Bed to
Wheelchair
Patient is highly susceptible to decubitus ulcers
Patient is in a nursing home
Patient is conscious
Treatment is rendered related to the terminal illness
Severe
Moderate
Sudden Onset of Disorientation
Sudden Onset of Severe, Incapacitating Pain
Patient Requires Protective Isolation
Patient Requires Frequent Monitoring
Agitated
Complete Bedrest
Comatose
Disoriented
Depressed
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Code Name
FO
HO
LE
MC
OT
UN
BPD
BTD
CRC05
1321
Forgetful
Hostile
Lethargic
Other Mental Condition
Oriented
Uncooperative
Beneficiary is Partially Dependent
Beneficiary is Totally Dependent
Condition Indicator
O
ID
2/3
Situational
Description: Code indicating a condition
Situational Rule: Required when multiple conditions apply to the certification. If not
required by this implementation guide, do not send.
IMPLEMENTATION NAME: Condition Code
Use codes listed in CRC03.
CodeList Summary (Total Codes: 1316, Included: 30)
Code Name
01
05
07
13
20
22
23
26
33
34
5A
68
69
9E
9F
9J
9K
AG
CB
CM
DI
DP
FO
HO
LE
MC
OT
UN
Patient was admitted to a hospital
Patient was unconscious or in shock
Patient had to be physically restrained
Patient is Confined to a Room or an Area Without Bathroom Facilities
Siderails Are to be Attached to a Hospital Bed Owned by the Beneficiary
Mattress or Siderails are Being Used with Prescribed Medically Necessary Hospital
Bed Owned by the Beneficiary
Patient Needs Lift to Get In or Out of Bed or to Assist in Transfer from Bed to
Wheelchair
Patient is highly susceptible to decubitus ulcers
Patient is in a nursing home
Patient is conscious
Treatment is rendered related to the terminal illness
Severe
Moderate
Sudden Onset of Disorientation
Sudden Onset of Severe, Incapacitating Pain
Patient Requires Protective Isolation
Patient Requires Frequent Monitoring
Agitated
Complete Bedrest
Comatose
Disoriented
Depressed
Forgetful
Hostile
Lethargic
Other Mental Condition
Oriented
Uncooperative
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Code Name
BPD
BTD
CRC06
1321
Beneficiary is Partially Dependent
Beneficiary is Totally Dependent
Condition Indicator
O
ID
2/3
Situational
Description: Code indicating a condition
Situational Rule: Required when multiple conditions apply to the certification. If not
required by this implementation guide, do not send.
IMPLEMENTATION NAME: Condition Code
Use codes listed in CRC03.
CodeList Summary (Total Codes: 1316, Included: 30)
Code Name
01
05
07
13
20
22
23
26
33
34
5A
68
69
9E
9F
9J
9K
AG
CB
CM
DI
DP
FO
HO
LE
MC
OT
UN
BPD
BTD
CRC07
1321
Patient was admitted to a hospital
Patient was unconscious or in shock
Patient had to be physically restrained
Patient is Confined to a Room or an Area Without Bathroom Facilities
Siderails Are to be Attached to a Hospital Bed Owned by the Beneficiary
Mattress or Siderails are Being Used with Prescribed Medically Necessary Hospital
Bed Owned by the Beneficiary
Patient Needs Lift to Get In or Out of Bed or to Assist in Transfer from Bed to
Wheelchair
Patient is highly susceptible to decubitus ulcers
Patient is in a nursing home
Patient is conscious
Treatment is rendered related to the terminal illness
Severe
Moderate
Sudden Onset of Disorientation
Sudden Onset of Severe, Incapacitating Pain
Patient Requires Protective Isolation
Patient Requires Frequent Monitoring
Agitated
Complete Bedrest
Comatose
Disoriented
Depressed
Forgetful
Hostile
Lethargic
Other Mental Condition
Oriented
Uncooperative
Beneficiary is Partially Dependent
Beneficiary is Totally Dependent
Condition Indicator
O
ID
2/3
Situational
Description: Code indicating a condition
Situational Rule: Required when multiple conditions apply to the certification. If not
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Id
Element Name
Req
Type
required by this implementation guide, do not send.
Min/Max
Usage
IMPLEMENTATION NAME: Condition Code
Use codes listed in CRC03.
CodeList Summary (Total Codes: 1316, Included: 30)
Code Name
01
05
07
13
20
22
23
26
33
34
5A
68
69
9E
9F
9J
9K
AG
CB
CM
DI
DP
FO
HO
LE
MC
OT
UN
BPD
BTD
Patient was admitted to a hospital
Patient was unconscious or in shock
Patient had to be physically restrained
Patient is Confined to a Room or an Area Without Bathroom Facilities
Siderails Are to be Attached to a Hospital Bed Owned by the Beneficiary
Mattress or Siderails are Being Used with Prescribed Medically Necessary Hospital
Bed Owned by the Beneficiary
Patient Needs Lift to Get In or Out of Bed or to Assist in Transfer from Bed to
Wheelchair
Patient is highly susceptible to decubitus ulcers
Patient is in a nursing home
Patient is conscious
Treatment is rendered related to the terminal illness
Severe
Moderate
Sudden Onset of Disorientation
Sudden Onset of Severe, Incapacitating Pain
Patient Requires Protective Isolation
Patient Requires Frequent Monitoring
Agitated
Complete Bedrest
Comatose
Disoriented
Depressed
Forgetful
Hostile
Lethargic
Other Mental Condition
Oriented
Uncooperative
Beneficiary is Partially Dependent
Beneficiary is Totally Dependent
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.
Situational Rule:
Required when the patient mental status is relevant to the health care services review. If not required by this
implementation guide, do not send.
TR3 Example:
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CRC*77*Y*07~
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Pos: 1100
CL1 Institutional Claim Code
Max: 1
Detail - Optional
Loop:
2000E
Elements: 4
User Option (Usage): Situational
Purpose: To supply information specific to hospital claims
Element Summary:
Ref
Id
Element Name
CL101
1315
Admission Type Code
Req
Type
Min/Max
Usage
O
ID
1/1
Situational
Description: Code indicating the priority of this admission
Situational Rule: Required when requesting admission to a hospital for inpatient services.
If not required by this implementation guide, do not send.
CODE SOURCE: 231: Admission Type Code
ExternalCodeList
Name: 231
Description: Admission Type Code
CL102
1314
Admission Source Code
O
ID
1/1
Situational
Description: Code indicating the source of this admission
Situational Rule: Required when certification requires information on the admission
source that is not provided in the Requester Loop 2000B. If not required by this
implementation guide, do not send.
CODE SOURCE: 230: Admission Source Code
ExternalCodeList
Name: 230
Description: Admission Source Code
CL103
1352
Patient Status Code
O
ID
1/2
Situational
Description: Code indicating patient status as of the "statement covers through date"
Situational Rule: Required when health care services review is for inpatient services. If
not required by this implementation guide, do not send.
CODE SOURCE: 239: Patient Status Code
ExternalCodeList
Name: 239
Description: Patient Status Code
CL104
1345
Nursing Home Residential Status Code
O
ID
1/1
Situational
Description: Code specifying the status of a nursing home resident at the time of service
Situational Rule: Required when certification involves a nursing home resident. If not
required by this implementation guide, do not send.
CodeList Summary (Total Codes: 9, Included: 9)
Code Name
1
2
Transferred to Intermediate Care Facility - Mentally Retarded (ICF-MR)
Newly Admitted
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Code
3
4
5
6
7
8
9
Name
Newly Eligible
No Longer Eligible
Still a Resident
Temporary Absence - Hospital
Temporary Absence - Other
Transferred to Intermediate Care Facility - Level II (ICF II)
Other
Situational Rule:
Required when requesting certification for admission (UM01 = AR) to a facility. If not required by this
implementation guide, do not send.
TR3 Example:
CL1*3**1~
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Pos: 1200
CR1 Ambulance Transport
Max: 1
Detail - Optional
Information
Loop:
2000E
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
X
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
Situational Rule: Required when CR102 is present. If not required by this implementation
guide, do not send.
CodeList Summary (Total Codes: 844, Included: 2)
Code Name
KG
LB
CR102
81
Kilogram
Pound
Weight
X
R
1/10
Situational
Description: Numeric value of weight
Situational Rule: Required when patient weight information is needed to justify the
medical necessity of the level of ambulance services. If not required by this implementation
guide, do not send.
IMPLEMENTATION NAME: Patient Weight
CR103
1316
Ambulance Transport Code
O
ID
1/1
Required
1/1
Situational
Description: Code indicating the type of ambulance transport
CodeList Summary (Total Codes: 4, Included: 4)
Code Name
I
R
T
X
CR104
1317
Initial Trip
Return Trip
Transfer Trip
Round Trip
Ambulance Transport Reason Code
O
ID
Description: Code indicating the reason for ambulance transport
Situational Rule: Required when ambulance transport reason is required to determine
medical necessity. If not required by this implementation guide, do not send.
CodeList Summary (Total Codes: 6, Included: 6)
Code Name
A
B
C
D
Patient was transported to nearest facility for care of symptoms, complaints, or both
Patient was transported for the benefit of a preferred physician
Patient was transported for the nearness of family members
Patient was transported for the care of a specialist or for availability of specialized
equipment
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Code Name
E
Patient Transferred to Rehabilitation Facility
F
Patient Transferred to Residential Facility
CR105
355
Unit or Basis for Measurement Code
X
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
Situational Rule: Required when distance of transportation is known. If not required by
this implementation guide, do not send.
CodeList Summary (Total Codes: 844, Included: 2)
Code Name
DH
DK
CR106
380
Miles
Kilometers
Quantity
X
R
1/15
Situational
Description: Numeric value of quantity
Situational Rule: Required when distance of transportation is known. If not required by
this implementation guide, do not send.
IMPLEMENTATION NAME: Transport Distance
CR109
352
Description
O
AN
1/80
Situational
Description: A free-form description to clarify the related data elements and their content
Situational Rule: Required when CR103 (Ambulance Transport Code) = “X Round Trip”. If
not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Round Trip Purpose Description
CR110
352
Description
O
AN
1/80
Situational
Description: A free-form description to clarify the related data elements and their content
Situational Rule: Required when a stretcher is requested for transportation. If not required
by this implementation guide, do not send.
IMPLEMENTATION NAME: Stretcher Purpose Description
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.
Situational Rule:
Required when health care services review is for non-emergency transportation services. If not required by this
implementation guide, do not send.
TR3 Notes:
1. When the CR1 segment is used, then Loop 2010EB is required.
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TR3 Example:
CR1*LB*155*T*A~
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CR2 Spinal Manipulation Service
Information
Pos: 1300
Max: 1
Detail - Optional
Loop:
2000E
Elements: 9
User Option (Usage): Situational
Purpose: To supply information related to the chiropractic service rendered to a patient
Element Summary:
Ref
Id
Element Name
CR201
609
Count
Req
Type
Min/Max
Usage
X
N0
1/9
Situational
Description: Occurrence counter
Situational Rule: Required when requesting certification for a specific treatment number in
a series of treatments. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Treatment Series Number
CR202
380
Quantity
X
R
1/15
Situational
Description: Numeric value of quantity
Situational Rule: Required when requesting certification for a specific treatment number in
a series of treatments. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Treatment Count
CR203
1367
Subluxation Level Code
X
ID
2/3
Situational
Description: Code identifying the specific level of subluxation
Situational Rule: Required when the patient’s condition or treatment involves subluxation.
If not required by this implementation guide, do not send.
CodeList Summary (Total Codes: 28, Included: 28)
Code Name
C1
C2
C3
C4
C5
C6
C7
CO
IL
L1
L2
L3
L4
L5
OC
SA
T1
T2
T3
T4
Cervical 1
Cervical 2
Cervical 3
Cervical 4
Cervical 5
Cervical 6
Cervical 7
Coccyx
Ilium
Lumbar 1
Lumbar 2
Lumbar 3
Lumbar 4
Lumbar 5
Occiput
Sacrum
Thoracic 1
Thoracic 2
Thoracic 3
Thoracic 4
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Code Name
T5
T6
T7
T8
T9
T10
T11
T12
CR204
1367
Thoracic
Thoracic
Thoracic
Thoracic
Thoracic
Thoracic
Thoracic
Thoracic
5
6
7
8
9
10
11
12
Subluxation Level Code
O
ID
2/3
Situational
Description: Code identifying the specific level of subluxation
Situational Rule: Required when the patient’s condition or treatment involves subluxation
to express the ending level of subluxation. If not required by this implementation guide, do
not send.
CodeList Summary (Total Codes: 28, Included: 28)
Code Name
C1
C2
C3
C4
C5
C6
C7
CO
IL
L1
L2
L3
L4
L5
OC
SA
T1
T2
T3
T4
T5
T6
T7
T8
T9
T10
T11
T12
CR208
1342
Cervical 1
Cervical 2
Cervical 3
Cervical 4
Cervical 5
Cervical 6
Cervical 7
Coccyx
Ilium
Lumbar 1
Lumbar 2
Lumbar 3
Lumbar 4
Lumbar 5
Occiput
Sacrum
Thoracic 1
Thoracic 2
Thoracic 3
Thoracic 4
Thoracic 5
Thoracic 6
Thoracic 7
Thoracic 8
Thoracic 9
Thoracic 10
Thoracic 11
Thoracic 12
Nature of Condition Code
O
ID
1/1
Required
Description: Code indicating the nature of a patient's condition
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Id
Element Name
Req
Type
IMPLEMENTATION NAME: Patient Condition Code
Min/Max
Usage
1/1
Required
1/80
Situational
CodeList Summary (Total Codes: 7, Included: 7)
Code Name
A
C
D
E
F
G
M
CR209
1073
Acute Condition
Chronic Condition
Non-acute
Non-Life Threatening
Routine
Symptomatic
Acute Manifestation of a Chronic Condition
Yes/No Condition or Response Code
O
ID
Description: Code indicating a Yes or No condition or response
IMPLEMENTATION NAME: Complication Indicator
CodeList Summary (Total Codes: 4, Included: 2)
Code Name
N
Y
CR210
352
No
Yes
Description
O
AN
Description: A free-form description to clarify the related data elements and their content
Situational Rule: Required when necessary to clarify patient condition. If not required by
this implementation guide, do not send.
IMPLEMENTATION NAME: Patient Condition Description
CR211
352
Description
O
AN
1/80
Situational
Description: A free-form description to clarify the related data elements and their content
Situational Rule: Required when necessary to clarify patient condition. If not required by
this implementation guide, do not send.
IMPLEMENTATION NAME: Patient Condition Description
CR212
1073
Yes/No Condition or Response Code
O
ID
1/1
Situational
Description: Code indicating a Yes or No condition or response
Situational Rule: Required when X-rays are available. If not required by this
implementation guide, do not send.
IMPLEMENTATION NAME: X-ray Availability Indicator
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.
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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.
Situational Rule:
Required when requesting certification for spinal manipulation services (UM01=HS) when the patient’s condition
or treatment involves subluxation. If not required by this implementation guide, do not send.
TR3 Example:
CR2*1*5******A*Y***Y~
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Pos: 1400
CR5 Home Oxygen Therapy
Max: 1
Detail - Optional
Information
Loop:
2000E
Elements: 16
User Option (Usage): Situational
Purpose: To supply information regarding certification of medical necessity for home oxygen therapy
Element Summary:
Ref
Id
Element Name
CR503
1348
Oxygen Equipment Type Code
Req
Type
Min/Max
Usage
O
ID
1/1
Required
Description: Code indicating the specific type of equipment being prescribed for the
delivery of oxygen
CodeList Summary (Total Codes: 6, Included: 6)
Code Name
A
B
C
D
E
O
CR504
1348
Concentrator
Liquid Stationary
Gaseous Stationary
Liquid Portable
Gaseous Portable
Other
Oxygen Equipment Type Code
O
ID
1/1
Situational
Description: Code indicating the specific type of equipment being prescribed for the
delivery of oxygen
Situational Rule: Required when CR503 is present and more than one type of equipment
is required to administer the oxygen therapy. If not required by this implementation guide,
do not send.
CodeList Summary (Total Codes: 6, Included: 6)
Code Name
A
B
C
D
E
O
CR505
352
Concentrator
Liquid Stationary
Gaseous Stationary
Liquid Portable
Gaseous Portable
Other
Description
O
AN
1/80
Situational
Description: A free-form description to clarify the related data elements and their content
Situational Rule: Required when needed to provide additional information that could
impact the medical decision. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Equipment Reason Description
CR506
380
Quantity
O
R
1/15
Required
R
1/15
Situational
Description: Numeric value of quantity
IMPLEMENTATION NAME: Oxygen Flow Rate
CR507
380
Quantity
O
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Id
Element Name
Req
Type
Min/Max
Usage
Description: Numeric value of quantity
Situational Rule: Required when daily oxygen use count is relevant to the type of home
oxygen therapy requested. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Daily Oxygen Use Count
CR508
380
Quantity
O
R
1/15
Situational
Description: Numeric value of quantity
Situational Rule: Required when daily oxygen use count is relevant to the type of home
oxygen therapy requested. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Oxygen Use Period Hour Count
CR509
352
Description
O
AN
1/80
Situational
Description: A free-form description to clarify the related data elements and their content
Situational Rule: Required when necessary to convey special orders for the respiratory
therapist. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Respiratory Therapist Order Text
CR510
380
Quantity
O
R
1/15
Situational
Description: Numeric value of quantity
Situational Rule: Required when arterial blood gas quantity is relevant to the type of home
oxygen therapy requested. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Arterial Blood Gas Quantity
Either CR510 or CR511 is required.
CR511
380
Quantity
O
R
1/15
Situational
Description: Numeric value of quantity
Situational Rule: Required when arterial blood gas quantity is relevant to the type of home
oxygen therapy requested. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Oxygen Saturation Quantity
Either CR510 or CR511 is required.
CR512
1349
Oxygen Test Condition Code
O
ID
1/1
Situational
Description: Code indicating the conditions under which a patient was tested
Situational Rule: Required when reporting oxygen test results. If not required by this
implementation guide, do not send.
CodeList Summary (Total Codes: 7, Included: 7)
Code Name
E
N
O
R
S
W
X
CR513
1350
Exercising
No special conditions for test
On oxygen
At rest on room air
Sleeping
Walking
Other
Oxygen Test Findings Code
O
ID
1/1
Situational
Description: Code indicating the findings of oxygen tests performed on a patient
Situational Rule: Required when patient’s arterial PO2 is greater than 55 mmHg and less
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Id
Element Name
Req
Type
Min/Max
Usage
than 60 mmHg, or oxygen saturation is greater than 88%. If not required by this
implementation guide, do not send.
CodeList Summary (Total Codes: 3, Included: 3)
Code Name
1
2
3
CR514
1350
Dependent edema suggesting congestive heart failure
"P" Pulmonale on Electrocardiogram (EKG)
Erythrocythemia with a hematocrit greater than 56 percent
Oxygen Test Findings Code
O
ID
1/1
Situational
Description: Code indicating the findings of oxygen tests performed on a patient
Situational Rule: Required when patient’s arterial PO2 is greater than 55 mmHg and less
than 60 mmHg, or oxygen saturation is greater than 88%, and more than one finding is
applicable. If not required by this implementation guide, do not send.
CodeList Summary (Total Codes: 3, Included: 3)
Code Name
1
2
3
CR515
1350
Dependent edema suggesting congestive heart failure
"P" Pulmonale on Electrocardiogram (EKG)
Erythrocythemia with a hematocrit greater than 56 percent
Oxygen Test Findings Code
O
ID
1/1
Situational
Description: Code indicating the findings of oxygen tests performed on a patient
Situational Rule: Required when patient’s arterial PO2 is greater than 55 mmHg and less
than 60 mmHg, or oxygen saturation is greater than 88%, and more than two findings are
applicable. If not required by this implementation guide, do not send.
CodeList Summary (Total Codes: 3, Included: 3)
Code Name
1
2
3
CR516
380
Dependent edema suggesting congestive heart failure
"P" Pulmonale on Electrocardiogram (EKG)
Erythrocythemia with a hematocrit greater than 56 percent
Quantity
O
R
1/15
Situational
Description: Numeric value of quantity
Situational Rule: Required when either CR503, CR504 or CR518 = “D” (Liquid Portable)
or “E” (Gaseous Portable). If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Portable Oxygen System Flow Rate
CR517
1382
Oxygen Delivery System Code
O
ID
1/1
Required
Description: Code to indicate if a particular form of delivery was prescribed
CodeList Summary (Total Codes: 5, Included: 5)
Code Name
A
B
C
D
E
CR518
1348
Nasal Cannula
Oxygen Conserving Device
Oxygen Conserving Device with Oxygen Pulse System
Oxygen Conserving Device with Reservoir System
Transtracheal Catheter
Oxygen Equipment Type Code
159
O
ID
1/1
Situational
For internal use only
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Id
Element Name
Req
Type
Min/Max
Usage
Description: Code indicating the specific type of equipment being prescribed for the
delivery of oxygen
Situational Rule: Required when CR503 and CR504 are present and more than two types
of equipment are required to administer the oxygen therapy. If not required by this
implementation guide, do not send.
CodeList Summary (Total Codes: 6, Included: 6)
Code Name
A
B
C
D
E
O
Concentrator
Liquid Stationary
Gaseous Stationary
Liquid Portable
Gaseous Portable
Other
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.
Situational Rule:
Required when requesting initial, extended, or revised certification of home oxygen therapy. If not required by this
implementation guide, do not send.
TR3 Notes:
1. Use the UM segment data element UM02 instead of CR501 to specify the Certification Type Code.
2. Use the HSD segment instead of CR502 to specify the treatment period.
TR3 Example:
CR5***D***1*****87*N*****A~
160
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Pos: 1500
CR6 Home Health Care
Max: 1
Detail - Optional
Information
Loop:
2000E
Elements: 15
User Option (Usage): Situational
Purpose: To supply information related to the certification of a home health care patient
Element Summary:
Ref
Id
Element Name
CR601
923
Prognosis Code
Req
Type
Min/Max
Usage
M
ID
1/1
Required
Description: Code indicating physician's prognosis for the patient
CodeList Summary (Total Codes: 8, Included: 8)
Code Name
1
2
3
4
5
6
7
8
CR602
373
Poor
Guarded
Fair
Good
Very Good
Excellent
Less than 6 Months to Live
Terminal
Date
M
DT
8/8
Required
Description: Date expressed as CCYYMMDD where CC represents the first two digits of
the calendar year
IMPLEMENTATION NAME: Home Health Start Date
CR603
1250
Date Time Period Format Qualifier
X
ID
2/3
Situational
Description: Code indicating the date format, time format, or date and time format
Situational Rule: Required when the event date has not been identified in DTP, Event
Date in this loop and the duration of this plan of treatment is known. If not required by this
implementation guide, do not send.
CodeList Summary (Total Codes: 42, Included: 1)
Code Name
RD8
CR604
1251
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
Date Time Period
X
AN
1/35
Situational
Description: Expression of a date, a time, or range of dates, times or dates and times
Situational Rule: Required when the event date has not been identified in DTP, Event
Date in this loop and the duration of this plan of treatment is known. If not required by this
implementation guide, do not send.
IMPLEMENTATION NAME: Home Health Certification Period
CR607
1073
Yes/No Condition or Response Code
M
ID
1/1
Required
Description: Code indicating a Yes or No condition or response
IMPLEMENTATION NAME: Medicare Coverage Indicator
CodeList Summary (Total Codes: 4, Included: 1)
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Code Name
W
CR608
1322
Not Applicable
Certification Type Code
M
ID
1/1
Required
Description: Code indicating the type of certification
This element must have the same value as UM02.
CodeList Summary (Total Codes: 15, Included: 8)
Code Name
CR609
373
1
Appeal - Immediate
Use this value only for appeals of review decisions where the level of service
required is emergency or urgent.
2
Appeal - Standard
Use this value for appeals of review decisions where the level of service required
is not emergency or urgent.
3
4
Cancel
Extension
Indicates that this is an extension request to a prior approved service.
6
Verification
This code is used to request the UMO to reconsider a previously denied referral or
certification request.
I
R
Initial
Renewal
Indicates that this is a request to renew a prior approved service.
S
Revised
Use if the requester is revising the specifics of a certification for which services
have not been rendered.
Date
X
DT
8/8
Situational
Description: Date expressed as CCYYMMDD where CC represents the first two digits of
the calendar year
Situational Rule: Required when home health care is related to a specific surgical
procedure, the surgery date is known, and the surgical procedure code is known. If not
required by this implementation guide, do not send.
IMPLEMENTATION NAME: Surgery Date
CR610
235
Product/Service ID Qualifier
X
ID
2/2
Situational
Description: Code identifying the type/source of the descriptive number used in
Product/Service ID (234)
Situational Rule: Required when home health care is related to a specific surgical
procedure, the surgery date is known, and the surgical procedure code is known. If not
required by this implementation guide, do not send.
IMPLEMENTATION NAME: Product or Service ID Qualifier
CodeList Summary (Total Codes: 519, Included: 2)
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:
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Code Name
130: Health Care Financing Administration Common Procedural Coding System
ID
International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM) - Procedure
CODE SOURCE:
131: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
CR611
1137
Medical Code Value
X
AN
1/15
Situational
Description: Code value for describing a medical condition or procedure
Situational Rule: Required when home health care is related to a specific surgical
procedure, the surgery date is known, and the surgical procedure code is known. If not
required by this implementation guide, do not send.
IMPLEMENTATION NAME: Surgical Procedure Code
ExternalCodeList
Name: 130
Description: Health Care Financing Administration Common Procedural Coding System
ExternalCodeList
Name: 131P
Description: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
CR612
373
Date
O
DT
8/8
Situational
Description: Date expressed as CCYYMMDD where CC represents the first two digits of
the calendar year
Situational Rule: Required when the requester received verbal orders from the physician
for the start of home health care and the date when the order was received is known. If not
required by this implementation guide, do not send.
IMPLEMENTATION NAME: Physician Order Date
CR613
373
Date
O
DT
8/8
Situational
Description: Date expressed as CCYYMMDD where CC represents the first two digits of
the calendar year
Situational Rule: Required when the date the patient was last seen by the physician is
known. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Last Visit Date
CR614
373
Date
O
DT
8/8
Situational
Description: Date expressed as CCYYMMDD where CC represents the first two digits of
the calendar year
Situational Rule: Required when the physician has been contacted by the home health
service provider. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Physician Contact Date
CR615
1250
Date Time Period Format Qualifier
X
ID
2/3
Situational
Description: Code indicating the date format, time format, or date and time format
Situational Rule: Required when home health care is associated with a recent inpatient
stay, the admission stay date is known, and the facility type is known. If not required by this
implementation guide, do not send.
CodeList Summary (Total Codes: 42, Included: 1)
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Code Name
RD8
CR616
1251
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
Date Time Period
X
AN
1/35
Situational
Description: Expression of a date, a time, or range of dates, times or dates and times
Situational Rule: Required when home health care is associated with a recent inpatient
stay, the admission stay date is known, and the facility type is known. If not required by this
implementation guide, do not send.
IMPLEMENTATION NAME: Last Admission Period
CR617
1384
Patient Location Code
X
ID
1/1
Situational
Description: Code identifying the location where patient is receiving medical treatment
Situational Rule: Required when home health care is associated with a recent inpatient
stay, the admission stay date is known, and the facility type is known. If not required by this
implementation guide, do not send.
CodeList Summary (Total Codes: 15, Included: 15)
Code Name
A
B
C
D
E
F
G
H
L
M
O
P
R
S
T
Acute Care Facility
Boarding Home
Hospice
Intermediate Care Facility
Long-term or Extended Care Facility
Not Specified
Nursing Home
Sub-acute Care Facility
Other Location
Rehabilitation Facility
Outpatient Facility
Private Home
Residential Treatment Facility
Skilled Nursing Home
Rest Home
Syntax Rules:
1. P0304 - If either CR603 or CR604 is present, then the other is required.
2. P091011 - If either CR609, CR610 or CR611 are present, then the others are required.
3. P151617 - If either CR615, CR616 or CR617 are present, then the others are required.
Semantics:
1.
2.
3.
4.
CR602 is the date covered home health services began.
CR604 is the certification period covered by this plan of treatment.
CR605 is the date of onset or exacerbation of the principal diagnosis.
A "Y" value indicates patient is receiving care in a 1861J1 (skilled nursing) facility. An "N" value indicates
patient is not receiving care in a 1861J1 facility. A "U" value indicates it is unknown whether or not the patient
is receiving care in a 1861J1 facility.
5. CR607 indicates if the patient is covered by Medicare. A "Y" value indicates the patient is covered by
Medicare; an "N" value indicates patient is not covered by Medicare.
6. CR609 is the date that the surgery identified in CR611 was performed.
7. CR610 qualifies CR611.
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8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
Health Care Services Review Information - Request - 278
CR611 is the surgical procedure most relevant to the care being rendered.
CR612 is the date the agency received the verbal orders from the physician for start of care.
CR613 is the date that the patient was last seen by the physician.
CR614 is the date of the home health agency's most recent contact with the physician.
CR616 is the date range of the most recent inpatient stay.
CR617 indicates the type of facility from which the patient was most recently discharged.
CR618 is the date of onset or exacerbation of the first secondary diagnosis.
CR619 is the date of onset or exacerbation of the second secondary diagnosis.
CR620 is the date of onset or exacerbation of the third secondary diagnosis.
CR621 is the date of onset or exacerbation of the fourth secondary diagnosis.
Situational Rule:
Required when requesting for certification of home health care, private duty nursing, or services by a nurses’
agency. If not required by this implementation guide, do not send.
TR3 Notes:
1. Requests for home health care must include a principal diagnosis (HI01=BK) and principal diagnosis date in
the HI segment in Loop 2000E, Patient Event.
TR3 Example:
CR6*7*20050429*****N*I~
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Pos: 1550
PWK Additional Patient
Max: 10
Detail - Optional
Information
Loop:
2000E
Elements: 5
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
IMPLEMENTATION NAME: Attachment Report Type Code
CodeList Summary (Total Codes: 541, Included: 66)
Code Name
03
04
05
06
07
Report Justifying Treatment Beyond Utilization Guidelines
Drugs Administered
Treatment Diagnosis
Initial Assessment
Functional Goals
Expected outcomes of rehabilitative services.
08
09
10
11
13
15
21
48
55
Plan of Treatment
Progress Report
Continued Treatment
Chemical Analysis
Certified Test Report
Justification for Admission
Recovery Plan
Social Security Benefit Letter
Rental Agreement
Use for medical or dental equipment rental.
59
77
A3
A4
AM
Benefit Letter
Support Data for Verification
Allergies/Sensitivities Document
Autopsy Report
Ambulance Certification
Information to support necessity of ambulance trip.
AS
Admission Summary
A brief patient summary; it lists the patient’s chief complaints and the reasons for
admitting the patient to the hospital.
AT
Purchase Order Attachment
Use for purchase of medical or dental equipment.
B2
B3
BR
BS
BT
Prescription
Physician Order
Benchmark Testing Results
Baseline
Blanket Test Results
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Code Name
PWK02
756
CB
Chiropractic Justification
Lists the reasons chiropractic is just and appropriate treatment.
CK
D2
DA
DB
DG
DJ
DS
FM
HC
HR
I5
IR
LA
M1
NN
OB
OC
OD
OE
OX
P4
P5
P6
Consent Form(s)
Drug Profile Document
Dental Models
Durable Medical Equipment Prescription
Diagnostic Report
Discharge Monitoring Report
Discharge Summary
Family Medical History Document
Health Certificate
Health Clinic Records
Immunization Record
State School Immunization Records
Laboratory Results
Medical Record Attachment
Nursing Notes
Operative Note
Oxygen Content Averaging Report
Orders and Treatments Document
Objective Physical Examination (including vital signs) Document
Oxygen Therapy Certification
Pathology Report
Patient Medical History Document
Periodontal Charts
Required when using the PWK segment to provide missing teeth information.
P7
PE
PN
PO
PQ
PY
PZ
QC
QR
RB
RR
RT
RX
SG
V5
XP
Periodontal Reports
Parenteral or Enteral Certification
Physical Therapy Notes
Prosthetics or Orthotic Certification
Paramedical Results
Physician's Report
Physical Therapy Certification
Cause and Corrective Action Report
Quality Report
Radiology Films
Radiology Reports
Report of Tests and Analysis Report
Renewable Oxygen Content Averaging Report
Symptoms Document
Death Notification
Photographs
Report Transmission Code
O
ID
1/2
Required
Description: Code defining timing, transmission method or format by which reports are to
be sent
CodeList Summary (Total Codes: 55, Included: 6)
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Code Name
PWK05
66
AA
Available on Request at Provider Site
Required when using the PWK segment to provide missing teeth information.
This means that the paperwork is not being sent with the request at this time.
Instead, it is available to the UMO (or appropriate entity) on request.
BM
EL
By Mail
Electronically Only
Use to indicate that the attachment is being transmitted in a separate X12
functional group.
EM
FX
VO
E-Mail
By Fax
Voice
Use this for voicemail or phone communication.
Identification Code Qualifier
X
ID
1/2
Situational
Description: Code designating the system/method of code structure used for Identification
Code (67)
Situational Rule: Required when PWK02 equals BM, EL, EM or FX. If not required by this
implementation guide, may be provided at the sender’s discretion but cannot be required
by the receiver.
CodeList Summary (Total Codes: 241, Included: 1)
Code Name
AC
PWK06
67
Attachment Control Number
Identification Code
X
AN
2/80
Situational
Description: Code identifying a party or other code
Situational Rule: Required when PWK02 equals BM, EL, EM or FX. If not required by this
implementation guide, may be provided at the sender’s discretion but cannot be required
by the receiver.
IMPLEMENTATION NAME: Attachment Control Number
The requester can use it when PWK02 equals “AA” if the requester wants to send a
document control number for an attachment remaining at the Provider’s office.
PWK07
352
Description
O
AN
1/80
Situational
Description: A free-form description to clarify the related data elements and their content
Situational Rule: Required when needed to report tooth number(s) of missing teeth or if
needed to add any additional information about the attachment described in this segment.
If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Attachment Description
To report tooth number(s) for missing teeth, use a variable length format. Allocate two (2)
bytes for each missing tooth. When reporting tooth numbers 1 through 9, zero fill the first
byte so the field will be 01, 02, etc. When reporting primary dentition (A through P), pad the
second byte with a space.
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.
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3. PWK08 may be used to indicate action pertaining to a report.
Situational Rule:
Required when needed to report missing teeth on requests for dental services, or if the requester has additional
documentation (electronic, paper, or other medium) associated with this health care services review that applies
to the patient event and/or all the services requested and the 278 request (ST-SE) does not support this
information in its segments and data elements. If not required by this implementation guide, do not send.
TR3 Notes:
1. This PWK segment is required to identify attachments that are sent electronically (PWK02 = EL) but are
transmitted in another X12 functional group rather than by paper or other medium. PWK06 is used to identify the
attached electronic documentation. The number in PWK06 would be referenced in the electronic attachment.
2. The requester can also use this PWK segment to identify paperwork that is held at the provider’s office and is
available upon request by the UMO (or appropriate entity). Use code AA in PWK02 to convey this specific use of
the PWK segment. See code note under PWK02, code AA.
Refer to Section 2.5 for more information on using this PWK segment.
TR3 Example:
PWK*OB*BM***AC*DMN0012~
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Pos: 1600
MSG Message Text
Max: 1
Detail - Optional
Loop:
2000E
Elements: 1
User Option (Usage): Situational
Purpose: To provide a free-form format that allows the transmission of text information
Element Summary:
Ref
Id
Element Name
MSG01
933
Free-form Message Text
Req
Type
Min/Max
Usage
M
AN
1/264
Required
Description: Free-form message text
IMPLEMENTATION NAME: Free Form Message Text
Syntax Rules:
1. C0302 - If MSG03 is present, then MSG02 is required.
Semantics:
1. MSG03 is the number of lines to advance before printing.
Comments:
1. MSG02 is not related to the specific characteristics of a printer, but identifies top of page, advance a line, etc.
2. If MSG02 is "AA - Advance the specified number of lines before print" then MSG03 is required.
Situational Rule:
Required when needed to transmit a text message to the UMO about the patient event. If not required by this
implementation guide, do not send.
TR3 Notes:
1. Do not use the MSG segment to relay information that you can send using codified information in existing data
elements. If you need to use the MSG segment, you should approach X12N with data maintenance to solve the
business need without the use of the MSG segment.
TR3 Example:
MSG*This is a free-form text message~
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Loop Patient Event Provider Name
Pos: 1700
Repeat: 14
Optional
Loop:
2010EA
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
1700
1800
NM1
REF
2000
2100
N3
N4
2200
2400
PER
PRV
Patient Event Provider Name
Patient Event Provider Supplemental
Information
Patient Event Provider Address
Patient Event Provider City, State, Zip
Code
Patient Event Provider Contact Information
Patient Event Provider Information
171
Req
Max Use
Repeat
Usage
O
O
1
7
Situational
Situational
O
O
1
1
Situational
Situational
O
O
1
1
Situational
Situational
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NM1 Patient Event Provider Name
Pos: 1700
Max: 1
Detail - Optional
Loop:
2010EA
Elements: 9
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: 1500, Included: 14)
Code Name
NM102
1065
71
72
73
77
DD
DK
DN
Attending Physician
Operating Physician
Other Physician
Service Location
Assistant Surgeon
Ordering Physician
Referring Provider
Do not use if the entity identified in 2010B is the referring provider.
FA
G3
P3
QB
QV
SJ
AAJ
Facility
Clinic
Primary Care Provider
Purchase Service Provider
Group Practice
Service Provider
Admitting Services
Entity Type Qualifier
M
ID
1/1
Required
AN
1/60
Situational
Description: Code qualifying the type of entity
CodeList Summary (Total Codes: 16, Included: 2)
Code Name
1
2
NM103
1035
Person
Non-Person Entity
Name Last or Organization Name
X
Description: Individual last name or organizational name
Situational Rule: Required when identifying a specialty person, facility, group practice, or
clinic and NM108/NM109 are not present. If not required by this implementation guide, may
be provided at the sender’s discretion but cannot be required by the receiver.
IMPLEMENTATION NAME: Patient Event Provider Last or Organization Name
NM104
1036
Name First
O
AN
1/35
Situational
Description: Individual first name
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Id
Element Name
Req
Type
Min/Max
Usage
Situational Rule: Required when the service provider is a specific person (NM102 = 1)
and NM103 is present. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Patient Event Provider First Name
NM105
1037
Name Middle
O
AN
1/25
Situational
Description: Individual middle name or initial
Situational Rule: Required when NM104 is present and the middle name/initial of the
person is known. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Patient Event Provider Middle Name
NM106
1038
Name Prefix
O
AN
1/10
Situational
Description: Prefix to individual name
Situational Rule: Required when military title or rank further identifies the provider. If not
required by this implementation, may be provided at the sender’s discretion, but cannot be
required by the receiver.
IMPLEMENTATION NAME: Patient Event Provider Name Prefix
NM107
1039
Name Suffix
O
AN
1/10
Situational
Description: Suffix to individual name
Situational Rule: Required when NM104 is present and the suffix of the individual’s name
is known; e.g. Sr., Jr., or III. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Patient Event Provider Name Suffix
NM108
66
Identification Code Qualifier
X
ID
1/2
Situational
Description: Code designating the system/method of code structure used for Identification
Code (67)
Situational Rule: Required when requesting the services of a specific person, facility,
group practice, or clinic and the provider ID is known by the requester. If not required by
this implementation guide, do not send.
CodeList Summary (Total Codes: 241, Included: 4)
Code Name
24
34
46
XX
Employer's Identification Number
Social Security Number
Electronic Transmitter Identification Number (ETIN)
Centers for Medicare and Medicaid Services National Provider Identifier
Required for providers on or after the mandated
HIPAA National Provider Identifier (NPI) implementation date when the provider
has an NPI and it is available to the submitter.
OR
Required for providers before the mandated HIPAA NPI implementation date when
the provider has an NPI and the submitter has the capability to send it. If not
required by this implementation guide, do not send.
CODE SOURCE:
537: Centers for Medicare and Medicaid Services National Provider Identifier
NM109
67
Identification Code
X
AN
2/80
Situational
Description: Code identifying a party or other code
Situational Rule: Required when requesting the services of a specific person, facility,
group practice, or clinic and the provider ID is known by the requester. If not required by
this implementation guide, do not send.
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Id
Element Name
Req
Type
Min/Max
Usage
IMPLEMENTATION NAME: Patient Event Provider Identifier
ExternalCodeList
Name: 537
Description: Centers for Medicare and Medicaid Services 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.
3. C1203 - If NM112 is present, then NM103 is required.
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
2. NM112 can identify a second surname.
Situational Rule:
Required when loop 2000E UM01 = AR (Admission Review) or when loop 2000F is not valued or when loop
2000F is valued and at least one occurrence of loop 2000F does not contain a 2010F loop. If not required by this
implementation guide, do not send.
TR3 Notes:
1. If Loop 2000F is not valued, this segment conveys the name and identification number of the service provider
(person, group, or facility) specialist, or specialty entity to provide services to the patient for this patient event.
2. If Loop 2000F is valued, the providers identified in this Loop 2010EA apply to all the services identified in Loop
2000F unless Loop 2010F is valued. Providers identified in Loop 2010F override the providers identified in Loop
2010EA for that service only.
TR3 Example:
NM1*SJ*1*WATSON*SUSAN****34*987654321~
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Pos: 1800
REF Patient Event Provider
Max: 7
Detail - Optional
Supplemental Information
Loop:
2010EA
Elements: 3
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: 1731, Included: 8)
Code Name
REF02
127
0B
1G
1J
EI
State License Number
Provider UPIN Number
Facility ID Number
Employer's Identification Number
Not used if NM108 = 24.
N5
N7
SY
Provider Plan Network Identification Number
Facility Network Identification Number
Social Security Number
The social security number may not be used for Medicare. Not used if NM108 =
34.
ZH
Carrier Assigned Reference Number
Use when the requestor has not been assigned an NPI, or NPI is not mandated
for use and the UMO identified in loop 2010A has assigned its own identifier for
this provider.
Reference Identification
X
AN
1/50
Required
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
IMPLEMENTATION NAME: Patient Event Provider Supplemental Identifier
REF03
352
Description
X
AN
1/80
Situational
Description: A free-form description to clarify the related data elements and their content
Situational Rule: Required when REF01 = 0B to report the two character state ID of the
state assigning the State License Number. If not required by this implementation guide, do
not send.
IMPLEMENTATION NAME: License Number State Code
ExternalCodeList
Name: 22C
Description: States and Provinces
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
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1. REF04 contains data relating to the value cited in REF02.
Situational Rule:
Required on or after the mandated implementation date for the HIPAA National Provider Identifier (NPI) when the
provider is not a specialty entity and the NPI is not reported in NM109 of this loop and another identifier is
available to the submitter.
OR
Required prior to the mandated NPI implementation date when an additional identification number to the NPI
provided in NM109 of this loop is necessary for the UMO to identify the patient event provider.
OR
Required prior to the mandated NPI implementation date when necessary for the UMO to identify the patient
event provider. If not required by this implementation guide, do not send.
TR3 Notes:
1. Use the NM1 Segment for the primary identifier.
TR3 Example:
REF*1G*12345~
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Pos: 2000
N3 Patient Event Provider
Max: 1
Detail - Optional
Address
Loop:
2010EA
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
Description: Address information
IMPLEMENTATION NAME: Patient Event Provider Address Line
Use this element for the first line of the provider’s address.
N302
166
Address Information
O
AN
1/55
Situational
Description: Address information
Situational Rule: Required when a second address line exists. If not required by this
implementation guide, do not send.
IMPLEMENTATION NAME: Patient Event Provider Address Line
Situational Rule:
Required when the provider has multiple locations to identify the specific location for this patient event. If not
required by this implementation guide, do not send.
TR3 Example:
N3*77 HOLLY BLVD~
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Pos: 2100
N4 Patient Event Provider City,
Max: 1
Detail - Optional
State, Zip Code
Loop:
2010EA
Elements: 5
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
2/2
Situational
Description: Free-form text for city name
IMPLEMENTATION NAME: Patient Event Provider City Name
N402
156
State or Province Code
X
ID
Description: Code (Standard State/Province) as defined by appropriate government
agency
Situational Rule: Required when the address is in the United States of America, including
its territories, or Canada. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Patient Event Provider State Code
CODE SOURCE: 22: States and Provinces
ExternalCodeList
Name: 22C
Description: States and Provinces
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)
Situational Rule: Required when the address is in the United States of America, including
its territories, or Canada, or when a postal code exists for the country in N404. If not
required by this implementation guide, do not send.
IMPLEMENTATION NAME: Patient Event Provider Postal Zone or ZIP Code
CODE SOURCE: 51: ZIP Code
932: Universal Postal Codes
ExternalCodeList
Name: 932
Description:
ExternalCodeList
Name: 51
Description: ZIP Code
N404
26
Country Code
X
ID
2/3
Situational
Description: Code identifying the country
Situational Rule: Required when the address is outside the United States of America. If
not required by this implementation guide, do not send.
CODE SOURCE: 5: Countries, Currencies and Funds
Use the alpha-2 country codes from Part 1 of ISO 3166.
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Id
Element Name
Req
Type
Min/Max
Usage
ID
1/3
Situational
ExternalCodeList
Name: 5
Description: Countries, Currencies and Funds
N407
1715
Country Subdivision Code
X
Description: Code identifying the country subdivision
Situational Rule: Required when the address is not in the United States of America,
including its territories, or Canada, and the country in N404 has administrative subdivisions
such as but not limited to states, provinces, cantons, etc. If not required by this
implementation guide, do not send.
CODE SOURCE: 5: Countries, Currencies and Funds
Use the country subdivision codes from Part 2 of ISO 3166.
ExternalCodeList
Name: 5
Description: Countries, Currencies and Funds
Syntax Rules:
1. E0207 - Only one of N402 or N407 may be present.
2. C0605 - If N406 is present, then N405 is required.
3. C0704 - If N407 is present, then N404 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.
Situational Rule:
Required when the provider has multiple locations to identify the specific location for this patient event. If not
required by this implementation guide, do not send.
TR3 Example:
N4*KANSAS CITY*MO*64108~
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Pos: 2200
PER Patient Event Provider
Max: 1
Detail - Optional
Contact Information
Loop:
2010EA
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: 238, Included: 1)
Code Name
IC
PER02
93
Information Contact
Name
O
AN
1/60
Situational
Description: Free-form name
Situational Rule: Required when the requester needs to indicate a particular contact. If
not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Patient Event 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). If not required,
do not send.
PER03
365
Communication Number Qualifier
X
ID
2/2
Situational
Description: Code identifying the type of communication number
Situational Rule: Required when PER02 is not valued or when the provider needs to
transmit a contact communication number. If not required by this implementation guide, do
not send.
CodeList Summary (Total Codes: 42, Included: 4)
Code Name
EM
FX
TE
UR
PER04
364
Electronic Mail
Facsimile
Telephone
Uniform Resource Locator (URL)
Communication Number
X
AN
1/256
Situational
Description: Complete communications number including country or area code when
applicable
Situational Rule: Required when PER02 is not valued or when the provider needs to
transmit a contact communication number. If not required by this implementation guide, do
not send.
IMPLEMENTATION NAME: Patient Event Provider Contact Communications Number
PER05
365
Communication Number Qualifier
X
ID
2/2
Situational
Description: Code identifying the type of communication number
Situational Rule: Required when the telephone extension or multiple communication types
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Id
Element Name
Req
Type
Min/Max
are available. If not required by this implementation guide, do not send.
Usage
CodeList Summary (Total Codes: 42, Included: 5)
Code Name
PER06
364
EM
EX
Electronic Mail
Telephone Extension
When used, the value following this code is the extension for the preceding
communications contact number.
FX
TE
UR
Facsimile
Telephone
Uniform Resource Locator (URL)
Communication Number
X
AN
1/256
Situational
Description: Complete communications number including country or area code when
applicable
Situational Rule: Required when the telephone extension or multiple communication types
are available. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Patient Event Provider Contact Communications Number
PER07
365
Communication Number Qualifier
X
ID
2/2
Situational
Description: Code identifying the type of communication number
Situational Rule: Required when the telephone extension or multiple communication types
are available. If not required by this implementation guide, do not send.
CodeList Summary (Total Codes: 42, Included: 5)
Code Name
PER08
364
EM
EX
Electronic Mail
Telephone Extension
When used, the value following this code is the extension for the preceding
communications contact number.
FX
TE
UR
Facsimile
Telephone
Uniform Resource Locator (URL)
Communication Number
X
AN
1/256
Situational
Description: Complete communications number including country or area code when
applicable
Situational Rule: Required when the telephone extension or multiple communication types
are available. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Patient Event Provider Contact Communications Number
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.
Situational Rule:
Required when needed to identify a contact name and/or communications number for the provider. If not required
by this implementation guide, may be provided at the sender’s discretion but cannot be required by the receiver.
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TR3 Notes:
1. When the communication number represents a telephone number in the United States and other countries
using the North American Dialing Plan (for voice, data, fax, etc.), the communication number should always
include the area code and telephone 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.
TR3 Example:
PER*IC*M TUCKER*TE*8189993456*FX*8188769304~
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Pos: 2400
PRV Patient Event Provider
Max: 1
Detail - Optional
Information
Loop:
2010EA
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
1/50
Required
Description: Code identifying the type of provider
CodeList Summary (Total Codes: 26, Included: 9)
Code Name
PRV02
128
AD
Admitting
Use only when NM101 = AAJ.
AS
Assistant Surgeon
Use only when NM101 = DD.
AT
Attending
Use only when NM101 = 71.
OP
Operating
Use only when NM101 = 72.
OR
Ordering
Use only when NM101 = DK.
OT
Other Physician
Use only when NM101 = 73.
PC
Primary Care Physician
Use only when NM101 = P3.
PE
Performing
Use only when NM101 = SJ.
RF
Referring
Use only when NM101 = DN.
Reference Identification Qualifier
X
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1731, Included: 1)
Code Name
PXC
Health Care Provider Taxonomy Code
CODE SOURCE:
682: Health Care Provider Taxonomy
PRV03
127
Reference Identification
X
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
IMPLEMENTATION NAME: Provider Taxonomy Code
ExternalCodeList
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Name: 682
Description: Health Care Provider Taxonomy
Syntax Rules:
1. P0203 - If either PRV02 or PRV03 is present, then the other is required.
Situational Rule:
Required when request is for services of a specialist or specialty entity to indicate the provider’s specialty. If not
required by this implementation guide, may be provided a the sender’s discretion but cannot be required by the
receiver.
TR3 Example:
PRV*PE*PXC*203BS0133X~
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Pos: 1700
Loop Patient Event Transport
Information
Repeat: 5
Optional
Loop:
2010EB
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
1700
2000
2100
NM1
N3
N4
Patient Event Transport Information
Patient Event Transport Location Address
Patient Event Transport Location
City/State/ZIP Code
185
Req
Max Use
O
O
O
1
1
1
Repeat
Usage
Situational
Required
Required
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Pos: 1700
NM1 Patient Event Transport
Max: 1
Detail - Optional
Information
Loop:
2010EB
Elements: 3
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: 1500, Included: 5)
Code Name
45
FS
ND
PW
R3
NM102
1065
Drop-off Location
Final Scheduled Destination
Next Destination
Pickup Address
Next Scheduled Destination
Entity Type Qualifier
M
ID
1/1
Required
AN
1/60
Situational
Description: Code qualifying the type of entity
CodeList Summary (Total Codes: 16, Included: 1)
Code Name
2
NM103
1035
Non-Person Entity
Name Last or Organization Name
X
Description: Individual last name or organizational name
Situational Rule: Required when the name of the location for which the patient is being
transported is known. If not required by this implementation, do not send.
IMPLEMENTATION NAME: Patient Event Transport Location Name
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.
3. C1203 - If NM112 is present, then NM103 is required.
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
2. NM112 can identify a second surname.
Situational Rule:
Required when Health Care Service Review is requesting transport of the patient. If not required by this
implementation guide, do not send.
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TR3 Notes:
1. At least two iterations of this loop are necessary to indicate the pick up address, NM101 = PW, and the final
scheduled destination, NM101 = FS.
2. When the transport includes more than one destination, the following NM101 values are used to determine the
sequence of stops:
a. ND is used to indicate the first stop
b. R3 is used to indicate the second stop
c. 45 is used to indicate the third stop
TR3 Example:
NM1*PW*2*PATIENT DIALYSIS CENT~
NM1*FS*2~
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Pos: 2000
N3 Patient Event Transport
Max: 1
Detail - Optional
Location Address
Loop:
2010EB
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
IMPLEMENTATION NAME: Patient Event Transport Location Address Line
Use this element for the first line of the Transport Location address.
N302
166
Address Information
O
AN
1/55
Situational
Description: Address information
Situational Rule: Required when a second address line exists. If not required by this
implementation guide, do not send.
IMPLEMENTATION NAME: Patient Event Transport Location Address Line
TR3 Example:
N3*77 HOLLY BLVD~
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Pos: 2100
N4 Patient Event Transport
Max: 1
Detail - Optional
Location City/State/ZIP Code
Loop:
2010EB
Elements: 3
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
Situational
Description: Free-form text for city name
Situational Rule: Required when N403 is not valued. If not required by this implementation
guide, may be provided at the sender’s discretion but cannot be required by the receiver.
IMPLEMENTATION NAME: Patient Event Transport Location City Name
N402
156
State or Province Code
X
ID
2/2
Situational
Description: Code (Standard State/Province) as defined by appropriate government
agency
Situational Rule: Required when N403 is not valued. If not required by this implementation
guide, may be provided at the sender’s discretion but cannot be required by the receiver.
IMPLEMENTATION NAME: Patient Event Transport Location State or Province Code
CODE SOURCE: 22: States and Provinces
ExternalCodeList
Name: 22C
Description: States and Provinces
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)
Situational Rule: Required when N401 and N402 are not valued. If not required by this
implementation guide, may be provided at the sender’s discretion but cannot be required
by the receiver.
IMPLEMENTATION NAME: Patient Event Transport Location Postal Zone or ZIP Code
CODE SOURCE: 51: ZIP Code
932: Universal Postal Codes
ExternalCodeList
Name: 932
Description:
ExternalCodeList
Name: 51
Description: ZIP Code
Syntax Rules:
1. E0207 - Only one of N402 or N407 may be present.
2. C0605 - If N406 is present, then N405 is required.
3. C0704 - If N407 is present, then N404 is required.
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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.
TR3 Example:
N4*HOLLYWOOD*CA*90214~
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Pos: 1700
Loop Patient Event Other UMO
Name
Repeat: 3
Optional
Loop:
2010EC
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
1700
1800
2700
NM1
REF
DTP
Patient Event Other UMO Name
Other UMO Denial Reason
Other UMO Denial Date
191
Req
Max Use
O
O
O
1
1
1
Repeat
Usage
Situational
Required
Required
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Pos: 1700
NM1 Patient Event Other UMO
Max: 1
Detail - Optional
Name
Loop:
2010EC
Elements: 3
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: 1500, Included: 3)
Code Name
NM102
1065
00
Alternate Insurer
Use this code to indicate that the other UMO is
commercial insurance.
CA
Carrier
Use this code to indicate that the other UMO is
Medicare Part B.
GG
Intermediary
Use this code to indicate that the other UMO is
Medicare Part A.
Entity Type Qualifier
M
ID
1/1
Required
AN
1/60
Situational
Description: Code qualifying the type of entity
CodeList Summary (Total Codes: 16, Included: 1)
Code Name
2
NM103
1035
Non-Person Entity
Name Last or Organization Name
X
Description: Individual last name or organizational name
Situational Rule: Required when NM101 is equal to “00" to indicate the name name of the
other UMO. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Other UMO Name
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.
3. C1203 - If NM112 is present, then NM103 is required.
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
2. NM112 can identify a second surname.
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Situational Rule:
Required when Health Care Services Review has been denied by another UMO. If not required by this
implementation guide, do not send.
TR3 Notes:
1. At least two iterations of this loop are necessary to indicate the pick up address, NM101 = PW, and the final
scheduled destination, NM101 = FS.
2. When the transport includes more than one destination, the following NM101 values are used to determine the
sequence of stops:
a. ND is used to indicate the first stop
b. R3 is used to indicate the second stop
c. 45 is used to indicate the third stop
TR3 Example:
NM1*FS*2~
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REF Other UMO Denial Reason
Pos: 1800
Max: 1
Detail - Optional
Loop:
2010EC
Elements: 3
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
1/50
Situational
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1731, Included: 1)
Code Name
ZZ
REF02
127
Mutually Defined
Use ZZ to indicate Health Care Service Review
Decision Reason Code from Code Source 886.
Reference Identification
X
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
IMPLEMENTATION NAME: Other UMO Denial Reason
ExternalCodeList
Name: 886
Description: Health Care Decision Reason Code
REF04
C040
Reference Identifier
O
Comp
Situational
Description: To identify one or more reference numbers or identification numbers as
specified by the Reference Qualifier
Situational Rule: Required when the Health Care Services Review was denied by other
UMO for more than one reason. If not required by this implementation guide, do not send.
REF04-01
128
Reference Identification Qualifier
M
ID
2/3
Required
1/50
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1731, Included: 1)
Code Name
ZZ
REF04-02
127
Mutually Defined
Use ZZ to indicate Health Care Service Review
Decision Reason Code from Code Source 886.
Reference Identification
M
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
IMPLEMENTATION NAME: Other UMO Denial Reason
ExternalCodeList
Name: 886
Description: Health Care Decision Reason Code
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128
Reference Identification Qualifier
X
ID
2/3
Situational
Description: Code qualifying the Reference Identification
Situational Rule: Required when the other UMO denied the
request for more than two reasons. If not required by this implementation guide, do not
send.
CodeList Summary (Total Codes: 1731, Included: 1)
Code Name
ZZ
REF04-04
127
Mutually Defined
Use ZZ to indicate Health Care Service Review
Decision Reason Code from Code Source 886.
Reference Identification
X
AN
1/50
Situational
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Situational Rule: Required when the other UMO denied the
request for more than two reasons. If not required by this implementation guide, do not
send.
IMPLEMENTATION NAME: Other UMO Denial Reason
ExternalCodeList
Name: 886
Description: Health Care Decision Reason Code
REF04-05
128
Reference Identification Qualifier
X
ID
2/3
Situational
Description: Code qualifying the Reference Identification
Situational Rule: Required when the other UMO denied the
request for more than three reasons. If not required by this implementation guide, do not
send.
CodeList Summary (Total Codes: 1731, Included: 1)
Code Name
ZZ
REF04-06
127
Mutually Defined
Use ZZ to indicate Health Care Service Review
Decision Reason Code from Code Source 886.
Reference Identification
X
AN
1/50
Situational
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Situational Rule: Required when the other UMO denied the
request for more than three reasons. If not required by this implementation guide, do not
send.
ExternalCodeList
Name: 886
Description: Health Care Decision Reason Code
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
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Semantics:
1. REF04 contains data relating to the value cited in REF02.
TR3 Example:
REF*ZZ*0M~
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Pos: 2700
DTP Other UMO Denial Date
Max: 1
Detail - Optional
Loop:
2010EC
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
IMPLEMENTATION NAME: Date Time Qualifier
CodeList Summary (Total Codes: 1280, Included: 1)
Code Name
598
DTP02
1250
Rejected
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: 42, 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
IMPLEMENTATION NAME: Other UMO Denial Date
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
TR3 Example:
DTP*598*D8*20050516~
197
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Pos: 0100
Loop Service Level
Repeat: >1
Optional
Loop:
2000F
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
0100
0200
0400
0600
0600
HL
TRN
UM
REF
REF
0700
0810
0820
0830
0840
0900
1550
1600
1700
DTP
SV1
SV2
SV3
TOO
HSD
PWK
MSG
Service Level
Service Trace Number
Health Care Services Review Information
Previous Review Authorization Number
Previous Review Administrative Reference
Number
Service Date
Professional Service
Institutional Service Line
Dental Service
Tooth Information
Health Care Services Delivery
Additional Service Information
Message Text
Loop 2010F
198
Req
Max Use
Repeat
O
O
O
O
O
1
2
1
1
1
Situational
Situational
Situational
Situational
Situational
O
O
O
O
O
O
O
O
O
1
1
1
1
32
1
10
1
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
10
Usage
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Pos: 0100
HL Service Level
Max: 1
Detail - Optional
Loop:
2000F
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: 250, Included: 1)
Code Name
SS
HL04
736
Services
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.
Situational Rule:
Required when specific services are associated with this patient event. If not required by this implementation
guide, do not send.
TR3 Example:
199
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HL*6*5*SS*0~
200
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Pos: 0200
TRN Service Trace Number
Max: 2
Detail - Optional
Loop:
2000F
Elements: 4
User Option (Usage): Situational
Purpose: To uniquely identify a transaction to an application
Element Summary:
Ref
Id
Element Name
TRN01
481
Trace Type Code
Req
Type
Min/Max
Usage
M
ID
1/2
Required
Description: Code identifying which transaction is being referenced
CodeList Summary (Total Codes: 3, Included: 1)
Code Name
1
TRN02
127
Current Transaction Trace Numbers
Reference Identification
M
AN
1/50
Required
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
IMPLEMENTATION NAME: Service Trace Number
TRN03
509
Originating Company Identifier
O
AN
10/10
Required
Description: A unique identifier designating the company initiating the funds transfer
instructions, business transaction or assigning tracking reference identification.
IMPLEMENTATION NAME: Trace Assigning Entity Identifier
Use this element to identify the organization that assigned this trace number. TRN03 must
be completed to aid requesters and clearinghouses in identifying their TRN in the 278
response.
The first position must be either a “1" if an EIN is used, a ”3" if a DUNS is used or a “9" if a
user assigned identifier is used.
TRN04
127
Reference Identification
O
AN
1/50
Situational
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Situational Rule: Required when a specific division or group, of the company identified in
the previous data element (TRN03) is needed by the requester to further identify a specific
component of the entity. If not required by this implementation guide, may be provided at
the sender’s discretion but cannot be required by the receiver.
IMPLEMENTATION NAME: Trace Assigning Entity Additional Identifier
Semantics:
1. TRN02 provides unique identification for the transaction.
2. TRN03 identifies an organization.
3. TRN04 identifies a further subdivision within the organization.
Situational Rule:
Required when the requester needs to assign a unique trace number to the service line request. If not required by
this implementation guide, may be provided at the sender’s discretion but cannot be required by the receiver.
TR3 Notes:
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1. This enables the requester to
• uniquely identify this service line request
• trace the request
• match the response to the request
• reference this request in any associated attachments containing additional service information related to this
service line request.
2. If the transaction is routed through a clearinghouse, the clearinghouse may add their own TRN segment. If the
transaction passes through multiple clearinghouses, and the second clearinghouse needs to assign their own
TRN segment, they must replace the TRN from the first clearinghouse and retain it to be returned in the 278
response. If the second clearinghouse does not need to assign a TRN segment, they should pass all received
TRN segments.
3. Each trace number provided in the TRN segment at this level on the request must be returned by the UMO in
the TRN segment at the corresponding level of the response.
4. If the request contains more than one occurrence of Loop 2000F and the requester needs to uniquely identify
each service level request this TRN segment is required in each Service loop.
TR3 Example:
TRN*1*111099*9012345678*RADIOLOGY~
202
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UM Health Care Services Review
Information
Pos: 0400
Max: 1
Detail - Optional
Loop:
2000F
Elements: 4
User Option (Usage): Situational
Purpose: To specify health care services review information
Element Summary:
Ref
Id
Element Name
UM01
1525
Request Category Code
Req
Type
Min/Max
Usage
M
ID
1/2
Required
Description: Code indicating a type of request
CodeList Summary (Total Codes: 7, Included: 2)
Code Name
UM02
1322
HS
Health Services Review
Required if requesting a review of services related to an episode of care.
SC
Specialty Care Review
Required if requesting a referral to a specialty provider.
Certification Type Code
O
ID
1/1
Situational
Description: Code indicating the type of certification
Situational Rule: Required when different from the UM02 value at the Patient Event level
(Loop 2000E). If not required by this implementation guide, do not send.
CodeList Summary (Total Codes: 15, Included: 8)
Code Name
1
Appeal - Immediate
Use this value only for appeals of review decisions where the level of service
required is emergency or urgent.
2
Appeal - Standard
Use this value for appeals of review decisions where the level of service is not
emergency or urgent.
3
4
Cancel
Extension
A “UM02 = 4" indicates that this is an extension request to a prior approved
service.
I
N
R
Initial
Reconsideration
Renewal
Various services, such as physical therapy, spinal manipulation, and allergy
treatment, have both a delivery pattern and a time span of authorization. Many
UMOs place time limits - as in will not authorize anything for more than 30 days at
a time. For example, blanket authorization for allergy treatments as required for 30
days. At the end of the 30 days, the provider must request to renew the
certification - not extend it - because the UMO authorizes for 30 day intervals, one
interval at a time.
S
Revised
Use if the requester is revising the specifics of a certification for which services
have not been rendered. For example, the requester may be requesting additional
procedures or other procedures for the same patient event.
203
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UM03
Health Care Services Review Information - Request - 278
1365
Service Type Code
O
ID
1/2
Situational
Description: Code identifying the classification of service
Situational Rule: Required when different from the UM03 value at the Patient Event level
(Loop 2000E) or when SV1, SV2, or SV3 is not valued in this Service loop. If not required
by this implementation guide, may be provided at the sender’s discretion but cannot be
required by the receiver.
Values at the Service Level override the values entered at the Patient Event Level for this
service.
CodeList Summary (Total Codes: 190, Included: 102)
Code Name
1
2
3
4
5
6
7
8
11
12
14
15
16
17
18
20
21
23
24
25
Medical Care
Surgical
Consultation
Diagnostic X-Ray
Diagnostic Lab
Radiation Therapy
Anesthesia
Surgical Assistance
Used Durable Medical Equipment
Durable Medical Equipment Purchase
Renal Supplies in the Home
Alternate Method Dialysis
Chronic Renal Disease (CRD) Equipment
Pre-Admission Testing
Durable Medical Equipment Rental
Second Surgical Opinion
Third Surgical Opinion
Diagnostic Dental
Periodontics
Restorative
Use for restorative dental services.
26
27
28
33
35
36
37
38
39
40
42
44
45
46
54
56
Endodontics
Maxillofacial Prosthetics
Adjunctive Dental Services
Chiropractic
Dental Care
Dental Crowns
Dental Accident
Orthodontics
Prosthodontics
Oral Surgery
Home Health Care
Home Health Visits
Hospice
Respite Care
Long Term Care
Medically Related Transportation
204
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Code Name
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
82
83
84
85
86
87
88
93
A4
A6
A9
AD
AE
AF
AG
AI
AJ
AK
AL
AR
B1
BB
BC
BD
BE
BF
BG
In-vitro Fertilization
MRI/CAT Scan
Donor Procedures
Acupuncture
Newborn Care
Pathology
Smoking Cessation
Well Baby Care
Maternity
Transplants
Audiology Exam
Inhalation Therapy
Diagnostic Medical
Private Duty Nursing
Prosthetic Device
Dialysis
Otological Exam
Chemotherapy
Allergy Testing
Immunizations
Family Planning
Infertility
Abortion
AIDS
Emergency Services
Cancer
Pharmacy
Podiatry
Psychiatric
Psychotherapy
Rehabilitation
Occupational Therapy
Physical Medicine
Speech Therapy
Skilled Nursing Care
Substance Abuse
Alcoholism
Drug Addiction
Vision (Optometry)
Experimental Drug Therapy
Burn Care
Partial Hospitalization (Psychiatric)
Day Care (Psychiatric)
Cognitive Therapy
Massage Therapy
Pulmonary Rehabilitation
Cardiac Rehabilitation
205
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Code Name
BL
BN
BP
BQ
BS
BY
BZ
C1
GY
IC
MH
NI
ON
PT
PU
RN
RT
TC
TN
UM04
C023
Cardiac
Gastrointestinal
Endocrine
Neurology
Invasive Procedures
Physician Visit - Office: Sick
Physician Visit - Office: Well
Coronary Care
Allergy
Intensive Care
Mental Health
Neonatal Intensive Care
Oncology
Physical Therapy
Pulmonary
Renal
Residential Psychiatric Treatment
Transitional Care
Transitional Nursery Care
Health Care Service Location
Information
O
Comp
Situational
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
Situational Rule: Required when different from the UM04 value at the Patient Event level
(Loop 2000E). If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Values entered at the Service Level overrides the value at the
Patient Event Level for this service.
UM04-01
1331
Facility Code Value
M
AN
1/2
Required
Description: Code identifying where services were, or may be, performed; the first and
second positions of the Uniform Bill Type Code for Institutional Services or the Place of
Service Codes for Professional or Dental Services.
IMPLEMENTATION NAME: Facility Type Code
Use to indicate a facility code value from the code source referenced in UM04-2.
ExternalCodeList
Name: 236
Description: Uniform Billing Claim Form Bill Type
ExternalCodeList
Name: 237
Description: Place of Service Codes for Professional Claims
UM04-02
1332
Facility Code Qualifier
O
ID
1/2
Required
Description: Code identifying the type of facility referenced
CodeList Summary (Total Codes: 2, Included: 2)
Code Name
A
Uniform Billing Claim Form Bill Type
206
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Code Name
CODE SOURCE:
236: Uniform Billing Claim Form Bill Type
B
Place of Service Codes for Professional or Dental Services
CODE SOURCE:
237: Place of Service Codes for Professional Claims
Situational Rule:
Required when the health care services review information for this service differs from the health care services
review information specified in the UM segment at the Patient Event level (Loop 2000E). If not required by this
implementation guide, do not send.
TR3 Example:
UM*SC*I*3~
207
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Pos: 0600
REF Previous Review
Max: 1
Detail - Optional
Authorization Number
Loop:
2000F
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
1/50
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1731, Included: 1)
Code Name
BB
REF02
127
Authorization Number
Reference Identification
X
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
IMPLEMENTATION NAME: Previous Review 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.
Situational Rule:
Required when different from the Previous Review Authorization Number specified at the Patient Event Level
(Loop 2000E). If not required by this implementation guide, do not send.
TR3 Notes:
1. This is the authorization number assigned by the UMO to the original review outcome associated with this
service. This is not the trace number assigned by the requester.
TR3 Example:
REF*BB*A123~
208
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Pos: 0600
REF Previous Review
Max: 1
Detail - Optional
Administrative Reference
Number
Loop:
2000F
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
1/50
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1731, Included: 1)
Code Name
NT
REF02
127
Administrator's Reference Number
Reference Identification
X
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
IMPLEMENTATION NAME: Previous Administrative 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.
Situational Rule:
Required when different from the Previous Review Administrative Reference Number specified at the Patient
Event Level (Loop 2000E). If not required by this implementation guide, do not send.
TR3 Notes:
1. This is the administrative number assigned by the UMO to the original service review outcome associated with
this service review. This is not the trace number assigned by the requester.
TR3 Example:
REF*NT*123Z~
209
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Pos: 0700
DTP Service Date
Max: 1
Detail - Optional
Loop:
2000F
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
IMPLEMENTATION NAME: Date Time Qualifier
CodeList Summary (Total Codes: 1280, Included: 1)
Code Name
472
DTP02
1250
Service
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: 42, Included: 2)
Code Name
D8
RD8
DTP03
1251
Date Expressed in Format CCYYMMDD
Range of Dates Expressed in Format CCYYMMDD-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
IMPLEMENTATION NAME: Proposed or Actual Service Date
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
Situational Rule:
Required when proposed or actual date or range of dates of service is different from the Patient Event Date in
Loop 2000E. If not required by this implementation guide, do not send.
TR3 Example:
DTP*472*D8*20050516~
210
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Pos: 0810
SV1 Professional Service
Max: 1
Detail - Optional
Loop:
2000F
Elements: 7
User Option (Usage): Situational
Purpose: To specify the service line item 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
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)
IMPLEMENTATION NAME: Product or Service ID Qualifier
CodeList Summary (Total Codes: 519, Included: 4)
Code Name
HC
Health Care Financing Administration Common Procedural Coding System
(HCPCS) Codes
This code is required when reporting CPT codes and Level 1 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. Use
only in non-HIPAA implementations.
CODE SOURCE:
N4
National Drug Code in 5-4-2 Format
CODE SOURCE:
513: Home Infusion EDI Coalition (HIEC) Product/Service Code List
240: National Drug Code by Format
WK
Advanced Billing Concepts (ABC) Codes
This code set is not allowed for use under HIPAA at the time of this writing. The
qualifier can only be used:
If a new rule names the Complimentary, Alternative, or Holistic Procedure Codes
as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as
allowed under the law,
OR
For service reviews which are not covered under HIPAA.
CODE SOURCE:
843: Advanced Billing Concepts (ABC) Codes
SV101-02
234
Product/Service ID
M
211
AN
1/48
Required
For internal use only
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Id
Element Name
Req
Type
Description: Identifying number for a product or service
IMPLEMENTATION NAME: Procedure Code
Min/Max
Usage
ExternalCodeList
Name: 130
Description: Health Care Financing Administration Common Procedural Coding System
ExternalCodeList
Name: 240
Description: National Drug Code by Format
ExternalCodeList
Name: 513
Description: Home Infusion EDI Coalition (HIEC) Product/Service Code List
ExternalCodeList
Name: 843
Description: Advanced Billing Concepts (ABC) Codes
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
Situational Rule: Required when additional clarification to the associated procedure code
for which authorization is being requested. If not required by this implementation guide, do
not send.
Use this modifier for the first procedure code modifier.
ExternalCodeList
Name: 130
Description: Health Care Financing Administration Common Procedural Coding System
ExternalCodeList
Name: 513
Description: Home Infusion EDI Coalition (HIEC) Product/Service Code List
ExternalCodeList
Name: 843
Description: Advanced Billing Concepts (ABC) Codes
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
Situational Rule: Required when additional clarification to the associated procedure code
for which authorization is being requested. If not required by this implementation guide, do
not send.
Use this modifier for the second procedure code modifier.
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
212
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ExternalCodeList
Name: 843
Description: Advanced Billing Concepts (ABC) Codes
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
Situational Rule: Required when additional clarification to the associated procedure code
for which authorization is being requested. If not required by this implementation guide, do
not send.
Use this modifier for the third procedure code modifier.
ExternalCodeList
Name: 130
Description: Health Care Financing Administration Common Procedural Coding System
ExternalCodeList
Name: 513
Description: Home Infusion EDI Coalition (HIEC) Product/Service Code List
ExternalCodeList
Name: 843
Description: Advanced Billing Concepts (ABC) Codes
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
Situational Rule: Required when additional clarification to the associated procedure code
for which authorization is being requested. If not required by this implementation guide, do
not send.
Use this modifier for the fourth procedure code modifier.
ExternalCodeList
Name: 130
Description: Health Care Financing Administration Common Procedural Coding System
ExternalCodeList
Name: 513
Description: Home Infusion EDI Coalition (HIEC) Product/Service Code List
ExternalCodeList
Name: 843
Description: Advanced Billing Concepts (ABC) Codes
SV101-07
352
Description
O
AN
1/80
Situational
Description: A free-form description to clarify the related data elements and their content
Situational Rule: Required when the provider needs to convey additional clarification to
miscellaneous, unspecified, or non descriptive procedures or modifiers. If not required by
this implementation guide, may be provider at the sender’s discretion but cannot be
required by the receiver.
IMPLEMENTATION NAME: Procedure Code Description
SV101-08
234
Product/Service ID
O
AN
1/48
Situational
Description: Identifying number for a product or service
213
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Id
Element Name
Req
Type
Min/Max
Usage
Situational Rule: Required when the requester cannot determine the intensity or
complexity of the service to be performed and therefore requires authorization for a range
of procedures. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Procedure Code
Use SV101-2 to represent the beginning value in a procedure range and this data element
to represent the ending value in a range of codes.
ExternalCodeList
Name: 130
Description: Health Care Financing Administration Common Procedural Coding System
ExternalCodeList
Name: 240
Description: National Drug Code by Format
ExternalCodeList
Name: 513
Description: Home Infusion EDI Coalition (HIEC) Product/Service Code List
ExternalCodeList
Name: 843
Description: Advanced Billing Concepts (ABC) Codes
SV102
782
Monetary Amount
O
R
1/18
Situational
Description: Monetary amount
Situational Rule: Required when the procedure charge amount is necessary to approve a
monetary limitation for the health care services requests. If not required by this
implementation guide, do not send.
IMPLEMENTATION NAME: Service Line Amount
SV103
355
Unit or Basis for Measurement Code
X
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
Situational Rule: Required when service units were not provided in the HSD segment and
a specific number of services are being requested for this procedure. If not required by this
implementation guide, do not send.
CodeList Summary (Total Codes: 844, 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
X
R
1/15
Situational
Description: Numeric value of quantity
Situational Rule: Required when service units were not provided in the HSD segment and
a specific number of services are being requested for this procedure. If not required by this
implementation guide, do not send.
IMPLEMENTATION NAME: Service Unit Count
214
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Ref
Id
Element Name
SV107
C004
Composite Diagnosis Code Pointer
Req
Type
O
Comp
Min/Max
Usage
Situational
Description: To identify one or more diagnosis code pointers
Situational Rule: Required when this procedure relates to a specific diagnosis reported in
HI Loop 2000E to point to the specific diagnosis. If not required by the implementation, do
not send.
Acceptable values are 1 through 12.
If no diagnosis pointer is provided, then this procedure applies to all diagnosis.
SV107-01
1328
Diagnosis Code Pointer
M
N0
1/2
Required
Description: A pointer to the diagnosis code in the order of importance to this service
SV107-02
1328
Diagnosis Code Pointer
O
N0
1/2
Situational
Description: A pointer to the diagnosis code in the order of importance to this service
Situational Rule: Required when procedure is related to more than one diagnosis. If not
required by this implementation guide, do not send.
Use this pointer for the second diagnosis code pointer.
SV107-03
1328
Diagnosis Code Pointer
O
N0
1/2
Situational
Description: A pointer to the diagnosis code in the order of importance to this service
Situational Rule: Required when procedure is related to more than two diagnosis. If not
required by this implementation guide, do not send.
Use this pointer for the third diagnosis code pointer.
SV107-04
1328
Diagnosis Code Pointer
O
N0
1/2
Situational
Description: A pointer to the diagnosis code in the order of importance to this service
Situational Rule: Required when procedure is related to more than three diagnosis. If not
required by this implementation guide, do not send.
Use this pointer for the fourth diagnosis code pointer.
SV111
1073
Yes/No Condition or Response Code
O
ID
1/1
Situational
Description: Code indicating a Yes or No condition or response
Situational Rule: Required when the requested service is based on EPSDT. If not
required by this implementation guide, do not send.
IMPLEMENTATION NAME: EPSDT Indicator
CodeList Summary (Total Codes: 4, Included: 2)
Code Name
N
Y
SV120
1337
No
Yes
Level of Care Code
O
ID
1/1
Situational
Description: Code specifying the level of care provided by a nursing home facility
Situational Rule: Required when needed to further clarify the level of care in which a
patient resides. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Nursing Home Level of Care
CodeList Summary (Total Codes: 8, Included: 8)
Code Name
1
Skilled Nursing Facility (SNF)
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Code Name
2
3
4
5
6
7
8
Intermediate Care Facility (ICF)
Intermediate Care Facility - Mentally Retarded (ICF-MR)
Chronic Disease Hospital (CD)
Intermediate Care Facility (ICF) Level II
Special Skilled Nursing Facility (SNF)
Nursing Facility (NF)
Hospice
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 service line item 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 non-covered service amount.
Comments:
1. If SV113 is equal to "L" or "N", then SV114 is required.
Situational Rule:
Required when requesting a specific Professional Service. If not required by this implementation guide, do not
send.
TR3 Example:
SV1*HC:99211:25*12.25*UN*1***1:2:3****N~
216
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Pos: 0820
SV2 Institutional Service Line
Max: 1
Detail - Optional
Loop:
2000F
Elements: 8
User Option (Usage): Situational
Purpose: To specify the service line item detail for a health care institution
Element Summary:
Ref
Id
Element Name
SV201
234
Product/Service ID
Req
Type
Min/Max
Usage
X
AN
1/48
Situational
Description: Identifying number for a product or service
Situational Rule: Required when requesting approval on a revenue code. If not required
by this implementation guide, do not send.
IMPLEMENTATION NAME: Service Line Revenue Code
See Code Source 132: National Uniform Billing Committee (NUBC) Codes.
ExternalCodeList
Name: 132
Description: National Uniform Billing Committee (NUBC) Codes
SV202
C003
Composite Medical Procedure
Identifier
X
Comp
Situational
Description: To identify a medical procedure by its standardized codes and applicable
modifiers
Situational Rule: Required when requesting approval for a specific procedure code. If not
required by this implementation guide, do not send.
SV202-01
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)
IMPLEMENTATION NAME: Product or Service ID Qualifier
CodeList Summary (Total Codes: 519, Included: 6)
Code Name
HC
Health Care Financing Administration Common Procedural Coding System
(HCPCS) Codes
This code is required when reporting CPT codes and Level 1 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
ID
International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM) - Procedure
CODE SOURCE:
131: International Classification of Diseases, 9th
Revision, Clinical Modification (ICD-9-CM)
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. Use
only in non-HIPAA implementations.
CODE SOURCE:
217
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Code Name
513: Home Infusion EDI Coalition (HIEC) Product/Service Code List
N4
National Drug Code in 5-4-2 Format
CODE SOURCE:
240: National Drug Code by Format
WK
Advanced Billing Concepts (ABC) Codes
This code set is not allowed for use under HIPAA at the time of this writing. The
qualifier can only be used:
If a new rule names the Complimentary, Alternative, or Holistic Procedure Codes
as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as
allowed under the law,
OR
For service reviews which are not covered under HIPAA.
CODE SOURCE:
843: Advanced Billing Concepts (ABC) Codes
ZZ
Mutually Defined
Use this code when reporting ICD-10-PCS. This
code can only be used if mandated by HIPAA or for services not covered under
HIPAA.
CODE SOURCE:
896 International Classification of Diseases, 10th Revision, Procedure Coding
System (ICD-10-PCS)
SV202-02
234
Product/Service ID
M
AN
1/48
Required
Description: Identifying number for a product or service
IMPLEMENTATION NAME: Procedure Code
ExternalCodeList
Name: 130
Description: Health Care Financing Administration Common Procedural Coding System
ExternalCodeList
Name: 131P
Description: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
ExternalCodeList
Name: 240
Description: National Drug Code by Format
ExternalCodeList
Name: 513
Description: Home Infusion EDI Coalition (HIEC) Product/Service Code List
ExternalCodeList
Name: 843
Description: Advanced Billing Concepts (ABC) Codes
ExternalCodeList
Name: 896
Description: International Classification of Diseases, 10th Revision, Procedure Coding
System (ICD-10-PCS)
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Id
1339
Element Name
Procedure Modifier
Req
O
Type
AN
Min/Max
2/2
Usage
Situational
Description: This identifies special circumstances related to the performance of the
service, as defined by trading partners
Situational Rule: Required when additional clarification to the associated procedure code
for which authorization is being requested. If not required by this implementation guide, do
not send.
Use this data element for the first procedure code modifier.
ExternalCodeList
Name: 130
Description: Health Care Financing Administration Common Procedural Coding System
ExternalCodeList
Name: 513
Description: Home Infusion EDI Coalition (HIEC) Product/Service Code List
ExternalCodeList
Name: 843
Description: Advanced Billing Concepts (ABC) Codes
SV202-04
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
Situational Rule: Required when additional clarification to the associated procedure code
for which authorization is being requested. If not required by this implementation guide, do
not send.
Use this data element for the second procedure code modifier.
ExternalCodeList
Name: 130
Description: Health Care Financing Administration Common Procedural Coding System
ExternalCodeList
Name: 513
Description: Home Infusion EDI Coalition (HIEC) Product/Service Code List
ExternalCodeList
Name: 843
Description: Advanced Billing Concepts (ABC) Codes
SV202-05
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
Situational Rule: Required when additional clarification to the associated procedure code
for which authorization is being requested. If not required by this implementation guide, do
not send.
Use this data element for the third procedure code modifier.
ExternalCodeList
Name: 130
Description: Health Care Financing Administration Common Procedural Coding System
ExternalCodeList
Name: 513
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Description: Home Infusion EDI Coalition (HIEC) Product/Service Code List
ExternalCodeList
Name: 843
Description: Advanced Billing Concepts (ABC) Codes
SV202-06
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
Situational Rule: Required when additional clarification to the associated procedure code
for which authorization is being requested. If not required by this implementation guide, do
not send.
Use this data element for the fourth procedure code modifier.
ExternalCodeList
Name: 130
Description: Health Care Financing Administration Common Procedural Coding System
ExternalCodeList
Name: 513
Description: Home Infusion EDI Coalition (HIEC) Product/Service Code List
ExternalCodeList
Name: 843
Description: Advanced Billing Concepts (ABC) Codes
SV202-07
352
Description
O
AN
1/80
Situational
Description: A free-form description to clarify the related data elements and their content
Situational Rule: Required when the provider needs to convey additional clarification to
miscellaneous, unspecified, or non descriptive procedures or modifiers. If not required by
this implementation guide, may be provider at the sender’s discretion but cannot be
required by the receiver.
IMPLEMENTATION NAME: Procedure Code Description
SV202-08
234
Product/Service ID
O
AN
1/48
Situational
Description: Identifying number for a product or service
Situational Rule: Required when the requester cannot determine the intensity or
complexity of the service to be performed and therefore requires authorization for a range
of procedures. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Procedure Code
Use SV202-2 to represent the beginning value in the procedure range and this data
element to represent the ending value in a range of codes.
ExternalCodeList
Name: 130
Description: Health Care Financing Administration Common Procedural Coding System
ExternalCodeList
Name: 131P
Description: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
ExternalCodeList
Name: 240
Description: National Drug Code by Format
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ExternalCodeList
Name: 513
Description: Home Infusion EDI Coalition (HIEC) Product/Service Code List
ExternalCodeList
Name: 843
Description: Advanced Billing Concepts (ABC) Codes
ExternalCodeList
Name: 896
Description: International Classification of Diseases, 10th Revision, Procedure Coding
System (ICD-10-PCS)
SV203
782
Monetary Amount
O
R
1/18
Situational
Description: Monetary amount
Situational Rule: Required when the procedure charge amount is necessary to approve a
monetary limitation for the health care services requests. If not required by this
implementation guide, do not send.
IMPLEMENTATION NAME: Service Line Amount
SV204
355
Unit or Basis for Measurement Code
X
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
Situational Rule: Required when service units were not provided in the HSD segment and
a specific number of services are being requested for this procedure. If not required by this
implementation guide, do not send.
CodeList Summary (Total Codes: 844, Included: 3)
Code Name
SV205
380
DA
F2
Days
International Unit
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).
UN
Unit
Quantity
X
R
1/15
Situational
Description: Numeric value of quantity
Situational Rule: Required when service units were not provided in the HSD segment and
a specific number of services are being requested for this procedure. If not required by this
implementation guide, do not send.
IMPLEMENTATION NAME: Service Unit Count
SV206
1371
Unit Rate
O
R
1/10
Situational
Description: The rate per unit of associate revenue for hospital accommodation
Situational Rule: Required when SV201 is valued and accommodation rate is necessary
to approve a monetary limitation for the health care services requests. If not required by
this implementation guide, do not send.
IMPLEMENTATION NAME: Service Line Rate
SV209
1345
Nursing Home Residential Status Code
O
ID
1/1
Situational
Description: Code specifying the status of a nursing home resident at the time of service
Situational Rule: Required when the Health Care Services Review Request is for Long
Term Care. If not required by this implementation guide, do not send.
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Id
Element Name
Req
Type
Min/Max
Usage
CodeList Summary (Total Codes: 9, Included: 8)
Code Name
1
2
3
4
5
6
7
8
SV210
1337
Transferred to Intermediate Care Facility - Mentally Retarded (ICF-MR)
Newly Admitted
Newly Eligible
No Longer Eligible
Still a Resident
Temporary Absence - Hospital
Temporary Absence - Other
Transferred to Intermediate Care Facility - Level II (ICF II)
Level of Care Code
O
ID
1/1
Situational
Description: Code specifying the level of care provided by a nursing home facility
Situational Rule: Required when needed to further clarify the level of care being
requested for admission to a nursing facility, or when the request is for non-nursing facility
and the level of care in which the patient resides is needed. If not required by this
implementation guide, do not send.
IMPLEMENTATION NAME: Nursing Home Level of Care
CodeList Summary (Total Codes: 8, Included: 8)
Code Name
1
2
3
4
5
6
7
8
Skilled Nursing Facility (SNF)
Intermediate Care Facility (ICF)
Intermediate Care Facility - Mentally Retarded (ICF-MR)
Chronic Disease Hospital (CD)
Intermediate Care Facility (ICF) Level II
Special Skilled Nursing Facility (SNF)
Nursing Facility (NF)
Hospice
Syntax Rules:
1. R0102 - At least one of SV201 or SV202 is required.
2. P0405 - If either SV204 or SV205 is present, then the other is required.
Semantics:
1.
2.
3.
4.
SV201 is the revenue code.
SV203 is the submitted service line item amount.
SV207 is a non-covered service amount.
SV208 is the detail service line indicator. A "Y" value indicates a detail service line; an "N" value indicates a
summary service line.
Situational Rule:
Required when requesting a specific Institutional Service or requesting a specific Revenue Code for the
Institutional Service. If not required by this implementation guide, do not send.
TR3 Example:
SV2*300*HC:80019*73.42*UN*1~
SV2*120**1500*DA*5*300~
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Pos: 0830
SV3 Dental Service
Max: 1
Detail - Optional
Loop:
2000F
Elements: 6
User Option (Usage): Situational
Purpose: To specify the service line item detail for dental work
Element Summary:
Ref
Id
Element Name
SV301
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
SV301-01
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)
IMPLEMENTATION NAME: Product or Service ID Qualifier
CodeList Summary (Total Codes: 519, Included: 1)
Code Name
AD
American Dental Association Codes
CDT = Current Dental Terminology
CODE SOURCE:
135: American Dental Association
SV301-02
234
Product/Service ID
M
AN
1/48
Required
2/2
Situational
Description: Identifying number for a product or service
IMPLEMENTATION NAME: Procedure Code
ExternalCodeList
Name: 135
Description: American Dental Association
SV301-03
1339
Procedure Modifier
O
AN
Description: This identifies special circumstances related to the performance of the
service, as defined by trading partners
Situational Rule: Required when additional clarification to the associated procedure code
for which authorization is being requested. If not required by this implementation guide, do
not send.
Use this data element for the first procedure code modifier.
A modifier must be from code source 135 (American Dental Association) found in the ‘Code
on Dental Procedures and Nomenclature’, if such modifier is available.
SV301-04
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
Situational Rule: Required when additional clarification to the associated procedure code
for which authorization is being requested. If not required by this implementation guide, do
not send.
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Id
Element Name
Req
Type
Min/Max
Usage
Use this data element for the second procedure code modifier.
A modifier must be from code source 135 (American Dental Association) found in the ‘Code
on Dental Procedures and Nomenclature’, if such modifier is available.
SV301-05
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
Situational Rule: Required when additional clarification to the associated procedure code
for which authorization is being requested. If not required by this implementation guide, do
not send.
Use this data element for the third procedure code modifier.
A modifier must be from code source 135 (American Dental Association) found in the ‘Code
on Dental Procedures and Nomenclature’, if such modifier is available.
SV301-06
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
Situational Rule: Required when additional clarification to the associated procedure code
for which authorization is being requested. If not required by this implementation guide, do
not send.
Use this data element for the fourth procedure code modifier.
A modifier must be from code source 135 (American Dental Association) found in the ‘Code
on Dental Procedures and Nomenclature’, if such modifier is available.
SV301-07
352
Description
O
AN
1/80
Situational
Description: A free-form description to clarify the related data elements and their content
Situational Rule: Required when the service request is for a “Not Otherwise Classified”
(NOC) or “By Report” procedure code or to report the following information on this service
line: Date of Initial Impression, Date of Initial Preparation Crown, Initial Preparation Crown
Tooth Number, or Initial Endodontic Treatment. If not required by this implementation guide,
do not send.
IMPLEMENTATION NAME: Procedure Code Description
SV301-08
234
Product/Service ID
O
AN
1/48
Situational
Description: Identifying number for a product or service
Situational Rule: Required when the requester cannot determine the intensity or
complexity of the service to be performed and therefore requires authorization for a range
of procedures. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Procedure Code
Use SV301-2 to represent the beginning value in the procedure range and this data
element to represent the ending value in a range of codes.
ExternalCodeList
Name: 135
Description: American Dental Association
SV302
782
Monetary Amount
O
R
1/18
Situational
Description: Monetary amount
Situational Rule: Required when the usual and customary cost is necessary to approve a
monetary limitation for the health care services requests. If not required by this
implementation guide, do not send.
IMPLEMENTATION NAME: Service Line Amount
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Ref
Id
Element Name
SV304
C006
Oral Cavity Designation
Req
Type
O
Comp
Min/Max
Usage
Situational
Description: To identify one or more areas of the oral cavity
Situational Rule: Required when necessary to report areas of the mouth that are being
treated. If not required by this implementation guide, do not send.
SV304-01
1361
Oral Cavity Designation Code
M
ID
1/3
Required
Description: Code Identifying the area of the oral cavity in which service is rendered
CODE SOURCE: 135: American Dental Association Codes
ExternalCodeList
Name: 135C
Description: ADA Oral Cavity Designation Codes
SV304-02
1361
Oral Cavity Designation Code
O
ID
1/3
Situational
Description: Code Identifying the area of the oral cavity in which service is rendered
Situational Rule: Required when needed to identify additional oral cavity designation
codes. If not required by this implementation guide, do not send.
CODE SOURCE: 135: American Dental Association Codes
ExternalCodeList
Name: 135C
Description: ADA Oral Cavity Designation Codes
SV304-03
1361
Oral Cavity Designation Code
O
ID
1/3
Situational
Description: Code Identifying the area of the oral cavity in which service is rendered
Situational Rule: Required when needed to identify additional oral cavity designation
codes. If not required by this implementation guide, do not send.
CODE SOURCE: 135: American Dental Association Codes
ExternalCodeList
Name: 135C
Description: ADA Oral Cavity Designation Codes
SV304-04
1361
Oral Cavity Designation Code
O
ID
1/3
Situational
Description: Code Identifying the area of the oral cavity in which service is rendered
Situational Rule: Required when needed to identify additional oral cavity designation
codes. If not required by this implementation guide, do not send.
CODE SOURCE: 135: American Dental Association Codes
ExternalCodeList
Name: 135C
Description: ADA Oral Cavity Designation Codes
SV304-05
1361
Oral Cavity Designation Code
O
ID
1/3
Situational
Description: Code Identifying the area of the oral cavity in which service is rendered
Situational Rule: Required when needed to identify additional oral cavity designation
codes. If not required by this implementation guide, do not send.
CODE SOURCE: 135: American Dental Association Codes
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ExternalCodeList
Name: 135C
Description: ADA Oral Cavity Designation Codes
SV305
1358
Prosthesis, Crown or Inlay Code
O
ID
1/1
Situational
Description: Code specifying the placement status for the dental work
Situational Rule: Required when needed to indicate the placement status of the prosthetic
for this service. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Prosthesis, Crown, or Inlay Code
CodeList Summary (Total Codes: 2, Included: 2)
Code Name
I
R
SV306
380
Initial Placement
Replacement
Quantity
O
R
1/15
Required
AN
1/80
Situational
Description: Numeric value of quantity
IMPLEMENTATION NAME: Service Unit Count
Number of procedures
SV307
352
Description
O
Description: A free-form description to clarify the related data elements and their content
Situational Rule: Required when necessary to describe the reason for replacement. If not
required by this implementation guide, do not send.
Semantics:
1.
2.
3.
4.
5.
SV302 is the submitted service line item amount.
SV303 is the place of service code representing the location where the dental treatment was rendered.
SV306 is the number of procedures.
SV307 is the reason for replacement.
SV310 is the predetermination of benefits indicator. A "Y" value indicates that this service is being submitted
for predetermination of benefits.
Situational Rule:
Required when requesting a specific Dental Service. If not required by this implementation guide, do not send.
TR3 Example:
SV3*AD:D2150*80****1~
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Pos: 0840
TOO Tooth Information
Max: 32
Detail - Optional
Loop:
2000F
Elements: 3
User Option (Usage): Situational
Purpose: To identify a tooth by number and, if applicable, one or more tooth surfaces
Element Summary:
Ref
Id
Element Name
TOO01
1270
Code List Qualifier Code
Req
Type
Min/Max
Usage
X
ID
1/3
Required
1/30
Required
Description: Code identifying a specific industry code list
CodeList Summary (Total Codes: 948, Included: 1)
Code Name
JP
Universal National Tooth Designation System
CODE SOURCE:
135: American Dental Association
TOO02
1271
Industry Code
X
AN
Description: Code indicating a code from a specific industry code list
IMPLEMENTATION NAME: Tooth Code
CODE SOURCE: 135: American Dental Association Codes
TOO03
C005
Tooth Surface
O
Comp
Situational
Description: To identify one or more tooth surface codes
Situational Rule: Required when reporting tooth surface as defined by the procedure
code. If not required by this implementation guide, do not send.
TOO03-01 1369
Tooth Surface Code
M
ID
1/2
Required
Description: Code identifying the area of the tooth that was treated
CodeList Summary (Total Codes: 7, Included: 7)
Code Name
B
D
F
I
L
M
O
TOO03-02 1369
Buccal
Distal
Facial
Incisal
Lingual
Mesial
Occlusal
Tooth Surface Code
O
ID
1/2
Situational
Description: Code identifying the area of the tooth that was treated
Situational Rule: Required when necessary to report a second tooth surface. If not
required by this implementation guide, do not send.
Use code values from TOO03-1.
CodeList Summary (Total Codes: 7, Included: 7)
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Code Name
B
D
F
I
L
M
O
TOO03-03 1369
Buccal
Distal
Facial
Incisal
Lingual
Mesial
Occlusal
Tooth Surface Code
O
ID
1/2
Situational
Description: Code identifying the area of the tooth that was treated
Situational Rule: Required when necessary to report a third tooth surface. If not required
by this implementation guide, do not send.
Use code values from TOO03-1.
CodeList Summary (Total Codes: 7, Included: 7)
Code Name
B
D
F
I
L
M
O
TOO03-04 1369
Buccal
Distal
Facial
Incisal
Lingual
Mesial
Occlusal
Tooth Surface Code
O
ID
1/2
Situational
Description: Code identifying the area of the tooth that was treated
Situational Rule: Required when necessary to report a fourth tooth surface. If not required
by this implementation guide, do not send.
Use code values from TOO03-1.
CodeList Summary (Total Codes: 7, Included: 7)
Code Name
B
D
F
I
L
M
O
TOO03-05 1369
Buccal
Distal
Facial
Incisal
Lingual
Mesial
Occlusal
Tooth Surface Code
O
ID
1/2
Situational
Description: Code identifying the area of the tooth that was treated
Situational Rule: Required when necessary to report a fifth tooth surface. If not required
by this implementation guide, do not send.
Use code values from TOO03-1.
CodeList Summary (Total Codes: 7, Included: 7)
Code Name
B
Buccal
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Code Name
D
F
I
L
M
O
Distal
Facial
Incisal
Lingual
Mesial
Occlusal
Syntax Rules:
1. P0102 - If either TOO01 or TOO02 is present, then the other is required.
Situational Rule:
Required when SV3 is valued and it is necessary to report tooth number and/or tooth surface. If not required by
this implementation guide, do not send.
TR3 Example:
TOO*JP*12*L:O~
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Pos: 0900
HSD Health Care Services
Max: 1
Detail - Optional
Delivery
Loop:
2000F
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
X
ID
2/2
Situational
Description: Code specifying the type of quantity
Situational Rule: Required when needed to indicate the type of service count quantified in
HSD02. If not required by this implementation guide, do not send.
CodeList Summary (Total Codes: 1123, Included: 5)
Code Name
DY
FL
HS
MN
VS
HSD02
380
Days
Units
Hours
Month
Visits
Quantity
X
R
1/15
Situational
Description: Numeric value of quantity
Situational Rule: Required when HSD01 is valued to indicate the service quantity. If not
required by this implementation guide, do not send.
IMPLEMENTATION NAME: Service Unit Count
If this is a request for an extension to an existing certification (UM02 = 4), then HSD02
represents the number of visits by which the certification is extended. If this is a request to
revise an existing certification (UM02 = S), then HSD02 represents the new total.
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
Situational Rule: Required when needed to indicate the timeframe in which the quantity of
services in HSD02 will be rendered. If not required by this implementation guide, do not
send.
CodeList Summary (Total Codes: 844, Included: 3)
Code Name
DA
MO
WK
HSD04
1167
Days
Months
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
Situational Rule: Required when needed to indicate sampling frequency for this service. If
not required by this implementation guide, do not send.
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Ref
Id
Element Name
HSD05
615
Time Period Qualifier
Req
Type
Min/Max
Usage
X
ID
1/2
Situational
Description: Code defining periods
Situational Rule: Required when needed to indicate the time period for which the services
will be continued. If not required by this implementation guide, do not send.
CodeList Summary (Total Codes: 38, Included: 7)
Code Name
6
7
21
26
27
34
35
HSD06
616
Hour
Day
Years
Episode
Visit
Month
Week
Number of Periods
O
N0
1/3
Situational
Description: Total number of periods
Situational Rule: Required when needed to indicate the number of time periods in HSD05
that are requested. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Period Count
HSD07
678
Ship/Delivery or Calendar Pattern Code
O
ID
1/2
Situational
Description: Code which specifies the routine shipments, deliveries, or calendar pattern
Situational Rule: Required when the patient event must be rendered within a specific
calendar delivery pattern. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Delivery Frequency Code
CodeList Summary (Total Codes: 45, Included: 43)
Code Name
1
2
3
4
5
6
7
8
9
A
B
C
D
E
F
G
H
J
K
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
1st Working Day of Period
Last Working Day of Period
Monday through Friday
Monday through Saturday
Monday through Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
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Code Name
L
M
N
O
P
Q
R
S
T
U
V
W
X
Y
SA
SB
SC
SD
SG
SL
SP
SX
SY
SZ
HSD08
679
Monday through Thursday
Immediately
As Directed
Daily Mon. through Fri.
1/2 Mon. & 1/2 Thurs.
1/2 Tues. & 1/2 Thurs.
1/2 Wed. & 1/2 Fri.
Once Anytime Mon. through Fri.
1/2 Tue. & 1/2 Fri.
1/2 Mon. & 1/2 Wed.
1/3 Mon., 1/3 Wed., 1/3 Fri.
Whenever Necessary
1/2 By Wed., Bal. By Fri.
None (Also Used to Cancel or Override a Previous Pattern)
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
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
Situational Rule: Required when needed to indicate the time delivery pattern for the
services. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Delivery Pattern Time Code
CodeList Summary (Total Codes: 9, Included: 8)
Code Name
A
B
C
D
E
F
G
Y
1st Shift (Normal Working Hours)
2nd Shift
3rd Shift
A.M.
P.M.
As Directed
Any Shift
None (Also Used to Cancel or Override a Previous Pattern)
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.
Situational Rule:
Required when requesting services that have a specific pattern of delivery and the pattern of delivery or usage for
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this service is different from the pattern of delivery or usage (HSD) in the Patient Event (Loop 2000E). If not
required by this implementation guide, do not send.
TR3 Notes:
1. An explanation of the uses of this segment follows.
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”.
TR3 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”.)
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Pos: 1550
PWK Additional Service
Max: 10
Detail - Optional
Information
Loop:
2000F
Elements: 5
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
IMPLEMENTATION NAME: Attachment Report Type Code
CodeList Summary (Total Codes: 541, Included: 66)
Code Name
03
04
05
06
07
Report Justifying Treatment Beyond Utilization Guidelines
Drugs Administered
Treatment Diagnosis
Initial Assessment
Functional Goals
Expected outcomes of rehabilitative services.
08
09
10
11
13
15
21
48
55
Plan of Treatment
Progress Report
Continued Treatment
Chemical Analysis
Certified Test Report
Justification for Admission
Recovery Plan
Social Security Benefit Letter
Rental Agreement
Use for medical or dental equipment rental.
59
77
A3
A4
AM
Benefit Letter
Support Data for Verification
Allergies/Sensitivities Document
Autopsy Report
Ambulance Certification
Information to support necessity of ambulance trip.
AS
Admission Summary
A brief patient summary; it lists the patient’s chief complaints and the reasons for
admitting the patient to the hospital.
AT
Purchase Order Attachment
Use for purchase of medical or dental equipment.
B2
B3
BR
BS
BT
Prescription
Physician Order
Benchmark Testing Results
Baseline
Blanket Test Results
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Code Name
PWK02
756
CB
Chiropractic Justification
Lists the reasons chiropractic is just and appropriate treatment.
CK
D2
DA
DB
DG
DJ
DS
FM
HC
HR
I5
IR
LA
M1
NN
OB
OC
OD
OE
OX
P4
P5
P6
P7
PE
PN
PO
PQ
PY
PZ
QC
QR
RB
RR
RT
RX
SG
V5
XP
Consent Form(s)
Drug Profile Document
Dental Models
Durable Medical Equipment Prescription
Diagnostic Report
Discharge Monitoring Report
Discharge Summary
Family Medical History Document
Health Certificate
Health Clinic Records
Immunization Record
State School Immunization Records
Laboratory Results
Medical Record Attachment
Nursing Notes
Operative Note
Oxygen Content Averaging Report
Orders and Treatments Document
Objective Physical Examination (including vital signs) Document
Oxygen Therapy Certification
Pathology Report
Patient Medical History Document
Periodontal Charts
Periodontal Reports
Parenteral or Enteral Certification
Physical Therapy Notes
Prosthetics or Orthotic Certification
Paramedical Results
Physician's Report
Physical Therapy Certification
Cause and Corrective Action Report
Quality Report
Radiology Films
Radiology Reports
Report of Tests and Analysis Report
Renewable Oxygen Content Averaging Report
Symptoms Document
Death Notification
Photographs
Report Transmission Code
O
ID
1/2
Required
Description: Code defining timing, transmission method or format by which reports are to
be sent
CodeList Summary (Total Codes: 55, Included: 6)
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Code Name
PWK05
66
AA
Available on Request at Provider Site
This means that the paperwork is not being sent with the request at this time.
Instead, it is available to the UMO (or appropriate entity) on request.
BM
EL
By Mail
Electronically Only
Use to indicate that the attachment is being transmitted in a separate X12
functional group.
EM
FX
VO
E-Mail
By Fax
Voice
Use this for voicemail or phone communication.
Identification Code Qualifier
X
ID
1/2
Situational
Description: Code designating the system/method of code structure used for Identification
Code (67)
Situational Rule: Required when PWK02 equals BM, EL, EM or FX. If not required by this
implementation guide, may be provided at the sender’s discretion but cannot be required
by the receiver.
CodeList Summary (Total Codes: 241, Included: 1)
Code Name
AC
PWK06
67
Attachment Control Number
Identification Code
X
AN
2/80
Situational
Description: Code identifying a party or other code
Situational Rule: Required when PWK02 equals BM, EL, EM or FX. If not required by this
implementation guide, may be provided at the sender’s discretion but cannot be required
by the receiver.
IMPLEMENTATION NAME: Attachment Control Number
The requester can use it when PWK02 equals “AA” if the requester wants to send a
document control number for an attachment remaining at the Provider’s office.
PWK07
352
Description
O
AN
1/80
Situational
Description: A free-form description to clarify the related data elements and their content
Situational Rule: Required when needed to add any additional information about the
attachment described in this segment. If not required by this implementation guide, do not
send.
IMPLEMENTATION NAME: Attachment Description
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.
Situational Rule:
Required when the requester has additional documentation (electronic, paper, or other medium) associated with
this health care services review that applies to the service(s) requested in this Service loop, and the 278 request
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(ST-SE) does not support this information in its segments and data elements. If not required by this
implementation guide, do not send.
TR3 Notes:
1. Additional documentation at the service level should apply to a specific service and/or all the services
requested in this service loop.
2. This PWK segment is required to identify attachments that are sent electronically (PWK02 = EL) but are
transmitted in another X12 functional group rather than by paper or other medium. PWK06 is used to identify the
attached electronic documentation. The number in PWK06 would be referenced in the electronic attachment.
3. The requester can also use this PWK segment to identify paperwork that is held at the provider’s office and is
available upon request by the UMO (or appropriate entity). Use code AA in PWK02 to convey this specific use of
the PWK segment. See code note under PWK02, code AA.
Refer to Section 2.5 for more information on using this PWK segment.
TR3 Example:
PWK*OB*BM***AC*DMN0012~
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Pos: 1600
MSG Message Text
Max: 1
Detail - Optional
Loop:
2000F
Elements: 1
User Option (Usage): Situational
Purpose: To provide a free-form format that allows the transmission of text information
Element Summary:
Ref
Id
Element Name
MSG01
933
Free-form Message Text
Req
Type
Min/Max
Usage
M
AN
1/264
Required
Description: Free-form message text
IMPLEMENTATION NAME: Free Form Message Text
Syntax Rules:
1. C0302 - If MSG03 is present, then MSG02 is required.
Semantics:
1. MSG03 is the number of lines to advance before printing.
Comments:
1. MSG02 is not related to the specific characteristics of a printer, but identifies top of page, advance a line, etc.
2. If MSG02 is "AA - Advance the specified number of lines before print" then MSG03 is required.
Situational Rule:
Required when needed to transmit a message to the UMO about the service. If not required by this
implementation guide, do not send.
TR3 Notes:
1. Do not use the MSG segment to relay information that you can send using codified information in existing data
elements. If you need to use the MSG segment, you should approach X12N with data maintenance to solve the
business need without the use of the MSG segment.
TR3 Example:
MSG*This is a free-form text message~
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Pos: 1700
Loop Service Provider Name
Repeat: 10
Optional
Loop:
2010F
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
1700
1800
NM1
REF
2000
2100
2200
2400
N3
N4
PER
PRV
Service Provider Name
Service Provider Supplemental
Identification
Service Provider Address
Service Provider City, State, ZIP Code
Service Provider Contact Information
Service Provider Information
239
Req
Max Use
Repeat
Usage
O
O
1
8
Situational
Situational
O
O
O
O
1
1
1
1
Situational
Situational
Situational
Situational
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Pos: 1700
NM1 Service Provider Name
Max: 1
Detail - Optional
Loop:
2010F
Elements: 9
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: 1500, Included: 13)
Code Name
1T
72
73
77
DD
DK
DQ
FA
G3
P3
QB
QV
SJ
NM102
1065
Physician, Clinic or Group Practice
Operating Physician
Other Physician
Service Location
Assistant Surgeon
Ordering Physician
Supervising Physician
Facility
Clinic
Primary Care Provider
Purchase Service Provider
Group Practice
Service Provider
Entity Type Qualifier
M
ID
1/1
Required
AN
1/60
Situational
Description: Code qualifying the type of entity
CodeList Summary (Total Codes: 16, Included: 2)
Code Name
1
2
NM103
1035
Person
Non-Person Entity
Name Last or Organization Name
X
Description: Individual last name or organizational name
Situational Rule: Required when identifying a specialty person, facility, group practice, or
clinic and NM108/NM109 are not present. If not required by this implementation guide, may
be provided at the sender’s discretion but cannot be required by the receiver.
IMPLEMENTATION NAME: Service Provider Last or Organization Name
NM104
1036
Name First
O
AN
1/35
Situational
Description: Individual first name
Situational Rule: Required when the service provider is a specific person (NM102 = 1)
and NM103 is present. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Service Provider First Name
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Ref
Id
Element Name
NM105
1037
Name Middle
Req
Type
Min/Max
Usage
O
AN
1/25
Situational
Description: Individual middle name or initial
Situational Rule: Required when NM104 is present and the middle name/initial of the
person is known. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Service Provider Middle Name
NM106
1038
Name Prefix
O
AN
1/10
Situational
Description: Prefix to individual name
Situational Rule: Required when military title or rank further identifies the provider. If not
required by this implementation, may be provided at the sender’s discretion, but cannot be
required by the receiver.
IMPLEMENTATION NAME: Service Provider Name Prefix
NM107
1039
Name Suffix
O
AN
1/10
Situational
Description: Suffix to individual name
Situational Rule: Required when NM104 is present and the suffix of the individual’s name
is known; e.g. Sr., Jr., or III. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Service Provider Name Suffix
NM108
66
Identification Code Qualifier
X
ID
1/2
Situational
Description: Code designating the system/method of code structure used for Identification
Code (67)
Situational Rule: Required when requesting the services of a specific person, facility,
group practice, or clinic and the provider ID is known by the requester. If not required by
this implementation guide, do not send.
CodeList Summary (Total Codes: 241, Included: 4)
Code Name
24
34
46
XX
Employer's Identification Number
Social Security Number
Electronic Transmitter Identification Number (ETIN)
Centers for Medicare and Medicaid Services National Provider Identifier
Required for providers on or after the mandated
HIPAA National Provider Identifier (NPI) implementation date when the provider
has an NPI and it is available to the submitter.
OR
Required for providers before the mandated HIPAA NPI implementation date when
the provider has an NPI and the submitter has the capability to send it. If not
required by this implementation guide, do not send.
CODE SOURCE:
537: Centers for Medicare and Medicaid Services National Provider Identifier
NM109
67
Identification Code
X
AN
2/80
Situational
Description: Code identifying a party or other code
Situational Rule: Required when requesting the services of a specific person, facility,
group practice, or clinic and the provider ID is known by the requester. If not required by
this implementation guide, do not send.
IMPLEMENTATION NAME: Service Provider Identifier
ExternalCodeList
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Name: 537
Description: Centers for Medicare and Medicaid Services 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.
3. C1203 - If NM112 is present, then NM103 is required.
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
2. NM112 can identify a second surname.
Situational Rule:
Required when requesting a service provider, specialist, or specialty entity for this service that is different from
the provider, specialist, or specialty entity identified in Loop 2010EA (Patient Event Provider Name). If Loop
2010EA is not valued, Loop 2010F must be valued for each service associated with this patient event. If not
required by this implementation guide, may be provided at the sender’s discretion but cannot be required by the
receiver.
TR3 Notes:
1. Use this segment to convey the name and identification number of the service provider (person, group, or
facility) specialist, or specialty entity to provide services to the patient.
2. If this loop is not valued, loop 2010E is required to identify the service provider, specialist, or speciality entity to
provide services.
TR3 Example:
NM1*SJ*1*WATSON*SUSAN****34*987654321~
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Pos: 1800
REF Service Provider
Max: 8
Detail - Optional
Supplemental Identification
Loop:
2010F
Elements: 3
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: 1731, Included: 8)
Code Name
REF02
127
0B
1G
1J
EI
State License Number
Provider UPIN Number
Facility ID Number
Employer's Identification Number
Not used if NM108 = 24.
N5
N7
SY
Provider Plan Network Identification Number
Facility Network Identification Number
Social Security Number
The social security number may not be used for Medicare. Not used if NM108 =
34.
ZH
Carrier Assigned Reference Number
Required when necessary to provide the provider ID as assigned by the UMO
identified in Loop 2000A.
Reference Identification
X
AN
1/50
Required
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
IMPLEMENTATION NAME: Service Provider Supplemental Identifier
REF03
352
Description
X
AN
1/80
Situational
Description: A free-form description to clarify the related data elements and their content
Situational Rule: Required when REF01 = 0B to report the two character state ID of the
state assigning the State License Number. If not required by this implementation guide, do
not send.
IMPLEMENTATION NAME: License Number State Code
See code source 22: State and Outlying Areas of the US.
ExternalCodeList
Name: 22C
Description: States and Provinces
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
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1. REF04 contains data relating to the value cited in REF02.
Situational Rule:
Required on or after the mandated implementation date for the HIPAA National Provider Identifier (NPI) when the
provider is not a specialty entity and the NPI is not reported in NM109 of this loop and another identifier is
available to the submitter.
OR
Required prior to the mandated NPI implementation date when an additional identification number to the NPI
provided in NM109 of this loop is necessary for the UMO to identify the service provider.
OR
Required prior to the mandated NPI implementation date when necessary for the UMO to identify the service
provider. If not required by this implementation guide, do not send.
TR3 Notes:
1. Use the NM1 Segment for the primary identifier.
TR3 Example:
REF*1G*12345~
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Pos: 2000
N3 Service Provider Address
Max: 1
Detail - Optional
Loop:
2010F
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
1/55
Situational
Description: Address information
IMPLEMENTATION NAME: Service Provider Address Line
Use this element for the first line of the provider’s address.
N302
166
Address Information
O
AN
Description: Address information
Situational Rule: Required when a second address line exists. If not required by this
implementation guide, do not send.
IMPLEMENTATION NAME: Service Provider Address Line
Situational Rule:
Required when the provider has multiple locations to identify the specific location for this patient event. If not
required by this implementation guide, do not send.
TR3 Example:
N3*77 HOLLY BLVD~
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N4 Service Provider City, State,
ZIP Code
Pos: 2100
Max: 1
Detail - Optional
Loop:
2010F
Elements: 5
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
2/2
Situational
Description: Free-form text for city name
IMPLEMENTATION NAME: Service Provider City Name
N402
156
State or Province Code
X
ID
Description: Code (Standard State/Province) as defined by appropriate government
agency
Situational Rule: Required when the address is in the United States of America, including
its territories, or Canada. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Service Provider State or Province Code
CODE SOURCE: 22: States and Provinces
ExternalCodeList
Name: 22C
Description: States and Provinces
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)
Situational Rule: Required when the address is in the United States of America, including
its territories, or Canada, or when a postal code exists for the country in N404. If not
required by this implementation guide, do not send.
IMPLEMENTATION NAME: Service Provider Postal Zone or ZIP Code
CODE SOURCE: 51: ZIP Code
932: Universal Postal Codes
ExternalCodeList
Name: 932
Description:
ExternalCodeList
Name: 51
Description: ZIP Code
N404
26
Country Code
X
ID
2/3
Situational
Description: Code identifying the country
Situational Rule: Required when the address is outside the United States of America. If
not required by this implementation guide, do not send.
CODE SOURCE: 5: Countries, Currencies and Funds
Use the alpha-2 country codes from Part 1 of ISO 3166.
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Id
Element Name
Req
Type
Min/Max
Usage
ID
1/3
Situational
ExternalCodeList
Name: 5
Description: Countries, Currencies and Funds
N407
1715
Country Subdivision Code
X
Description: Code identifying the country subdivision
Situational Rule: Required when the address is not in the United States of America,
including its territories, or Canada, and the country in N404 has administrative subdivisions
such as but not limited to states, provinces, cantons, etc. If not required by this
implementation guide, do not send.
CODE SOURCE: 5: Countries, Currencies and Funds
Use the country subdivision codes from Part 2 of ISO 3166.
ExternalCodeList
Name: 5
Description: Countries, Currencies and Funds
Syntax Rules:
1. E0207 - Only one of N402 or N407 may be present.
2. C0605 - If N406 is present, then N405 is required.
3. C0704 - If N407 is present, then N404 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.
Situational Rule:
Required when the provider has multiple locations to identify the specific location for this patient event. If not
required by this implementation guide, do not send.
TR3 Example:
N4*KANSAS CITY*MO*64108~
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Pos: 2200
PER Service Provider Contact
Max: 1
Detail - Optional
Information
Loop:
2010F
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: 238, Included: 1)
Code Name
IC
PER02
93
Information Contact
Name
O
AN
1/60
Situational
Description: Free-form name
Situational Rule: Required when the Information Source needs to indicate a particular
contact and the name of the entity to contact is not already defined or is different than the
name within the prior name segment (NM1). If not required by this implementation guide,
do not send.
IMPLEMENTATION NAME: Service Provider Contact Name
PER03
365
Communication Number Qualifier
X
ID
2/2
Situational
Description: Code identifying the type of communication number
Situational Rule: Required when PER02 is not valued or when the provider needs to
transmit a contact communication number. If not required by this implementation guide, do
not send.
CodeList Summary (Total Codes: 42, Included: 4)
Code Name
EM
FX
TE
UR
PER04
364
Electronic Mail
Facsimile
Telephone
Uniform Resource Locator (URL)
Communication Number
X
AN
1/256
Situational
Description: Complete communications number including country or area code when
applicable
Situational Rule: Required when PER02 is not valued or when the provider needs to
transmit a contact communication number. If not required by this implementation guide, do
not send.
IMPLEMENTATION NAME: Service Provider Contact Communication Number
PER05
365
Communication Number Qualifier
X
ID
2/2
Situational
Description: Code identifying the type of communication number
Situational Rule: Required when the telephone extension or multiple communication types
are available. If not required by this implementation guide, do not send.
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Id
Element Name
Req
Type
Min/Max
Usage
CodeList Summary (Total Codes: 42, Included: 5)
Code Name
PER06
364
EM
EX
Electronic Mail
Telephone Extension
When used, the value following this code is the extension for the preceding
communications contact number.
FX
TE
UR
Facsimile
Telephone
Uniform Resource Locator (URL)
Communication Number
X
AN
1/256
Situational
Description: Complete communications number including country or area code when
applicable
Situational Rule: Required when the telephone extension or multiple communication types
are available. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Service Provider Contact Communication Number
PER07
365
Communication Number Qualifier
X
ID
2/2
Situational
Description: Code identifying the type of communication number
Situational Rule: Required when the telephone extension or multiple communication types
are available. If not required by this implementation guide, do not send.
CodeList Summary (Total Codes: 42, Included: 5)
Code Name
PER08
364
EM
EX
Electronic Mail
Telephone Extension
When used, the value following this code is the extension for the preceding
communications contact number.
FX
TE
UR
Facsimile
Telephone
Uniform Resource Locator (URL)
Communication Number
X
AN
1/256
Situational
Description: Complete communications number including country or area code when
applicable
Situational Rule: Required when the telephone extension or multiple communication types
are available. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Service Provider Contact Communication Number
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.
Situational Rule:
Required when needed to identify a contact name and/or communications number for the provider. If not required
by this implementation guide, may be provided at the sender’s discretion but cannot be required by the receiver.
TR3 Notes:
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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 telephone 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.
TR3 Example:
PER*IC*M TUCKER*TE*8185551212*FX*8185551212~
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PRV Service Provider Information
Pos: 2400
Max: 1
Detail - Optional
Loop:
2010F
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
1/50
Required
Description: Code identifying the type of provider
CodeList Summary (Total Codes: 26, Included: 6)
Code Name
PRV02
128
AS
Assistant Surgeon
Use only when NM101 = DD.
OP
Operating
Use only when NM101 = 72.
OR
Ordering
Use only when NM101 = DK.
OT
Other Physician
Use only when NM101 = 73.
PC
Primary Care Physician
Use only when NM101 = P3.
PE
Performing
Use only when NM101 = SJ.
Reference Identification Qualifier
X
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1731, Included: 1)
Code Name
PXC
Health Care Provider Taxonomy Code
CODE SOURCE:
682: Health Care Provider Taxonomy
PRV03
127
Reference Identification
X
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
IMPLEMENTATION NAME: Provider Taxonomy Code
ExternalCodeList
Name: 682
Description: Health Care Provider Taxonomy
Syntax Rules:
1. P0203 - If either PRV02 or PRV03 is present, then the other is required.
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Situational Rule:
Required when request is for services of a specialist or specialty entity to indicate the provider’s specialty. If not
required by this implementation guide, may be provided a the sender’s discretion but cannot be required by the
receiver.
TR3 Example:
PRV*PE*PXC*203BS0133X~
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Pos: 2800
SE Transaction Set Trailer
Max: 1
Detail - Mandatory
Loop: N/A
Elements: 2
User Option (Usage): Required
Purpose: To indicate the end of the transaction set and provide the count of the transmitted segments (including the
beginning (ST) and ending (SE) segments)
Element Summary:
Ref
Id
Element Name
SE01
96
Number of Included Segments
Req
Type
Min/Max
Usage
M
N0
1/10
Required
Description: Total number of segments included in a transaction set including ST and SE
segments
IMPLEMENTATION NAME: Transaction Segment Count
SE02
329
Transaction Set Control Number
M
AN
4/9
Required
Description: Identifying control number that must be unique within the transaction set
functional group assigned by the originator for a transaction set
The Transaction Set Control Numbers in ST02 and SE02 must be identical. The number is
assigned by the originator and must be unique within a functional group (GS-GE). For
example, start with the number 0001 and increment from there. The number also aids in
error resolution research.
Comments:
1. SE is the last segment of each transaction set.
TR3 Example:
SE*24*0001~
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Pos:
GE Functional Group Trailer
Max: 1
Not Defined - Mandatory
Loop: N/A
Elements: 2
User Option (Usage): Required
Purpose: To indicate the end of a functional group and to provide control information
Element Summary:
Ref
Id
Element Name
GE01
97
Number of Transaction Sets Included
Req
Type
Min/Max
Usage
M
N0
1/6
Required
Description: Total number of transaction sets included in the functional group or
interchange (transmission) group terminated by the trailer containing this data element
GE02
28
Group Control Number
M
N0
1/9
Required
Description: Assigned number originated and maintained by the sender
Semantics:
1. The data interchange control number GE02 in this trailer must be identical to the same data element in the
associated functional group header, GS06.
Comments:
1. The use of identical data interchange control numbers in the associated functional group header and trailer is
designed to maximize functional group integrity. The control number is the same as that used in the
corresponding header.
TR3 Example:
GE*1*1~
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IEA Interchange Control Trailer
Pos:
Max: 1
Not Defined - Mandatory
Loop: N/A
Elements: 2
User Option (Usage): Required
Purpose: To define the end of an interchange of zero or more functional groups and interchange-related control
segments
Element Summary:
Ref
Id
Element Name
IEA01
I16
Number of Included Functional Groups
Req
Type
Min/Max
Usage
M
N0
1/5
Required
Description: A count of the number of functional groups included in an interchange
IEA02
I12
Interchange Control Number
M
N0
9/9
Required
Description: A control number assigned by the interchange sender
TR3 Example:
IEA*1*000000905~
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Version: 1.0
Company:
Publication:
Blue Shield of California
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Table of Contents
278
. . .
Health Care Services Review Information - Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
1
ISA
. . .
Interchange Control Header . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
6
GS
. .
Functional Group Header . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
10
ST
. .
Transaction Set Header . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
12
BHT
. .
Beginning of Hierarchical Transaction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
13
2000A
. .
Loop Utilization Management Organization (UMO) Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
15
HL
. .
Utilization Management Organization (UMO) Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
16
AAA
. .
Request Validation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
17
2010A
. .
Loop Utilization Management Organization (UMO) Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
19
NM1
. .
Utilization Management Organization (UMO) Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
20
PER
. .
Utilization Management Organization (UMO) Contact Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
22
AAA
. .
Utilization Management Organization (UMO) Request Validation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
25
2000B
. .
Loop Requester Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
27
HL
. .
Requester Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
28
2010B
. .
Loop Requester Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
30
NM1
. .
Requester Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
31
REF
. .
Requester Supplemental Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
33
AAA
. .
Requester Request Validation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
34
PRV
. .
Requester Provider Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
36
2000C
. .
Loop Subscriber Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
38
HL
. .
Subscriber Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
39
2010C
. .
Loop Subscriber Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
41
NM1
. .
Subscriber Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
42
REF
. .
Subscriber Supplemental Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
44
N3
. .
Subscriber Mailing Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
46
N4
. .
Subscriber City, State, ZIP Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
47
AAA
. .
Subscriber Request Validation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
49
DMG
. .
Subscriber Demographic Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
51
INS
. .
Subscriber Relationship . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
52
2000D
. .
Loop Dependent Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
54
HL
. .
Dependent Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
55
2010D
. .
Loop Dependent Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
57
NM1
. .
Dependent Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
58
REF
. .
Dependent Supplemental Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
60
N3
. .
Dependent Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
61
N4
. .
Dependent City, State, ZIP Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
62
AAA
. .
Dependent Request Validation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
64
DMG
. .
Dependent Demographic Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
66
INS
. .
Dependent Relationship . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
67
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2000E
. .
Loop Patient Event Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
69
HL
. .
Patient Event Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
70
TRN
. .
Patient Event Tracking Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
72
AAA
. .
Patient Event Request Validation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
74
UM
. .
Health Care Services Review Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
76
HCR
. .
Health Care Services Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
81
REF
. .
Administrative Reference Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
83
REF
. .
Previous Review Authorization Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
84
DTP
. .
Accident Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
85
DTP
. .
Last Menstrual Period Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
86
DTP
. .
Estimated Date of Birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
87
DTP
. .
Onset of Current Symptoms or Illness Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
88
DTP
. .
Event Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
89
DTP
. .
Admission Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
90
DTP
. .
Discharge Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
91
DTP
. .
Certification Issue Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
92
DTP
. .
Certification Expiration Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
93
DTP
. .
Certification Effective Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
94
HI
. .
Patient Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
95
HSD
Health Care Services Delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
114
CL1
Institutional Claim Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
118
CR1
Ambulance Transport Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
119
CR2
Spinal Manipulation Service Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
121
CR5
Home Oxygen Therapy Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
124
CR6
Home Health Care Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
127
PWK
Additional Patient Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
130
MSG
Message Text . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
134
2010EA Loop Patient Event Provider Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
135
NM1
Patient Event Provider Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
136
REF
Patient Event Provider Supplemental Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
139
N3
Patient Event Provider Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
141
N4
Patient Event Provider City, State, ZIP Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
142
PER
Provider Contact Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
144
AAA
Patient Event Provider Request Validation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
147
PRV
Patient Event Provider Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
149
2010EB Loop Additional Patient Information Contact Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
151
NM1
Additional Patient Information Contact Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
152
N3
Additional Patient Information Contact Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
155
N4
Additional Patient Information Contact City, State, ZIP Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
156
PER
Additional Patient Information Contact Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
158
2010EC Loop Patient Event Transport Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
161
NM1
Patient Event Transport Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
162
N3
Patient Event Transport Location Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
ii
For internal use only
1/12/2012
Health Care Services Review Information - Response - 278
N4
164
Patient Event Transport Location City/State/ZIP Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
165
AAA
Patient Event Transport Location Request Validation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
167
2000F
Loop Service Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
169
HL
Service Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
170
TRN
Service Trace Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
172
AAA
Service Request Validation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
174
UM
Health Care Services Review Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
176
HCR
Health Care Services Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
181
REF
Administrative Reference Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
183
REF
Previous Review Authorization Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
184
DTP
Service Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
185
DTP
Certification Issue Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
186
DTP
Certification Expiration Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
187
DTP
Certification Effective Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
188
HI
Request For Additional Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
189
SV1
Professional Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
196
SV2
Institutional Service Line . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
201
SV3
Dental Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
207
TOO
Tooth Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
211
HSD
Health Care Services Delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
214
PWK
Additional Service Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
218
MSG
Message Text . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
222
2010FA Loop Service Provider Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
223
NM1
Service Provider Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
224
REF
Service Provider Supplemental Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
227
N3
Service Provider Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
229
N4
Service Provider City, State, ZIP Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
230
PER
Service Provider Contact Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
232
AAA
Service Provider Request Validation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
235
PRV
Service Provider Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
237
2010FB Loop Additional Service Information Contact Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
239
NM1
Additional Service Information Contact Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
240
N3
Additional Service Information Contact Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
243
N4
Additional Service Information Contact City, State, ZIP Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
244
PER
Additional Service Information Contact Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
246
SE
Transaction Set Trailer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . <PH>
249
GE
Functional Group Trailer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
250
IEA
Interchange Control Trailer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <PH>
251
iii
For internal use only
1/12/2012
Health Care Services Review Information - Response - 278
278
Health Care Services Review Information
- Response
Functional Group= HI
Purpose: This X12 Transaction Set contains the format and establishes the data contents of the Health Care
Services Review Information Transaction Set (278) for use within the context of an Electronic Data Interchange (EDI)
environment. This transaction set can be used to transmit health care service information, such as subscriber,
patient, demographic, diagnosis or treatment data for the purpose of request for review, certification, notification or
reporting the outcome of a health care services review. Expected users of this transaction set are payors, plan
sponsors, providers, utilization management and other entities involved in health care services review.
Not Defined:
Pos
Id
Segment Name
ISA
GS
Interchange Control Header
Functional Group Header
Pos
Id
Segment Name
0100
0200
ST
BHT
Transaction Set Header
Beginning of Hierarchical
Transaction
Id
Segment Name
Req
Max Use
M
M
1
1
Req
Max Use
M
M
1
1
Req
Max Use
Repeat
Notes
Usage
Required
Required
Heading:
Repeat
Notes
Usage
Required
Required
Detail:
Pos
LOOP ID - 2000A
0100
HL
0300
AAA
NM1
2200
PER
2300
AAA
Utilization Management
Organization (UMO) Level
Request Validation
M
1
O
9
HL
NM1
REF
2300
AAA
2400
PRV
Required
Situational
Utilization Management
Organization (UMO) Name
Utilization Management
Organization (UMO)
Contact Information
Utilization Management
Organization (UMO)
Request Validation
O
1
Required
O
1
Situational
O
9
Situational
Requester Level
O
1
Requester Name
Requester Supplemental
Identification
Requester Request
Validation
Requester Provider
Information
O
O
1
8
Required
Situational
O
9
Situational
O
1
Situational
1
LOOP ID - 2010B
1700
1800
Usage
1
LOOP ID - 2000B
0100
Notes
1
LOOP ID - 2010A
1700
Repeat
Situational
2
LOOP ID - 2000C
1
1
For internal use only
1/12/2012
Health Care Services Review Information - Response - 278
Pos
Id
Segment Name
Req
Max Use
0100
HL
Subscriber Level
O
1
LOOP ID - 2010C
1700
1800
NM1
REF
2000
2100
N3
N4
2300
AAA
2500
DMG
2600
INS
HL
NM1
REF
2000
2100
N3
N4
2300
AAA
2500
DMG
2600
INS
HL
TRN
0300
AAA
0400
UM
0500
HCR
0600
REF
0600
REF
0700
0700
0700
0700
DTP
DTP
DTP
DTP
0700
0700
0700
DTP
DTP
DTP
Situational
O
O
1
9
Required
Situational
O
O
1
1
Situational
Situational
O
9
Situational
O
1
Situational
O
1
Situational
Dependent Level
O
1
Dependent Name
Dependent Supplemental
Identification
Dependent Address
Dependent City, State, ZIP
Code
Dependent Request
Validation
Dependent Demographic
Information
Dependent Relationship
O
O
1
3
Required
Situational
O
O
1
1
Situational
Situational
O
9
Situational
O
1
Situational
O
1
Situational
1
Situational
1
LOOP ID - 2000E
0100
0200
Usage
Subscriber Name
Subscriber Supplemental
Identification
Subscriber Mailing Address
Subscriber City, State, ZIP
Code
Subscriber Request
Validation
Subscriber Demographic
Information
Subscriber Relationship
LOOP ID - 2010D
1700
1800
Notes
1
LOOP ID - 2000D
0100
Repeat
>1
Patient Event Level
Patient Event Tracking
Number
Patient Event Request
Validation
Health Care Services
Review Information
Health Care Services
Review
Administrative Reference
Number
Previous Review
Authorization Number
Accident Date
Last Menstrual Period Date
Estimated Date of Birth
Onset of Current Symptoms
or Illness Date
Event Date
Admission Date
Discharge Date
O
O
1
3
Situational
Situational
O
9
Situational
O
1
Required
O
1
Situational
O
1
Situational
O
1
Situational
O
O
O
O
1
1
1
1
Situational
Situational
Situational
Situational
O
O
O
1
1
1
Situational
Situational
Situational
2
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Pos
Id
Segment Name
0700
0700
0700
0800
0900
DTP
DTP
DTP
HI
HSD
1100
1200
CL1
CR1
1300
CR2
1400
CR5
1500
CR6
1550
PWK
1600
MSG
Certification Issue Date
Certification Expiration Date
Certification Effective Date
Patient Diagnosis
Health Care Services
Delivery
Institutional Claim Code
Ambulance Transport
Information
Spinal Manipulation Service
Information
Home Oxygen Therapy
Information
Home Health Care
Information
Additional Patient
Information
Message Text
Req
Max Use
O
O
O
O
O
1
1
1
1
1
Situational
Situational
Situational
Situational
Situational
O
O
1
1
Situational
Situational
O
1
Situational
O
1
Situational
O
1
Situational
O
10
Situational
O
1
LOOP ID - 2010EA
1700
NM1
1800
REF
2000
N3
2100
N4
2200
PER
2300
AAA
2400
PRV
Patient Event Provider
Name
Patient Event Provider
Supplemental Identification
Patient Event Provider
Address
Patient Event Provider City,
State, ZIP Code
Provider Contact
Information
Patient Event Provider
Request Validation
Patient Event Provider
Information
NM1
2000
N3
2100
N4
2200
PER
Additional Patient
Information Contact Name
Additional Patient
Information Contact
Address
Additional Patient
Information Contact City,
State, ZIP Code
Additional Patient
Information Contact
Information
NM1
2000
N3
2100
N4
Patient Event Transport
Information
Patient Event Transport
Location Address
Patient Event Transport
Usage
Situational
O
1
Situational
O
7
Situational
O
1
Situational
O
1
Situational
O
1
Situational
O
9
Situational
O
1
Situational
O
1
Situational
O
1
Situational
O
1
Situational
O
1
Situational
O
1
Situational
O
1
Required
O
1
Required
1
LOOP ID - 2010EC
1700
Notes
14
LOOP ID - 2010EB
1700
Repeat
5
3
For internal use only
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Pos
Id
2300
AAA
Segment Name
Location City/State/ZIP
Code
Patient Event Transport
Location Request Validation
Req
Max Use
O
9
Service Level
Service Trace Number
Service Request Validation
Health Care Services
Review Information
Health Care Services
Review
Administrative Reference
Number
Previous Review
Authorization Number
Service Date
Certification Issue Date
Certification Expiration Date
Certification Effective Date
Request For Additional
Information
Professional Service
Institutional Service Line
Dental Service
Tooth Information
Health Care Services
Delivery
Additional Service
Information
Message Text
O
O
O
O
1
3
9
1
Situational
Situational
Situational
Situational
O
1
Situational
O
1
Situational
O
1
Situational
O
O
O
O
O
1
1
1
1
1
Situational
Situational
Situational
Situational
Situational
O
O
O
O
O
1
1
1
32
1
Situational
Situational
Situational
Situational
Situational
O
10
Situational
O
1
Situational
O
O
1
8
Situational
Situational
O
O
1
1
Situational
Situational
O
1
Situational
O
9
Situational
O
1
Situational
O
1
Situational
O
1
Situational
LOOP ID - 2000F
0100
0200
0300
0400
HL
TRN
AAA
UM
0500
HCR
0600
REF
0600
REF
0700
0700
0700
0700
0800
DTP
DTP
DTP
DTP
HI
0810
0820
0830
0840
0900
SV1
SV2
SV3
TOO
HSD
1550
PWK
1600
MSG
NM1
REF
2000
2100
N3
N4
2200
PER
2300
AAA
2400
PRV
Service Provider Name
Service Provider
Supplemental Identification
Service Provider Address
Service Provider City, State,
ZIP Code
Service Provider Contact
Information
Service Provider Request
Validation
Service Provider
Information
NM1
2000
N3
Usage
Situational
12
LOOP ID - 2010FB
1700
Notes
>1
LOOP ID - 2010FA
1700
1800
Repeat
Additional Service
Information Contact Name
Additional Service
Information Contact
Address
1
4
For internal use only
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Pos
Id
Segment Name
2100
N4
2200
PER
2800
SE
Additional Service
Information Contact City,
State, ZIP Code
Additional Service
Information Contact
Information
Transaction Set Trailer
Req
Max Use
Repeat
Notes
Usage
O
1
Required
O
1
Situational
M
1
Required
Req
Max Use
M
M
1
1
Not Defined:
Pos
Id
Segment Name
GE
IEA
Functional Group Trailer
Interchange Control Trailer
Repeat
Notes
Usage
Required
Required
It is required that separate transaction sets be used for different patients.
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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 identifying the type of information in the Authorization Information
CodeList Summary (Total Codes: 7, Included: 2)
Code Name
00
03
ISA02
I02
No Authorization Information Present (No Meaningful Information in I02)
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 identifying the type of information in the Security Information
CodeList Summary (Total Codes: 2, Included: 2)
Code Name
00
01
ISA04
I04
No Security Information Present (No Meaningful Information in I04)
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: Code indicating 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: 41, Included: 9)
Code Name
01
14
20
Duns (Dun & Bradstreet)
Duns Plus Suffix
Health Industry Number (HIN)
CODE SOURCE:
121: Health Industry Identification Number
27
28
Carrier Identification Number as assigned by Health Care Financing Administration
(HCFA)
Fiscal Intermediary Identification Number as assigned by Health Care Financing
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Code Name
Administration (HCFA)
29
Medicare Provider and Supplier Identification Number as assigned by Health Care
Financing Administration (HCFA)
30
U.S. Federal Tax Identification Number
33
National Association of Insurance Commissioners Company Code (NAIC)
ZZ
Mutually Defined
ISA06
I06
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: Code indicating 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: 41, Included: 9)
Code Name
01
14
20
Duns (Dun & Bradstreet)
Duns Plus Suffix
Health Industry Number (HIN)
CODE SOURCE:
121: Health Industry Identification Number
27
28
29
30
33
ZZ
ISA08
I07
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 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
Notes: Blue Shield of CA Receiver Id = 940360524
ISA09
I08
Interchange Date
M
DT
6/6
Required
M
TM
4/4
Required
1/1
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.
ISA11
I65
Repetition Separator
M
Description: Type is not applicable; the repetition separator is a delimiter and not a data
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Ref
Id
Element Name
Req
Type
Min/Max
Usage
element; this field provides the delimiter used to separate repeated occurrences of a
simple data element or a composite data structure; this value must be different than the
data element separator, component element separator, and the segment terminator
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: 20, Included: 1)
Code Name
00501 Standards Approved for Publication by ASC X12 Procedures Review Board
through October 2003
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.
Must be a positive unsigned number and must be identical to the value in IEA02.
ISA14
I13
Acknowledgment Requested
M
ID
1/1
Required
Description: Code indicating sender's request for an interchange acknowledgment
See Section B.1.1.5.1 for interchange acknowledgment information.
CodeList Summary (Total Codes: 2, Included: 2)
Code Name
0
1
ISA15
I14
No Interchange Acknowledgment Requested
Interchange Acknowledgment Requested (TA1)
Interchange Usage Indicator
M
ID
1/1
Required
Description: Code indicating 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
TR3 Notes:
1. All positions within each of the data elements must be filled.
2. For compliant implementations under this implementation guide, ISA13, the interchange Control Number, must
be a positive unsigned number. Therefore, the ISA segment can be considered a fixed record length segment.
3. The first element separator defines the element separator to be used through the entire interchange.
4. The ISA segment terminator defines the segment terminator used throughout the entire interchange.
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5. Spaces in the example interchanges are represented by “.” for clarity.
TR3 Example:
ISA*00*..........*01*SECRET....*ZZ*SUBMITTERS.ID..*ZZ*RECEIVERS.ID...*030101*1253*^*00501*000000905*1
*T*:~
9
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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
This is the 2-character Functional Identifier Code assigned to each transaction set by X12.
The specific code for a transaction set defined by this implementation guide is presented in
section 1.2, Version Information.
CodeList Summary (Total Codes: 262, Included: 1)
Code Name
HI
GS02
142
Health Care Services Review Information (278)
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
Notes: Blue Shield of CA Receiver Id = 940360524
Use this code to identify the unit receiving the information.
GS04
373
Date
M
DT
8/8
Required
Description: Date expressed as CCYYMMDD where CC represents the first two digits of
the calendar year
Use this date for the functional group creation date.
GS05
337
Time
M
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)
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
For implementations compliant with this guide, GS06 must be unique within a single
transmission (that is, within a single ISA to IEA enveloping structure). The authors
recommend that GS06 be unique within all transmissions over a period of time to be
determined by the sender.
GS07
455
Responsible Agency Code
M
ID
1/2
Required
Description: Code identifying the issuer of the standard; this code is used in conjunction
with Data Element 480
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Id
Element Name
Req
Type
Min/Max
Usage
AN
1/12
Required
CodeList Summary (Total Codes: 2, Included: 1)
Code Name
X
GS08
480
Accredited Standards Committee X12
Version / Release / Industry Identifier
Code
M
Description: Code indicating the version, release, subrelease, and industry identifier of the
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
CODE SOURCE: 881: Version / Release / Industry Identifier Code
This is the unique Version/Release/Industry Identifier Code assigned to an implementation
by X12N. The specific code for a transaction set defined by this implementation guide is
presented in section 1.2, Version Information.
CodeList Summary (Total Codes: 65, Included: 1)
Code
Name
005010X21
7
Standards Approved for Publication by ASC X12 Procedures Review Board
through October 2003
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.
TR3 Example:
GS*XX*SENDER CODE*RECEIVERCODE*19991231*0802*1*X*005010X212~
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Pos: 0100
ST Transaction Set Header
Max: 1
Heading - Mandatory
Loop: N/A
Elements: 3
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
CodeList Summary (Total Codes: 318, Included: 1)
Code Name
278
ST02
329
Health Care Services Review Information
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
The Transaction Set Control Numbers in ST02 and SE02 must be identical. The number is
assigned by the originator and must be unique within a functional group (GS-GE). For
example, start with the number 0001 and increment from there. The number also aids in
error resolution research. Use the corresponding value in SE02 for this transaction set.
ST03
1705
Implementation Convention Reference
O
AN
1/35
Required
Description: Reference assigned to identify Implementation Convention
IMPLEMENTATION NAME: Implementation Guide Version Name
This element must be populated with the guide identifier named in Section 1.2.
This field contains the same value as GS08. Some translator products strip off the ISA and
GS segments prior to application (STSE) processing. Providing the information from the
GS08 at this level will ensure that the appropriate application mapping is utilized at
translation time.
Semantics:
1. The transaction set identifier (ST01) is used by the translation routines of the interchange partners to select
the appropriate transaction set definition (e.g., 810 selects the Invoice Transaction Set).
2. The implementation convention reference (ST03) is used by the translation routines of the interchange
partners to select the appropriate implementation convention to match the transaction set definition. When
used, this implementation convention reference takes precedence over the implementation reference
specified in the GS08.
TR3 Notes:
1. This segment indicates the start of a health care services review information response transaction set with all
the supporting detail information. This transaction set is the electronic equivalent of a phone, fax, or paper-based
utilization management response.
TR3 Example:
ST*278*0001*005010X217~
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Pos: 0200
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: 81, Included: 1)
Code Name
0007 Information Source, Information Receiver, Subscriber, Dependent, Event, Services
BHT02
353
Transaction Set Purpose Code
M
ID
2/2
Required
1/50
Required
Description: Code identifying purpose of transaction set
CodeList Summary (Total Codes: 66, Included: 1)
Code Name
11
BHT03
127
Response
Reference Identification
O
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
IMPLEMENTATION NAME: Submitter Transaction Identifier
Return the transaction identifier entered in BHT03 on the 278 request.
BHT04
373
Date
O
DT
8/8
Required
Description: Date expressed as CCYYMMDD where CC represents the first two digits of
the calendar year
IMPLEMENTATION NAME: Transaction Set Creation Date
BHT05
337
Time
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)
IMPLEMENTATION NAME: Transaction Set Creation Time
BHT06
640
Transaction Type Code
O
ID
2/2
Required
Description: Code specifying the type of transaction
CodeList Summary (Total Codes: 534, Included: 4)
Code Name
18
Response - No Further Updates to Follow
Use this code to indicate that this is a final response. This indicates that no
additional EDI responses are necessary or forthcoming from the UMO in relation to
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Code Name
the original request.
19
Response - Further Updates to Follow
Use this code to indicate that one or more of the services requested are pending
further review and an EDI response will be delivered later.
AT
Administrative Action
BHT06 must be valued with “AT” if this 278 response contains a request for
additional information.
Delivery of follow-up response(s) is as mutually agreed by trading partners.
RU
Medical Services Reservation
Use this code to respond to a request for medical services reservations.
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.
TR3 Example:
BHT*0007*11*200300114000001*20050501*1400*18~
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Pos: 0100
Loop Utilization Management
Organization (UMO) 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
0100
HL
0300
1700
AAA
Utilization Management Organization
(UMO) Level
Request Validation
Loop 2010A
15
Req
Max Use
M
1
O
O
9
Repeat
Usage
Required
1
Situational
Required
For internal use only
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Pos: 0100
HL Utilization Management
Max: 1
Detail - Mandatory
Organization (UMO) 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
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: 250, 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: 2)
Code Name
0
1
No Subordinate HL Segment in This Hierarchical Structure.
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.
TR3 Notes:
1. This segment indicates the information source hierarchical level. The information source corresponds to the
payer, HMO, or other utilization management organization that is the source of the health care services review
decision/response.
TR3 Example:
HL*1**20*1~
16
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Pos: 0300
AAA Request Validation
Max: 9
Detail - Optional
Loop:
2000A
Elements: 3
User Option (Usage): Situational
Purpose: To specify the validity of the request and indicate follow-up action authorized
Element Summary:
Ref
Id
Element Name
AAA01
1073
Yes/No Condition or Response Code
Req
Type
Min/Max
Usage
M
ID
1/1
Required
Description: Code indicating a Yes or No condition or response
IMPLEMENTATION NAME: Valid Request Indicator
CodeList Summary (Total Codes: 4, Included: 2)
Code Name
AAA03
901
N
No
Use this code to indicate that the request or an element in the request is not valid.
The transaction has been rejected as identified by the code in AAA03.
Y
Yes
Use this code to indicate that the request is valid, however the transaction has
been rejected as identified by the code in AAA03.
Reject Reason Code
O
ID
2/2
Required
Description: Code assigned by issuer to identify reason for rejection
CodeList Summary (Total Codes: 204, Included: 4)
Code Name
AAA04
889
04
Authorized Quantity Exceeded
Use this code to indicate that the functional group exceeds the maximum number
of transactions as specified by agreement between the application sender GS02
and application receiver GS03.
41
Authorization/Access Restrictions
Use this code to indicate that the application sender (GS02) and application
receiver (GS03) do not have a trading partner agreement for the transaction sets
identified in GS01 or transaction sets with the purpose identified in BHT02. The
278 transaction set has three different implementations. The transaction set
purpose, as identified in BHT02, specifies the implementation.
42
Unable to Respond at Current Time
Use this code to indicate that the entity responsible for forwarding the request to
the information source (Loop 2010A) is unable to process the transaction at the
current time. This indicates a problem in the system forwarding the request and
not in the information source’s (UMO) system.
79
Invalid Participant Identification
Use this code to indicate that the identifier used in GS02 or GS03 is invalid or
unknown.
Follow-up Action Code
O
ID
1/1
Required
Description: Code identifying follow-up actions allowed
CodeList Summary (Total Codes: 10, Included: 4)
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Code Name
C
N
P
Y
Please Correct and Resubmit
Resubmission Not Allowed
Please Resubmit Original Transaction
Do Not Resubmit; We Will Hold Your Request and Respond Again Shortly
Semantics:
1. AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N"
indicates that the code is invalid.
Comments:
1. If AAA02 is used, AAA03 contains a code from an industry code list.
Situational Rule:
Required when the request cannot be processed at a system or application level based on the trading partner
information contained in the Functional Group Header (GS). If not required by this implementation guide, do not
send.
TR3 Example:
AAA*Y**42*Y~
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Pos: 1700
Loop Utilization Management
Organization (UMO) Name
Repeat: 1
Optional
Loop:
2010A
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
1700
NM1
2200
PER
2300
AAA
Utilization Management Organization
(UMO) Name
Utilization Management Organization
(UMO) Contact Information
Utilization Management Organization
(UMO) Request Validation
19
Req
Max Use
Repeat
Usage
O
1
Required
O
1
Situational
O
9
Situational
For internal use only
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Pos: 1700
NM1 Utilization Management
Max: 1
Detail - Optional
Organization (UMO) Name
Loop:
2010A
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: 1500, Included: 4)
Code Name
2B
36
PR
X3
NM102
1065
Third-Party Administrator
Employer
Payer
Utilization Management Organization
Entity Type Qualifier
M
ID
1/1
Required
AN
1/60
Situational
Description: Code qualifying the type of entity
CodeList Summary (Total Codes: 16, Included: 2)
Code Name
1
2
NM103
1035
Person
Non-Person Entity
Name Last or Organization Name
X
Description: Individual last name or organizational name
Situational Rule: Required when the responder needs to identify the UMO by name. If not
required by this implementation guide, do not send.
IMPLEMENTATION NAME: Utilization Management Organization (UMO) Last or
Organization Name
NM104
1036
Name First
O
AN
1/35
Situational
Description: Individual first name
Situational Rule: Required when NM103 is valued and the reviewing entity is an individual
(NM102 = 1), such as a primary care provider. If not required by this implementation guide,
do not send.
IMPLEMENTATION NAME: Utilization Management Organization (UMO) First Name
NM105
1037
Name Middle
O
AN
1/25
Situational
Description: Individual middle name or initial
Situational Rule: Required when NM104 is present and the middle name/initial of the
person is known. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Utilization Management Organization (UMO) Middle Name
NM107
1039
Name Suffix
O
20
AN
1/10
Situational
For internal use only
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Id
Element Name
Description: Suffix to individual name
Req
Type
Min/Max
Usage
Situational Rule: Required when NM104 is valued and the suffix of the individual’s name
is known; e.g. Sr., Jr., or III. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Utilization Management Organization (UMO) Name Suffix
NM108
66
Identification Code Qualifier
X
ID
1/2
Required
Description: Code designating the system/method of code structure used for Identification
Code (67)
CodeList Summary (Total Codes: 241, Included: 5)
Code Name
24
34
46
PI
Employer's Identification Number
Social Security Number
Electronic Transmitter Identification Number (ETIN)
Payor Identification
Use until the National PlanID is mandated if the UMO is a payer.
XV
Centers for Medicare and Medicaid Services PlanID
CODE SOURCE:
540: Centers for Medicare and Medicaid Services PlanID
NM109
67
Identification Code
X
AN
2/80
Required
Description: Code identifying a party or other code
IMPLEMENTATION NAME: Utilization Management Organization (UMO) Identifier
ExternalCodeList
Name: 540
Description: Centers for Medicare and Medicaid Services 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.
3. C1203 - If NM112 is present, then NM103 is required.
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
2. NM112 can identify a second surname.
TR3 Notes:
1. This segment identifies the source of information. In the case of a response to a request transaction, the
information source would normally be the payer or utilization review organization who is the source of the decision
regarding the request.
TR3 Example:
NM1*X3*2*ABC PAYER*****46*123450000~
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Pos: 2200
PER Utilization Management
Max: 1
Detail - Optional
Organization (UMO) Contact
Information
Loop:
2010A
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: 238, Included: 1)
Code Name
IC
PER02
93
Information Contact
Name
O
AN
1/60
Situational
Description: Free-form name
Situational Rule: Required when a particular contact is assigned and the name of the
entity to contact is not already defined in the NM1 segment in this loop (2010A NM1
Segment). If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Utilization Management Organization (UMO) Contact Name
PER03
365
Communication Number Qualifier
X
ID
2/2
Situational
Description: Code identifying the type of communication number
Situational Rule: Required when PER02 is not valued in order to transmit a contact
communication number. If not required by this implementation guide, do not send.
CodeList Summary (Total Codes: 42, Included: 4)
Code Name
EM
FX
TE
UR
PER04
364
Electronic Mail
Facsimile
Telephone
Uniform Resource Locator (URL)
Must not contain any characters used as delimiters in this transaction.
Communication Number
X
AN
1/256
Situational
Description: Complete communications number including country or area code when
applicable
Situational Rule: Required when PER02 is not valued in order to transmit a contact
communication number. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Utilization Management Organization (UMO) Contact
Communication Number
PER05
365
Communication Number Qualifier
X
ID
2/2
Situational
Description: Code identifying the type of communication number
Situational Rule: Required when a telephone extension or multiple communication types
22
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Id
Element Name
Req
Type
Min/Max
are available. If not required by this implementation guide, do not send.
Usage
CodeList Summary (Total Codes: 42, Included: 5)
Code Name
PER06
364
EM
EX
Electronic Mail
Telephone Extension
When used, the value following this code is the extension for the preceding
communications contact number.
FX
TE
UR
Facsimile
Telephone
Uniform Resource Locator (URL)
Must not contain any characters used as delimiters in this transaction.
Communication Number
X
AN
1/256
Situational
Description: Complete communications number including country or area code when
applicable
Situational Rule: Required when a telephone extension or multiple communication types
are available. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Utilization Management Organization (UMO) Contact
Communication Number
PER07
365
Communication Number Qualifier
X
ID
2/2
Situational
Description: Code identifying the type of communication number
Situational Rule: Required when a telephone extension or multiple communication types
are available. If not required by this implementation guide, do not send.
CodeList Summary (Total Codes: 42, Included: 5)
Code Name
PER08
364
EM
EX
Electronic Mail
Telephone Extension
When used, the value following this code is the extension for the preceding
communications contact number.
FX
TE
UR
Facsimile
Telephone
Uniform Resource Locator (URL)
Must not contain any characters used as delimiters in this transaction.
Communication Number
X
AN
1/256
Situational
Description: Complete communications number including country or area code when
applicable
Situational Rule: Required when a telephone extension or multiple communication types
are available. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Utilization Management Organization (UMO) Contact
Communication Number
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.
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Situational Rule:
Required when the requester must direct requests for follow-up to a specific UMO contact, email, facsimile, or
telephone. If not required by this implementation guide, do not send.
TR3 Notes:
1. Use this segment to identify a contact name and/or communications number for the UMO.
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 telephone 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.
TR3 Example:
PER*IC*ORCUTT*TE*8189991234*FX*8188769304~
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Pos: 2300
AAA Utilization Management
Max: 9
Detail - Optional
Organization (UMO) Request Loop:
2010A
Validation
Elements: 3
User Option (Usage): Situational
Purpose: To specify the validity of the request and indicate follow-up action authorized
Element Summary:
Ref
Id
Element Name
AAA01
1073
Yes/No Condition or Response Code
Req
Type
Min/Max
Usage
M
ID
1/1
Required
2/2
Required
Description: Code indicating a Yes or No condition or response
IMPLEMENTATION NAME: Valid Request Indicator
CodeList Summary (Total Codes: 4, Included: 1)
Code Name
N
AAA03
901
No
Reject Reason Code
O
ID
Description: Code assigned by issuer to identify reason for rejection
CodeList Summary (Total Codes: 204, Included: 4)
Code Name
AAA04
889
42
Unable to Respond at Current Time
Use this code to indicate that the information source (UMO) identified in Loop
2010A is unable to process the transaction at the current time.
79
Invalid Participant Identification
Use this code to indicate that the code used in Loop 2010A to identify the
information source (UMO) is invalid.
80
No Response received - Transaction Terminated
Use this code to indicate that the trading partner/application system responsible
for sending the request to the information source (UMO) has not received a
response in the expected timeframe and therefore has terminated the request.
T4
Payer Name or Identifier Missing
Use this code to indicate that either the name or
identifier for the information source (UMO) identified in Loop 2010A is missing.
Follow-up Action Code
O
ID
1/1
Required
Description: Code identifying follow-up actions allowed
CodeList Summary (Total Codes: 10, Included: 3)
Code Name
N
P
Y
Resubmission Not Allowed
Please Resubmit Original Transaction
Do Not Resubmit; We Will Hold Your Request and Respond Again Shortly
Semantics:
1. AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N"
indicates that the code is invalid.
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Comments:
1. If AAA02 is used, AAA03 contains a code from an industry code list.
Situational Rule:
Required when the request cannot be processed at the system or application level based on the Utilization
Management Organization (information source) identified in Loop 2010A. If not required by this implementation
guide, do not send.
TR3 Example:
AAA*N**42*Y~
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Pos: 0100
Loop Requester Level
Repeat: 1
Optional
Loop:
2000B
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
Req
Max Use
0100
1700
HL
Requester Level
Loop 2010B
O
O
1
27
Repeat
Usage
2
Situational
Required
For internal use only
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Pos: 0100
HL Requester Level
Max: 1
Detail - Optional
Loop:
2000B
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: 250, Included: 1)
Code Name
21
HL04
736
Information Receiver
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: 2)
Code Name
0
1
No Subordinate HL Segment in This Hierarchical Structure.
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.
Situational Rule:
Required when the UMO system processed any of the information contained in Loop 2000B. If not required by
this implementation guide, do not send.
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TR3 Notes:
1. If the UMO system was unable to process any data beyond Loop 2000A, Loop 2000B is not used.
2. This segment indicates the health care services review information receiver. For responses to request
transactions, this segment corresponds to the identification of the provider who initiated the request for review.
TR3 Example:
HL*2*1*21*1~
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Pos: 1700
Loop Requester Name
Repeat: 2
Optional
Loop:
2010B
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
1700
1800
2300
2400
NM1
REF
AAA
PRV
Requester
Requester
Requester
Requester
Name
Supplemental Identification
Request Validation
Provider Information
30
Req
Max Use
O
O
O
O
1
8
9
1
Repeat
Usage
Required
Situational
Situational
Situational
For internal use only
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Pos: 1700
NM1 Requester Name
Max: 1
Detail - Optional
Loop:
2010B
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: 1500, Included: 2)
Code Name
1P
FA
NM102
1065
Provider
Facility
Entity Type Qualifier
M
ID
1/1
Required
AN
1/60
Situational
Description: Code qualifying the type of entity
CodeList Summary (Total Codes: 16, Included: 2)
Code Name
1
2
NM103
1035
Person
Non-Person Entity
Name Last or Organization Name
X
Description: Individual last name or organizational name
Situational Rule: Required when name information is used by the UMO to identify the
requester. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Requester Last or Organization Name
NM104
1036
Name First
O
AN
1/35
Situational
Description: Individual first name
Situational Rule: Required when name information is used by the UMO to identify the
requester and the requester is a person. If not required by this implementation guide, do
not send.
IMPLEMENTATION NAME: Requester First Name
NM105
1037
Name Middle
O
AN
1/25
Situational
Description: Individual middle name or initial
Situational Rule: Required when NM104 is present and the middle name/initial of the
person is known. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Requester Middle Name
NM107
1039
Name Suffix
O
AN
1/10
Situational
Description: Suffix to individual name
Situational Rule: Required when NM104 is valued and the suffix of the individual’s name
is known; e.g. Sr., Jr., or III. If not required by this implementation guide, do not send.
31
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Id
Element Name
Req
Type
Min/Max
Usage
ID
1/2
Required
IMPLEMENTATION NAME: Requester Name Suffix
NM108
66
Identification Code Qualifier
X
Description: Code designating the system/method of code structure used for Identification
Code (67)
CodeList Summary (Total Codes: 241, Included: 4)
Code Name
24
34
46
XX
Employer's Identification Number
Social Security Number
Electronic Transmitter Identification Number (ETIN)
Centers for Medicare and Medicaid Services National Provider Identifier
CODE SOURCE:
537: Centers for Medicare and Medicaid Services National Provider Identifier
NM109
67
Identification Code
X
AN
2/80
Required
Description: Code identifying a party or other code
IMPLEMENTATION NAME: Requester Identifier
ExternalCodeList
Name: 537
Description: Centers for Medicare and Medicaid Services 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.
3. C1203 - If NM112 is present, then NM103 is required.
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
2. NM112 can identify a second surname.
TR3 Notes:
1. This loop identifies the receiver of information. In the case of a response to a request transaction, the receiver
would normally be the provider who is receiving the decision.
TR3 Example:
NM1*1P*1*GARDNER*JAMES****24*000012345~
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Pos: 1800
REF Requester Supplemental
Max: 8
Detail - Optional
Identification
Loop:
2010B
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: 1731, Included: 8)
Code Name
REF02
127
1G
1J
EI
Provider UPIN Number
Facility ID Number
Employer's Identification Number
Not used if NM108 = 24.
G5
Provider Site Number
Use to identify the physician, clinic, or group practice associated with the
requester identified in this NM1 loop.
N5
N7
SY
Provider Plan Network Identification Number
Facility Network Identification Number
Social Security Number
The social security number must not be used for Medicare. Not used if NM108 =
34.
ZH
Carrier Assigned Reference Number
Use for the requester/provider ID as assigned by the UMO identified in Loop
2000A.
Reference Identification
X
AN
1/50
Required
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
IMPLEMENTATION NAME: Requester 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.
Situational Rule:
Required when used by the UMO to identify the requester. If not required by this implementation guide, do not
send.
TR3 Example:
REF*1G*123456~
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Pos: 2300
AAA Requester Request
Max: 9
Detail - Optional
Validation
Loop:
2010B
Elements: 3
User Option (Usage): Situational
Purpose: To specify the validity of the request and indicate follow-up action authorized
Element Summary:
Ref
Id
Element Name
AAA01
1073
Yes/No Condition or Response Code
Req
Type
Min/Max
Usage
M
ID
1/1
Required
2/2
Required
Description: Code indicating a Yes or No condition or response
IMPLEMENTATION NAME: Valid Request Indicator
CodeList Summary (Total Codes: 4, Included: 1)
Code Name
N
AAA03
901
No
Reject Reason Code
O
ID
Description: Code assigned by issuer to identify reason for rejection
CodeList Summary (Total Codes: 204, Included: 12)
Code Name
AAA04
889
15
Required application data missing
Use for missing contact information (PER Segment) other than phone number.
35
41
Out of Network
Authorization/Access Restrictions
Use if the provider is not authorized for requests.
43
44
45
46
47
49
51
79
Invalid/Missing Provider Identification
Invalid/Missing Provider Name
Invalid/Missing Provider Specialty
Invalid/Missing Provider Phone Number
Invalid/Missing Provider State
Provider is Not Primary Care Physician
Provider Not on File
Invalid Participant Identification
Use for invalid/missing requester supplemental
identifier.
97
Invalid or Missing Provider Address
Follow-up Action Code
O
ID
1/1
Required
Description: Code identifying follow-up actions allowed
CodeList Summary (Total Codes: 10, Included: 3)
Code Name
C
N
R
Please Correct and Resubmit
Resubmission Not Allowed
Resubmission Allowed
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Semantics:
1. AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N"
indicates that the code is invalid.
Comments:
1. If AAA02 is used, AAA03 contains a code from an industry code list.
Situational Rule:
Required when the request is not valid at this level. If not required by this implementation guide, do not send.
TR3 Notes:
1. Use this segment to convey rejection information regarding the entity that initiated a request transaction.
TR3 Example:
AAA*N**46*C~
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Pos: 2400
PRV Requester Provider
Max: 1
Detail - Optional
Information
Loop:
2010B
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
Situational
Description: Code identifying the type of provider
CodeList Summary (Total Codes: 26, Included: 11)
Code Name
AD
AS
AT
CO
CV
OP
OR
OT
PC
PE
RF
PRV02
128
Admitting
Assistant Surgeon
Attending
Consulting
Covering
Operating
Ordering
Other Physician
Primary Care Physician
Performing
Referring
Reference Identification Qualifier
X
Description: Code qualifying the Reference Identification
Situational Rule: Required when used by the UMO to identify the requester. If not
required by this implementation guide, do not send.
CodeList Summary (Total Codes: 1731, Included: 1)
Code Name
PXC
Health Care Provider Taxonomy Code
CODE SOURCE:
682: Health Care Provider Taxonomy
PRV03
127
Reference Identification
X
AN
1/50
Situational
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Situational Rule: Required when used by the UMO to identify the requester. If not
required by this implementation guide, do not send.
IMPLEMENTATION NAME: Provider Taxonomy Code
ExternalCodeList
Name: 682
Description: Health Care Provider Taxonomy
Syntax Rules:
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1. P0203 - If either PRV02 or PRV03 is present, then the other is required.
Situational Rule:
Required when used by the UMO to identify the requester. If not required by this implementation guide, do not
send.
TR3 Example:
PRV*CO*PXC*203BS0133X~
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Pos: 0100
Loop Subscriber 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
Req
Max Use
0100
1700
HL
Subscriber Level
Loop 2010C
O
O
1
38
Repeat
Usage
1
Situational
Required
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Pos: 0100
HL Subscriber 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: 250, 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
CodeList Summary (Total Codes: 2, Included: 2)
Code Name
0
1
No Subordinate HL Segment in This Hierarchical Structure.
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.
Situational Rule:
Required when the UMO system processed any of the information contained in Loop 2000C of the request. If not
required by this implementation guide, do not send.
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TR3 Notes:
1. If the UMO system was unable to process any data beyond Loop 2000B of the request, Loop 2000C is not
required.
2. This segment corresponds to the identification of the subscriber or individual insured member. The subscriber
could also be the patient. If the subscriber is the patient, the dependent hierarchical level (Loop 2000D) is not
used.
TR3 Example:
HL*3*2*22*1~
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Pos: 1700
Loop Subscriber Name
Repeat: 1
Optional
Loop:
2010C
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
1700
1800
2000
2100
2300
2500
2600
NM1
REF
N3
N4
AAA
DMG
INS
Subscriber
Subscriber
Subscriber
Subscriber
Subscriber
Subscriber
Subscriber
Name
Supplemental Identification
Mailing Address
City, State, ZIP Code
Request Validation
Demographic Information
Relationship
41
Req
Max Use
O
O
O
O
O
O
O
1
9
1
1
9
1
1
Repeat
Usage
Required
Situational
Situational
Situational
Situational
Situational
Situational
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Pos: 1700
NM1 Subscriber Name
Max: 1
Detail - Optional
Loop:
2010C
Elements: 9
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: 1500, Included: 1)
Code Name
IL
NM102
1065
Insured or Subscriber
Entity Type Qualifier
M
ID
1/1
Required
AN
1/60
Situational
Description: Code qualifying the type of entity
CodeList Summary (Total Codes: 16, Included: 1)
Code Name
1
NM103
1035
Person
Name Last or Organization Name
X
Description: Individual last name or organizational name
Situational Rule: Required when valued on the request. If not required by this
implementation guide, do not send.
IMPLEMENTATION NAME: Subscriber Last Name
NM104
1036
Name First
O
AN
1/35
Situational
Description: Individual first name
Situational Rule: Required when valued on the request. If not required by this
implementation guide, do not send.
IMPLEMENTATION NAME: Subscriber First Name
NM105
1037
Name Middle
O
AN
1/25
Situational
Description: Individual middle name or initial
Situational Rule: Required when valued on the request. If not required by this
implementation guide, do not send.
IMPLEMENTATION NAME: Subscriber Middle Name or Initial
NM106
1038
Name Prefix
O
AN
1/10
Situational
Description: Prefix to individual name
Situational Rule: Required when valued on the request. If not required by this
implementation guide, do not send.
IMPLEMENTATION NAME: Subscriber Name Prefix
NM107
1039
Name Suffix
O
42
AN
1/10
Situational
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Id
Element Name
Req
Type
Min/Max
Usage
Description: Suffix to individual name
Situational Rule: Required when valued on the request. If not required by this
implementation guide, do not send.
IMPLEMENTATION NAME: Subscriber Name Suffix
NM108
66
Identification Code Qualifier
X
ID
1/2
Required
Description: Code designating the system/method of code structure used for Identification
Code (67)
CodeList Summary (Total Codes: 241, Included: 2)
Code Name
NM109
67
II
Standard Unique Health Identifier for each Individual in the United States
The value “II” when used in this data element, shall be defined as “HIPAA
Individual Identifier” if this identifier has been adopted, under the Health Insurance
Portability and Accountability Act of 1996, for use in this transaction.
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. Use
MI - Member Identification Number to convey the following terms: Insured’s ID,
Subscriber’s ID, Health Insurance Claim Number (HIC), etc.
Identification Code
X
AN
2/80
Required
Description: Code identifying a party or other code
IMPLEMENTATION NAME: Subscriber Primary 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.
3. C1203 - If NM112 is present, then NM103 is required.
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
2. NM112 can identify a second surname.
TR3 Notes:
1. This segment identifies the subscriber.
TR3 Example:
NM1*IL*1*SMITH*JOE****MI*12345678901~
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Pos: 1800
REF Subscriber Supplemental
Max: 9
Detail - Optional
Identification
Loop:
2010C
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: 1731, Included: 11)
Code Name
REF02
127
1L
Group or Policy Number
Use this code only if you cannot determine if the number is a Group Number (6P)
or a Policy Number (IG).
3L
6P
DP
EJ
Branch Identifier
Group Number
Department Number
Patient Account Number
The maximum number of characters to be
supported for this qualifier is ‘20’. Characters
beyond the maximum are not required to be stored nor returned by any receiving
system.
F6
Health Insurance Claim (HIC) Number
Use the NM1 (Subscriber Name) segment if the subscriber’s HIC number is the
primary identifier for his or her coverage. Use this code only in a REF segment
when the payer has a different member number, and there also is a need to pass
the dependent’s HIC number. This might occur in a Medicare HMO situation.
HJ
Identity Card Number
Use this code when the Identity Card Number differs from the Member
Identification Number. This is particularly prevalent in the Medicaid environment.
IG
N6
NQ
SY
Insurance Policy Number
Plan Network Identification Number
Medicaid Recipient Identification Number
Social Security Number
Use this code only if the Social Security Number is not the primary identifier for the
subscriber. The social security number may not be used for Medicare.
Reference Identification
X
AN
1/50
Required
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
IMPLEMENTATION NAME: Subscriber Supplemental Identifier
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
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1. REF04 contains data relating to the value cited in REF02.
Situational Rule:
Required when used by the UMO to identify the Subscriber or when REF01 = “EJ” (Patient Account Number) is
valued on the request. If not required by this implementation guide, do not send.
TR3 Notes:
1. Health Insurance Claim (HIC) Number or Medicaid Recipient Identification Number are to be provided in the
NM1 segment as a Member Identification Number when it is the primary number a UMO knows a member by
(such as for Medicare or Medicaid). Do not use this segment for the Health Insurance Claim (HIC) Number or
Medicaid Recipient Identification Number unless they are different from the Member Identification Number
provided in the NM1 segment.
TR3 Example:
REF*SY*123456789~
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N3 Subscriber Mailing Address
Pos: 2000
Max: 1
Detail - Optional
Loop:
2010C
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
1/55
Situational
Description: Address information
IMPLEMENTATION NAME: Subscriber Address Line
Use this element for the first line of the Subscriber address.
N302
166
Address Information
O
AN
Description: Address information
Situational Rule: Required when a second address lines exists. If not required by this
implementation guide, do not send.
IMPLEMENTATION NAME: Subscriber Address Line
Situational Rule:
Required when used by the UMO to determine the appropriate location or network for service. If not required by
this implementation guide, do not send.
TR3 Example:
N3*PO Box 171021~
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Pos: 2100
N4 Subscriber City, State, ZIP
Max: 1
Detail - Optional
Code
Loop:
2010C
Elements: 5
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
ID
2/2
Situational
Description: Free-form text for city name
IMPLEMENTATION NAME: Subscriber City Name
N402
156
State or Province Code
X
Description: Code (Standard State/Province) as defined by appropriate government
agency
Situational Rule: Required when the address is in the United States of America, including
its territories, or Canada. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Subscriber State Code
CODE SOURCE: 22: States and Provinces
ExternalCodeList
Name: 22C
Description: States and Provinces
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)
Situational Rule: Required when the address is in the United States of America, including
its territories, or Canada, or when a postal code exists for the country in N404. If not
required by this implementation guide, do not send.
IMPLEMENTATION NAME: Subscriber Postal Zone or ZIP Code
CODE SOURCE: 51: ZIP Code
932: Universal Postal Codes
ExternalCodeList
Name: 932
Description:
ExternalCodeList
Name: 51
Description: ZIP Code
N404
26
Country Code
X
ID
2/3
Situational
Description: Code identifying the country
Situational Rule: Required when the address is outside the United States of America. If
not required by this implementation guide, do not send.
CODE SOURCE: 5: Countries, Currencies and Funds
Use the alpha-2 country codes from Part 1 of ISO 3166.
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Id
Element Name
Req
Type
Min/Max
Usage
ID
1/3
Situational
ExternalCodeList
Name: 5
Description: Countries, Currencies and Funds
N407
1715
Country Subdivision Code
X
Description: Code identifying the country subdivision
Situational Rule: Required when the address is not in the United States of America,
including its territories, or Canada, and the country in N404 has administrative subdivisions
such as but not limited to states, provinces, cantons, etc. If not required by this
implementation guide, do not send.
CODE SOURCE: 5: Countries, Currencies and Funds
Use the country subdivision codes from Part 2 of ISO 3166.
ExternalCodeList
Name: 5
Description: Countries, Currencies and Funds
Syntax Rules:
1. E0207 - Only one of N402 or N407 may be present.
2. C0605 - If N406 is present, then N405 is required.
3. C0704 - If N407 is present, then N404 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.
Situational Rule:
Required when used by the UMO to determine the appropriate location or network for service. If not required by
this implementation guide, do not send.
TR3 Example:
N4*KANSAS CITY*MO*64108~
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Pos: 2300
AAA Subscriber Request
Max: 9
Detail - Optional
Validation
Loop:
2010C
Elements: 3
User Option (Usage): Situational
Purpose: To specify the validity of the request and indicate follow-up action authorized
Element Summary:
Ref
Id
Element Name
AAA01
1073
Yes/No Condition or Response Code
Req
Type
Min/Max
Usage
M
ID
1/1
Required
2/2
Required
Description: Code indicating a Yes or No condition or response
IMPLEMENTATION NAME: Valid Request Indicator
CodeList Summary (Total Codes: 4, Included: 1)
Code Name
N
AAA03
901
No
Reject Reason Code
O
ID
Description: Code assigned by issuer to identify reason for rejection
CodeList Summary (Total Codes: 204, Included: 16)
Code Name
AAA04
889
58
64
65
66
67
68
71
72
73
74
75
76
77
78
79
Invalid/Missing Date-of-Birth
Invalid/Missing Patient ID
Invalid/Missing Patient Name
Invalid/Missing Patient Gender Code
Patient Not Found
Duplicate Patient ID Number
Patient Birth Date Does Not Match That for the Patient on the Database
Invalid/Missing Subscriber/Insured ID
Invalid/Missing Subscriber/Insured Name
Invalid/Missing Subscriber/Insured Gender Code
Subscriber/Insured Not Found
Duplicate Subscriber/Insured ID Number
Subscriber Found, Patient Not Found
Subscriber/Insured Not in Group/Plan Identified
Invalid Participant Identification
Use for invalid subscriber supplemental identifier.
95
Patient Not Eligible
Follow-up Action Code
O
ID
1/1
Required
Description: Code identifying follow-up actions allowed
CodeList Summary (Total Codes: 10, Included: 2)
Code Name
C
N
Please Correct and Resubmit
Resubmission Not Allowed
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Semantics:
1. AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N"
indicates that the code is invalid.
Comments:
1. If AAA02 is used, AAA03 contains a code from an industry code list.
Situational Rule:
Required when the request is not valid at this level. If not required by this implementation guide, do not send.
TR3 Example:
AAA*N**67*N~
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Pos: 2500
DMG Subscriber Demographic
Max: 1
Detail - Optional
Information
Loop:
2010C
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
X
ID
2/3
Required
Description: Code indicating the date format, time format, or date and time format
CodeList Summary (Total Codes: 42, Included: 1)
Code Name
D8
DMG02
1251
Date Expressed in Format CCYYMMDD
Date Time Period
X
AN
1/35
Required
Description: Expression of a date, a time, or range of dates, times or dates and times
IMPLEMENTATION NAME: Subscriber Birth Date
DMG03
1068
Gender Code
O
ID
1/1
Situational
Description: Code indicating the sex of the individual
Situational Rule: Required when used by the UMO to render a medical decision. If not
required by this implementation guide, do not send.
IMPLEMENTATION NAME: Subscriber Gender Code
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.
2. P1011 - If either DMG10 or DMG11 is present, then the other is required.
3. C1105 - If DMG11 is present, then DMG05 is required.
Semantics:
1.
2.
3.
4.
DMG02 is the date of birth.
DMG07 is the country of citizenship.
DMG09 is the age in years.
DMG11 is used to specify how the information in DMG05, including repeats of C056, was collected.
Situational Rule:
Required when used by the UMO to determine medical necessity. If not required by this implementation guide, do
not send.
TR3 Example:
DMG*D8*19580322*M~
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Pos: 2600
INS Subscriber Relationship
Max: 1
Detail - Optional
Loop:
2010C
Elements: 3
User Option (Usage): Situational
Purpose: To provide benefit information on insured entities
Element Summary:
Ref
Id
Element Name
INS01
1073
Yes/No Condition or Response Code
Req
Type
Min/Max
Usage
M
ID
1/1
Required
2/2
Required
Description: Code indicating a Yes or No condition or response
IMPLEMENTATION NAME: Insured Indicator
CodeList Summary (Total Codes: 4, Included: 1)
Code Name
Y
INS02
1069
Yes
Individual Relationship Code
M
ID
Description: Code indicating the relationship between two individuals or entities
CodeList Summary (Total Codes: 154, Included: 1)
Code Name
18
INS08
584
Self
Employment Status Code
O
ID
2/2
Required
Description: Code showing the general employment status of an employee/claimant
Use to qualify the patient’s relationship to the military.
CodeList Summary (Total Codes: 91, Included: 5)
Code Name
AO
AU
DI
PV
RU
Active Military - Overseas
Active Military - USA
Deceased
Previous
Retired Military - USA
Syntax Rules:
1. P1112 - If either INS11 or INS12 is present, then the other is required.
Semantics:
1. INS01 indicates status of the insured. A "Y" value indicates the insured is a subscriber: an "N" value indicates
the insured is a dependent.
2. INS10 is the handicapped status indicator. A "Y" value indicates an individual is handicapped; an "N" value
indicates an individual is not handicapped.
3. INS12 is the date of death.
4. INS14, INS15, and INS16 identify where the employee works.
5. INS17 is the number assigned to each family member born with the same birth date. This number identifies
birth sequence for multiple births allowing proper tracking and response of benefits for each dependent (i.e.,
twins, triplets, etc.).
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Situational Rule:
Required when used by the UMO to determine the appropriate benefit/level of care. If not required by this
implementation guide, do not send.
TR3 Example:
INS*Y*18******AO~
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Pos: 0100
Loop Dependent Level
Repeat: 1
Optional
Loop:
2000D
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
Req
Max Use
0100
1700
HL
Dependent Level
Loop 2010D
O
O
1
54
Repeat
Usage
1
Situational
Required
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Pos: 0100
HL Dependent Level
Max: 1
Detail - Optional
Loop:
2000D
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: 250, Included: 1)
Code Name
23
HL04
736
Dependent
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: 2)
Code Name
0
1
No Subordinate HL Segment in This Hierarchical Structure.
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.
Situational Rule:
Required when the UMO system processed any of the information contained in Loop 2000D of the request. If not
required by this implementation guide, do not send.
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TR3 Notes:
1. If the UMO system was unable to process any data beyond Loop 2000C of the request, Loop 2000D is not
required.
TR3 Example:
HL*4*3*23*1~
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Pos: 1700
Loop Dependent Name
Repeat: 1
Optional
Loop:
2010D
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
1700
1800
2000
2100
2300
2500
2600
NM1
REF
N3
N4
AAA
DMG
INS
Dependent Name
Dependent Supplemental Identification
Dependent Address
Dependent City, State, ZIP Code
Dependent Request Validation
Dependent Demographic Information
Dependent Relationship
57
Req
Max Use
O
O
O
O
O
O
O
1
3
1
1
9
1
1
Repeat
Usage
Required
Situational
Situational
Situational
Situational
Situational
Situational
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Pos: 1700
NM1 Dependent Name
Max: 1
Detail - Optional
Loop:
2010D
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: 1500, Included: 1)
Code Name
QC
NM102
1065
Patient
Entity Type Qualifier
M
ID
1/1
Required
AN
1/60
Situational
Description: Code qualifying the type of entity
CodeList Summary (Total Codes: 16, Included: 1)
Code Name
1
NM103
1035
Person
Name Last or Organization Name
X
Description: Individual last name or organizational name
Situational Rule: Required when valued on the request. If not required by this
implementation guide, do not send.
IMPLEMENTATION NAME: Dependent Last Name
NM104
1036
Name First
O
AN
1/35
Situational
Description: Individual first name
Situational Rule: Required when valued on the request. If not required by this
implementation guide, do not send.
IMPLEMENTATION NAME: Dependent First Name
NM105
1037
Name Middle
O
AN
1/25
Situational
Description: Individual middle name or initial
Situational Rule: Required when valued on the request. If not required by this
implementation guide, do not send.
IMPLEMENTATION NAME: Dependent Middle Name
NM107
1039
Name Suffix
O
AN
1/10
Situational
Description: Suffix to individual name
Situational Rule: Required when valued on the request. If not required by this
implementation guide, do not send.
IMPLEMENTATION NAME: Dependent Name Suffix
NM108
66
Identification Code Qualifier
X
58
ID
1/2
Situational
For internal use only
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Id
Element Name
Req
Type
Min/Max
Usage
Description: Code designating the system/method of code structure used for Identification
Code (67)
Situational Rule: Required when the dependent has a unique member ID assigned by the
UMO that was not known or provided by the requester at the time of the request. If not
required by this implementation guide, do not send.
CodeList Summary (Total Codes: 241, Included: 2)
Code Name
NM109
67
II
Standard Unique Health Identifier for each Individual in the United States
The value “II” when used in this data element, shall be defined as “HIPAA
Individual Identifier” if this identifier has been adopted. Under the Health Insurance
Portability and Accountability Act of 1996, the Secretary of Health and Human
Services must adopt a standard individual identifier for use in this transaction.
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. Use
MI - Member Identification Number to convey the following terms: Insured’s ID,
Subscriber’s ID, Health Insurance Claim Number (HIC), etc.
Identification Code
X
AN
2/80
Situational
Description: Code identifying a party or other code
Situational Rule: Required when the dependent has a unique member ID assigned by the
UMO that was not known or provided by the requester at the time of the request. If not
required by this implementation guide, do not send.
IMPLEMENTATION NAME: Dependent Primary 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.
3. C1203 - If NM112 is present, then NM103 is required.
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
2. NM112 can identify a second surname.
TR3 Notes:
1. This segment conveys the name of the dependent who is the patient.
2. NM108 and NM109 are situational on the response but Not Used on the request. This enables the UMO to
return a unique member ID for the dependent that was not known to the requester at the time of the request.
When the dependent has a unique member ID, Loop 2000D is not used.
TR3 Example:
NM1*QC*1*SMITH*MARY~
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Pos: 1800
REF Dependent Supplemental
Max: 3
Detail - Optional
Identification
Loop:
2010D
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: 1731, Included: 2)
Code Name
REF02
127
EJ
Patient Account Number
The maximum number of characters to be
supported for this qualifier is ‘20’. Characters
beyond the maximum are not required to be stored nor returned by any receiving
system.
SY
Social Security Number
The social security number may not be used for Medicare.
Reference Identification
X
AN
1/50
Required
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
IMPLEMENTATION NAME: Dependent 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.
Situational Rule:
Required when used by the UMO to identify the Dependent or when REF01 = “EJ” (Patient Account Number) is
valued on the request. If not required by this implementation guide, do not send.
TR3 Example:
REF*SY*123456789~
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Pos: 2000
N3 Dependent Address
Max: 1
Detail - Optional
Loop:
2010D
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
1/55
Situational
Description: Address information
IMPLEMENTATION NAME: Dependent Address Line
Use this element for the first line of the Dependent address.
N302
166
Address Information
O
AN
Description: Address information
Situational Rule: Required when a second address lines exists. If not required by this
implementation guide, do not send.
IMPLEMENTATION NAME: Dependent Address Line
Situational Rule:
Required when used by the UMO to determine the appropriate location or network for service. If not required by
this implementation guide, do not send.
TR3 Example:
N3*PO Box 171021~
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Pos: 2100
N4 Dependent City, State, ZIP
Max: 1
Detail - Optional
Code
Loop:
2010D
Elements: 5
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
ID
2/2
Situational
Description: Free-form text for city name
IMPLEMENTATION NAME: Dependent City Name
N402
156
State or Province Code
X
Description: Code (Standard State/Province) as defined by appropriate government
agency
Situational Rule: Required when the address is in the United States of America, including
its territories, or Canada. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Dependent State Code
CODE SOURCE: 22: States and Provinces
ExternalCodeList
Name: 22C
Description: States and Provinces
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)
Situational Rule: Required when the address is in the United States of America, including
its territories, or Canada, or when a postal code exists for the country in N404. If not
required by this implementation guide, do not send.
IMPLEMENTATION NAME: Dependent Postal Zone or ZIP Code
CODE SOURCE: 51: ZIP Code
932: Universal Postal Codes
ExternalCodeList
Name: 932
Description:
ExternalCodeList
Name: 51
Description: ZIP Code
N404
26
Country Code
X
ID
2/3
Situational
Description: Code identifying the country
Situational Rule: Required when the address is outside the United States of America. If
not required by this implementation guide, do not send.
CODE SOURCE: 5: Countries, Currencies and Funds
Use the alpha-2 country codes from Part 1 of ISO 3166.
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Id
Element Name
Req
Type
Min/Max
Usage
ID
1/3
Situational
ExternalCodeList
Name: 5
Description: Countries, Currencies and Funds
N407
1715
Country Subdivision Code
X
Description: Code identifying the country subdivision
Situational Rule: Required when the address is not in the United States of America,
including its territories, or Canada, and the country in N404 has administrative subdivisions
such as but not limited to states, provinces, cantons, etc. If not required by this
implementation guide, do not send.
CODE SOURCE: 5: Countries, Currencies and Funds
Use the country subdivision codes from Part 2 of ISO 3166.
ExternalCodeList
Name: 5
Description: Countries, Currencies and Funds
Syntax Rules:
1. E0207 - Only one of N402 or N407 may be present.
2. C0605 - If N406 is present, then N405 is required.
3. C0704 - If N407 is present, then N404 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.
Situational Rule:
Required when used by the UMO to determine the appropriate location or network for service. If not required by
this implementation guide, do not send.
TR3 Example:
N4*KANSAS CITY*MO*64108~
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Pos: 2300
AAA Dependent Request
Max: 9
Detail - Optional
Validation
Loop:
2010D
Elements: 3
User Option (Usage): Situational
Purpose: To specify the validity of the request and indicate follow-up action authorized
Element Summary:
Ref
Id
Element Name
AAA01
1073
Yes/No Condition or Response Code
Req
Type
Min/Max
Usage
M
ID
1/1
Required
2/2
Required
Description: Code indicating a Yes or No condition or response
IMPLEMENTATION NAME: Valid Request Indicator
CodeList Summary (Total Codes: 4, Included: 1)
Code Name
N
AAA03
901
No
Reject Reason Code
O
ID
Description: Code assigned by issuer to identify reason for rejection
CodeList Summary (Total Codes: 204, Included: 11)
Code Name
AAA04
889
15
Required application data missing
Use this code to indicate missing dependent relationship information.
33
Input Errors
Use this code to indicate invalid dependent relationship information.
58
64
65
66
67
68
71
77
95
Invalid/Missing Date-of-Birth
Invalid/Missing Patient ID
Invalid/Missing Patient Name
Invalid/Missing Patient Gender Code
Patient Not Found
Duplicate Patient ID Number
Patient Birth Date Does Not Match That for the Patient on the Database
Subscriber Found, Patient Not Found
Patient Not Eligible
Follow-up Action Code
O
ID
1/1
Required
Description: Code identifying follow-up actions allowed
CodeList Summary (Total Codes: 10, Included: 2)
Code Name
C
N
Please Correct and Resubmit
Resubmission Not Allowed
Semantics:
1. AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N"
indicates that the code is invalid.
Comments:
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1. If AAA02 is used, AAA03 contains a code from an industry code list.
Situational Rule:
Required when the request is not valid at this level. If not required by this implementation guide, do not send.
TR3 Example:
AAA*N**67*N~
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Pos: 2500
DMG Dependent Demographic
Max: 1
Detail - Optional
Information
Loop:
2010D
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
X
ID
2/3
Required
Description: Code indicating the date format, time format, or date and time format
CodeList Summary (Total Codes: 42, Included: 1)
Code Name
D8
DMG02
1251
Date Expressed in Format CCYYMMDD
Date Time Period
X
AN
1/35
Required
Description: Expression of a date, a time, or range of dates, times or dates and times
IMPLEMENTATION NAME: Dependent Birth Date
DMG03
1068
Gender Code
O
ID
1/1
Situational
Description: Code indicating the sex of the individual
Situational Rule: Required when used by the UMO to render a medical decision. If not
required by this implementation guide, do not send.
IMPLEMENTATION NAME: Dependent Gender Code
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.
2. P1011 - If either DMG10 or DMG11 is present, then the other is required.
3. C1105 - If DMG11 is present, then DMG05 is required.
Semantics:
1.
2.
3.
4.
DMG02 is the date of birth.
DMG07 is the country of citizenship.
DMG09 is the age in years.
DMG11 is used to specify how the information in DMG05, including repeats of C056, was collected.
Situational Rule:
Required when used by the UMO to determine medical necessity. If not required by this implementation guide, do
not send.
TR3 Example:
DMG*D8*19580322*M~
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Pos: 2600
INS Dependent Relationship
Max: 1
Detail - Optional
Loop:
2010D
Elements: 3
User Option (Usage): Situational
Purpose: To provide benefit information on insured entities
Element Summary:
Ref
Id
Element Name
INS01
1073
Yes/No Condition or Response Code
Req
Type
Min/Max
Usage
M
ID
1/1
Required
2/2
Required
Description: Code indicating a Yes or No condition or response
IMPLEMENTATION NAME: Insured Indicator
CodeList Summary (Total Codes: 4, Included: 1)
Code Name
N
INS02
1069
No
Individual Relationship Code
M
ID
Description: Code indicating the relationship between two individuals or entities
CodeList Summary (Total Codes: 154, Included: 3)
Code Name
01
19
G8
INS17
1470
Spouse
Child
Other Relationship
Number
O
N0
1/9
Situational
Description: A generic number
Situational Rule: Required when used by the UMO to identify a dependent child from a
multiple birth. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Birth Sequence Number
Syntax Rules:
1. P1112 - If either INS11 or INS12 is present, then the other is required.
Semantics:
1. INS01 indicates status of the insured. A "Y" value indicates the insured is a subscriber: an "N" value indicates
the insured is a dependent.
2. INS10 is the handicapped status indicator. A "Y" value indicates an individual is handicapped; an "N" value
indicates an individual is not handicapped.
3. INS12 is the date of death.
4. INS14, INS15, and INS16 identify where the employee works.
5. INS17 is the number assigned to each family member born with the same birth date. This number identifies
birth sequence for multiple births allowing proper tracking and response of benefits for each dependent (i.e.,
twins, triplets, etc.).
Situational Rule:
Required when used by the UMO to determine the benefit/level of service for this patient. If not required by this
implementation guide, do not send.
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TR3 Example:
INS*N*19~
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Pos: 0100
Loop Patient Event Level
Repeat: >1
Optional
Loop:
2000E
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
0100
0200
0300
0400
0500
0600
0600
0700
0700
0700
0700
0700
0700
0700
0700
0700
0700
0800
0900
1100
1200
1300
1400
1500
1550
1600
1700
1700
1700
HL
TRN
AAA
UM
HCR
REF
REF
DTP
DTP
DTP
DTP
DTP
DTP
DTP
DTP
DTP
DTP
HI
HSD
CL1
CR1
CR2
CR5
CR6
PWK
MSG
Patient Event Level
Patient Event Tracking Number
Patient Event Request Validation
Health Care Services Review Information
Health Care Services Review
Administrative Reference Number
Previous Review Authorization Number
Accident Date
Last Menstrual Period Date
Estimated Date of Birth
Onset of Current Symptoms or Illness Date
Event Date
Admission Date
Discharge Date
Certification Issue Date
Certification Expiration Date
Certification Effective Date
Patient Diagnosis
Health Care Services Delivery
Institutional Claim Code
Ambulance Transport Information
Spinal Manipulation Service Information
Home Oxygen Therapy Information
Home Health Care Information
Additional Patient Information
Message Text
Loop 2010EA
Loop 2010EB
Loop 2010EC
69
Req
Max Use
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
1
3
9
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
10
1
Repeat
Usage
14
1
5
Situational
Situational
Situational
Required
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
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Pos: 0100
HL Patient Event Level
Max: 1
Detail - Optional
Loop:
2000E
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: 250, Included: 1)
Code Name
EV
HL04
736
Event
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: 2)
Code Name
0
1
No Subordinate HL Segment in This Hierarchical Structure.
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.
Situational Rule:
Required when the UMO system processed any of the information contained in Loop 2000E of the request. If not
required by this implementation guide, do not send.
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TR3 Notes:
1. If the UMO was unable to process any data beyond Loop 2000C or Loop 2000D of the request, this loop and
any subordinate loops are not required.
TR3 Example:
HL*5*4*EV*1~
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Pos: 0200
TRN Patient Event Tracking
Max: 3
Detail - Optional
Number
Loop:
2000E
Elements: 4
User Option (Usage): Situational
Purpose: To uniquely identify a transaction to an application
Element Summary:
Ref
Id
Element Name
TRN01
481
Trace Type Code
Req
Type
Min/Max
Usage
M
ID
1/2
Required
Description: Code identifying which transaction is being referenced
CodeList Summary (Total Codes: 3, Included: 2)
Code Name
TRN02
127
1
Current Transaction Trace Numbers
The term “Current Transaction Trace Number” refers to the trace number assigned
by the creator of the 278 response transaction (the UMO).
2
Referenced Transaction Trace Numbers
The term “Referenced Transaction Trace Number” refers to the trace number
originally sent in the 278 request transaction.
Reference Identification
M
AN
1/50
Required
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
IMPLEMENTATION NAME: Patient Event Trace Number
TRN03
509
Originating Company Identifier
O
AN
10/10
Required
Description: A unique identifier designating the company initiating the funds transfer
instructions, business transaction or assigning tracking reference identification.
IMPLEMENTATION NAME: Trace Assigning Entity Identifier
Use this element to identify the organization that assigned this trace number. If TRN01 is
“2", this is the value received in the original 278 request transaction. If TRN01 is ”1", use
this information to identify the UMO organization that assigned this trace number.
The first position must be either a “1" if an EIN is used, a ”3" if a DUNS is used or a “9" if a
user assigned identifier is used.
TRN04
127
Reference Identification
O
AN
1/50
Situational
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Situational Rule: Required when TRN01 = 2 and TRN04 was valued on the request or
when TRN01 = 1 and a specific division or group, of the company identified in the previous
data element (TRN03) is needed by the sender to further identify a specific component of
the entity. If not required by this implementation guide, may be provided at the sender’s
discretion, but can not be required by the receiver.
IMPLEMENTATION NAME: Trace Assigning Entity Additional Identifier
Semantics:
1. TRN02 provides unique identification for the transaction.
2. TRN03 identifies an organization.
3. TRN04 identifies a further subdivision within the organization.
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Situational Rule:
Required when this loop is returned and the request contained a tracking number at this level on the request, or
when the UMO or clearinghouse assigns a trace number to this patient event in the response for tracking
purposes. If not required by this implementation guide, do not send.
TR3 Notes:
1. Any trace numbers provided at this level on the request must be returned by the UMO at this level of the 278
response.
2. If the 278 request transaction passes through more than one clearinghouse, the second (and subsequent)
clearinghouse may choose one of the following options:
If the second or subsequent clearinghouse needs to assign their own TRN segment they may replace the
received TRN segment belonging to the sending clearinghouse with their own TRN segment. Upon returning a
278 response to the sending clearinghouse, they must remove their TRN segment and replace it with the sending
clearinghouse’s TRN segment.
If the second or subsequent clearinghouse does not need to assign their own TRN segment, they should merely
pass all TRN segments received in the 278 response transaction.
3. If the 278 request passes through a clearinghouse that adds their own TRN in addition to a requester TRN, the
clearinghouse will receive a response from the UMO containing two TRN segments that contain the value “2"
(Referenced Transaction Trace Number) in TRN01. If the UMO has assigned a TRN, the UMO’s TRN will contain
the value ”1" (Current Transaction Trace Number) in TRN01. If the clearinghouse chooses to pass their own TRN
values to the requester, the clearinghouse must change the value in their TRN01 to “1" because, from the
requester’s perspective, this is not a referenced transaction trace number.
TR3 Example:
TRN*1*2001042801*9012345678*CARDIOLOGY~
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Pos: 0300
AAA Patient Event Request
Max: 9
Detail - Optional
Validation
Loop:
2000E
Elements: 3
User Option (Usage): Situational
Purpose: To specify the validity of the request and indicate follow-up action authorized
Element Summary:
Ref
Id
Element Name
AAA01
1073
Yes/No Condition or Response Code
Req
Type
Min/Max
Usage
M
ID
1/1
Required
2/2
Required
Description: Code indicating a Yes or No condition or response
IMPLEMENTATION NAME: Valid Request Indicator
CodeList Summary (Total Codes: 4, Included: 1)
Code Name
N
AAA03
901
No
Reject Reason Code
O
ID
Description: Code assigned by issuer to identify reason for rejection
CodeList Summary (Total Codes: 204, Included: 17)
Code Name
15
Required application data missing
Use when data is missing that is not covered by another Reject Reason Code. For
example, use for missing procedure codes and procedure dates.
33
Input Errors
Use for input errors in the service data not covered by the other reject reason
codes listed. For example, use for invalid place of service codes and invalid
diagnosis codes and diagnosis dates.
52
Service Dates Not Within Provider Plan Enrollment
Use for Event Date(s).
56
Inappropriate Date
Use when the type of date (Accident, Last Menstrual Period, Estimated Date of
Birth, Onset of Current Symptoms or Illness) used on the request is inconsistent
with the patient condition or services requested.
57
Invalid/Missing Date(s) of Service
Use for invalid/missing event date.
60
Date of Birth Follows Date(s) of Service
Use for Date(s) of Event.
61
Date of Death Precedes Date(s) of Service
Use for Date(s) of Event.
62
Date of Service Not Within Allowable Inquiry Period
Use for Date of Event.
AA
AF
AH
AI
AJ
Authorization Number Not Found
Invalid/Missing Diagnosis Code(s)
Invalid/Missing Onset of Current Condition or Illness Date
Invalid/Missing Accident Date
Invalid/Missing Last Menstrual Period Date
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Code Name
AK
AM
AN
T5
AAA04
889
Invalid/Missing Expected Date of Birth
Invalid/Missing Admission Date
Invalid/Missing Discharge Date
Certification Information Missing
Use to indicate missing previous certification number information.
Follow-up Action Code
O
ID
1/1
Required
Description: Code identifying follow-up actions allowed
CodeList Summary (Total Codes: 10, Included: 2)
Code Name
C
N
Please Correct and Resubmit
Resubmission Not Allowed
Semantics:
1. AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N"
indicates that the code is invalid.
Comments:
1. If AAA02 is used, AAA03 contains a code from an industry code list.
Situational Rule:
Required when the request is not valid at this level. If not required by this implementation guide, do not send.
TR3 Notes:
1. Use this AAA segment to identify the reasons why a request could not be processed based on the data at this
level of the request.
TR3 Example:
AAA*N**15*C~
75
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UM Health Care Services Review
Information
Pos: 0400
Max: 1
Detail - Optional
Loop:
2000E
Elements: 5
User Option (Usage): Required
Purpose: To specify health care services review information
Element Summary:
Ref
Id
Element Name
UM01
1525
Request Category Code
Req
Type
Min/Max
Usage
M
ID
1/2
Required
Description: Code indicating a type of request
CodeList Summary (Total Codes: 7, Included: 4)
Code Name
UM02
1322
AR
Admission Review
Required when this is a response to a request regarding admission to a facility.
HS
Health Services Review
Required when this is a response to a request for review of services related to an
episode of care.
IN
Individual
Required when BHT06 is equal to “RU”.
SC
Specialty Care Review
Required when this is a response to a request for a referral to a specialty provider.
Certification Type Code
O
ID
1/1
Required
Description: Code indicating the type of certification
CodeList Summary (Total Codes: 15, Included: 8)
Code Name
1
Appeal - Immediate
Use this value only for appeals of review decisions where the level of service
required is emergency or urgent. If UM02 = 1 then UM06 must be valued.
2
Appeal - Standard
Use this value for appeals of review decisions where the level of service required
is not emergency or urgent.
3
4
Cancel
Extension
Use this value to indicate that this is an extension request to a prior approved
service.
I
N
R
Initial
Reconsideration
Renewal
Various services, such as physical therapy, spinal manipulation, and allergy
treatment, have both a delivery pattern and a time span of authorization. Many
UMOs place time limits - as in will not authorize anything for more than 30 days at
a time. For example, blanket authorization for allergy treatments as required for 30
days. At the end of the 30 days, the provider must request to renew the
certification - not extend it - because the UMO authorizes for 30 day intervals, one
interval at a time.
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Code Name
S
UM03
1365
Revised
Use if the requester is revising the specifics of a certification for which services
have not been rendered. For example, the requester may be requesting additional
procedures or other procedures for the same patient event.
Service Type Code
O
ID
1/2
Situational
Description: Code identifying the classification of service
Situational Rule: Required when valued on the request and used by the UMO to render a
medical decision. If not required by this implementation guide, do not send.
CodeList Summary (Total Codes: 190, Included: 104)
Code Name
1
2
3
4
5
6
7
8
11
12
14
15
16
17
18
20
21
23
24
25
Medical Care
Surgical
Consultation
Diagnostic X-Ray
Diagnostic Lab
Radiation Therapy
Anesthesia
Surgical Assistance
Used Durable Medical Equipment
Durable Medical Equipment Purchase
Renal Supplies in the Home
Alternate Method Dialysis
Chronic Renal Disease (CRD) Equipment
Pre-Admission Testing
Durable Medical Equipment Rental
Second Surgical Opinion
Third Surgical Opinion
Diagnostic Dental
Periodontics
Restorative
Use for restorative dental.
26
27
28
33
35
36
37
38
39
40
42
44
45
46
54
Endodontics
Maxillofacial Prosthetics
Adjunctive Dental Services
Chiropractic
Dental Care
Dental Crowns
Dental Accident
Orthodontics
Prosthodontics
Oral Surgery
Home Health Care
Home Health Visits
Hospice
Respite Care
Long Term Care
77
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Code Name
56
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
82
83
84
85
86
87
88
93
A4
A6
A9
AD
AE
AF
AG
AH
AI
AJ
AK
AL
AR
B1
BB
BC
BD
BE
Medically Related Transportation
In-vitro Fertilization
MRI/CAT Scan
Donor Procedures
Acupuncture
Newborn Care
Pathology
Smoking Cessation
Well Baby Care
Maternity
Transplants
Audiology Exam
Inhalation Therapy
Diagnostic Medical
Private Duty Nursing
Prosthetic Device
Dialysis
Otological Exam
Chemotherapy
Allergy Testing
Immunizations
Family Planning
Infertility
Abortion
AIDS
Emergency Services
Cancer
Pharmacy
Podiatry
Psychiatric
Psychotherapy
Rehabilitation
Occupational Therapy
Physical Medicine
Speech Therapy
Skilled Nursing Care
Skilled Nursing Care - Room and Board
Substance Abuse
Alcoholism
Drug Addiction
Vision (Optometry)
Experimental Drug Therapy
Burn Care
Partial Hospitalization (Psychiatric)
Day Care (Psychiatric)
Cognitive Therapy
Massage Therapy
78
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Code Name
BF
BG
BL
BN
BP
BQ
BS
BY
BZ
C1
CQ
GY
IC
MH
NI
ON
PT
PU
RN
RT
TC
TN
UM04
C023
Pulmonary Rehabilitation
Cardiac Rehabilitation
Cardiac
Gastrointestinal
Endocrine
Neurology
Invasive Procedures
Physician Visit - Office: Sick
Physician Visit - Office: Well
Coronary Care
Case Management
Allergy
Intensive Care
Mental Health
Neonatal Intensive Care
Oncology
Physical Therapy
Pulmonary
Renal
Residential Psychiatric Treatment
Transitional Care
Transitional Nursery Care
Health Care Service Location
Information
O
Comp
Situational
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
Situational Rule: Required when valued on the request and used by the UMO to render a
medical decision. If not required by this implementation guide, may be provided at the
sender’s discretion but cannot be required by the receiver.
Values entered at the Service Level for this data element override values at the Patient
Event Level for that service only.
UM04-01
1331
Facility Code Value
M
AN
1/2
Required
Description: Code identifying where services were, or may be, performed; the first and
second positions of the Uniform Bill Type Code for Institutional Services or the Place of
Service Codes for Professional or Dental Services.
IMPLEMENTATION NAME: Facility Type Code
Use to indicate a facility code value from the code source referenced in UM04-2.
ExternalCodeList
Name: 236
Description: Uniform Billing Claim Form Bill Type
ExternalCodeList
Name: 237
Description: Place of Service Codes for Professional Claims
UM04-02
1332
Facility Code Qualifier
O
ID
1/2
Required
Description: Code identifying the type of facility referenced
79
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Id
Element Name
Req
Type
Min/Max
Usage
CodeList Summary (Total Codes: 2, Included: 2)
Code Name
A
Uniform Billing Claim Form Bill Type
CODE SOURCE:
236: Uniform Billing Claim Form Bill Type
B
Place of Service Codes for Professional or Dental Services
CODE SOURCE:
237: Place of Service Codes for Professional Claims
UM06
1338
Level of Service Code
O
ID
1/3
Situational
Description: Code specifying the level of service rendered
Situational Rule: Required when used by the UMO in rendering a decision. If not required
by this implementation guide, do not send.
CodeList Summary (Total Codes: 18, Included: 3)
Code Name
E
U
03
Elective
Urgent
Emergency
TR3 Notes:
1. Identifies the type of health care services review.
TR3 Example:
UM*SC*I*3~
80
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Pos: 0500
HCR Health Care Services
Max: 1
Detail - Optional
Review
Loop:
2000E
Elements: 4
User Option (Usage): Situational
Purpose: To specify the outcome of a health care services review
Element Summary:
Ref
Id
Element Name
HCR01
306
Action Code
Req
Type
Min/Max
Usage
M
ID
1/2
Required
Description: Code indicating type of action
CodeList Summary (Total Codes: 320, Included: 8)
Code Name
HCR02
127
C
A1
A2
Cancelled
Certified in total
Certified - partial
Use to identify that the event is only partially certified. Consult HCR01, Loop
2000F for approved, denied or pended services.
A3
A4
A6
CT
NA
Not Certified
Pended
Modified
Contact Payer
No Action Required
Use only if certification is not required.
Reference Identification
O
AN
1/50
Situational
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Situational Rule: Required when HCR01 = A1, A2 or A6. If not required by this
implementation guide, do not send.
IMPLEMENTATION NAME: Review Identification Number
HCR03
1271
Industry Code
O
AN
1/30
Situational
Description: Code indicating a code from a specific industry code list
Situational Rule: Required when HCR01=A3 or A4. If not required by this implementation
guide, may be provided at the sender’s discretion but cannot be required by the receiver.
IMPLEMENTATION NAME: Review Decision Reason Code
This data element is a repeating data element and can be repeated the maximum number
allowed by the standard in this implementation guide.
HCR04
1073
Yes/No Condition or Response Code
O
ID
1/1
Situational
Description: Code indicating a Yes or No condition or response
Situational Rule: Required when certification pertains to a surgical procedure and the
contract under which the patient is covered has provisions regarding a second surgical
opinion. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Second Surgical Opinion Indicator
CodeList Summary (Total Codes: 4, Included: 2)
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Code Name
N
Y
No
Yes
Semantics:
1. HCR02 is the number assigned by the information source to this review outcome.
2. HCR03 is the code assigned by the information source to identify the reason for the health care service review
outcome indicated in HCR01.See Code Source 886
3. HCR04 is the second surgical opinion indicator. A "Y" value indicates a second surgical opinion is required; an
"N" value indicates a second surgical opinion is not required for this request.
Situational Rule:
Required when the UMO has reviewed the request at this level to provide patient event review outcome
information or to indicate that the final decision is pending. If not required by this implementation guide, do not
send.
TR3 Notes:
1. If the UMO for this service was unable to review the request due to missing or invalid application data at this
level, the UMO must return a 278 response containing a AAA segment at this level.
2. If Loop 2000E is present in the response, either the AAA segment or the HCR segment must be returned in
loop 2000E.
3. If the review outcome is pending additional medical information and the 278 response includes a request for
additional information using either a PWK segment or an HI segment that specifies LOINC values, then the
associated HCR segment must be valued with HCR01 = A4 (pended) and HCR03 must be valued with the
appropriate health care services review decision reason code to indicate that additional information is required.
Refer to Section 2.5 for more information.
4. If the response contains Service level information (Loop 2000F) where the HCR segment is valued, the HCR
values at the Service level override the HCR values at the Patient Event level for that service only.
TR3 Example:
HCR*A1*19950713~
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Pos: 0600
REF Administrative Reference
Max: 1
Detail - Optional
Number
Loop:
2000E
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
1/50
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1731, Included: 1)
Code Name
NT
REF02
127
Administrator's Reference Number
Reference Identification
X
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
IMPLEMENTATION NAME: Administrative 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.
Situational Rule:
Required when the HCR segment is valued in this loop, HCR01 = A3, A4 or CT and the UMO has assigned an
administrative reference number associated with this service review. If not required by this implementation guide,
do not send.
TR3 Notes:
1. This number can be used by the requester on a follow up request, such as an appeal (UM02=1) or request for
reconsideration (UM02=6), to reference this UMO response.
TR3 Example:
REF*NT*Y456~
83
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Pos: 0600
REF Previous Review
Max: 1
Detail - Optional
Authorization Number
Loop:
2000E
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
1/50
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1731, Included: 1)
Code Name
BB
REF02
127
Authorization Number
Reference Identification
X
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
IMPLEMENTATION NAME: Previous Review 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.
Situational Rule:
Required when the certification number assigned by the UMO to the original service review outcome was used by
the UMO to determine the outcome of this service review at the event level. If not required by this implementation
guide, do not send.
TR3 Notes:
1. This is the authorization number assigned by the UMO to the original review outcome associated with this
event. This is not the trace number assigned by the requester.
TR3 Example:
REF*BB*A123~
84
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Pos: 0700
DTP Accident Date
Max: 1
Detail - Optional
Loop:
2000E
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
IMPLEMENTATION NAME: Date Time Qualifier
CodeList Summary (Total Codes: 1280, 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: 42, 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
IMPLEMENTATION NAME: Accident Date
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
Situational Rule:
Required when valued on the request and used by the UMO to render a medical decision. If not required by this
implementation guide, do not send.
TR3 Notes:
1. The total number of DTP segments in the 2000E loop cannot exceed 9.
TR3 Example:
DTP*439*D8*20050430~
85
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DTP Last Menstrual Period Date
Pos: 0700
Max: 1
Detail - Optional
Loop:
2000E
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
IMPLEMENTATION NAME: Date Time Qualifier
CodeList Summary (Total Codes: 1280, 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: 42, 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
IMPLEMENTATION NAME: Last Menstrual Period Date
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
Situational Rule:
Required when valued on the request and used by the UMO to render a medical decision. If not required by this
implementation guide, do not send.
TR3 Notes:
1. The total number of DTP segments in the 2000E loop cannot exceed 9.
TR3 Example:
DTP*484*D8*20050312~
86
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Pos: 0700
DTP Estimated Date of Birth
Max: 1
Detail - Optional
Loop:
2000E
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
IMPLEMENTATION NAME: Date Time Qualifier
CodeList Summary (Total Codes: 1280, Included: 1)
Code Name
ABC
DTP02
1250
Estimated Date of Birth
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: 42, 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
IMPLEMENTATION NAME: Estimated Birth Date
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
Situational Rule:
Required when valued on the request and used by the UMO to render a medical decision. If not required by this
implementation guide, do not send.
TR3 Notes:
1. The total number of DTP segments in the 2000E loop cannot exceed 9.
TR3 Example:
DTP*ABC*D8*20051130~
87
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DTP Onset of Current Symptoms
or Illness Date
Pos: 0700
Max: 1
Detail - Optional
Loop:
2000E
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
IMPLEMENTATION NAME: Date Time Qualifier
CodeList Summary (Total Codes: 1280, 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: 42, 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
IMPLEMENTATION NAME: Onset Date
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
Situational Rule:
Required when valued on the request and used by the UMO to render a medical decision. If not required by this
implementation guide, do not send.
TR3 Notes:
1. The total number of DTP segments in the 2000E loop cannot exceed 9.
TR3 Example:
DTP*431*D8*200504015~
88
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Pos: 0700
DTP Event Date
Max: 1
Detail - Optional
Loop:
2000E
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
IMPLEMENTATION NAME: Date Time Qualifier
CodeList Summary (Total Codes: 1280, Included: 1)
Code Name
AAH
DTP02
1250
Event
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: 42, Included: 2)
Code Name
D8
RD8
DTP03
1251
Date Expressed in Format CCYYMMDD
Range of Dates Expressed in Format CCYYMMDD-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
IMPLEMENTATION NAME: Proposed or Actual Event Date
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
Situational Rule:
Required when the UMO authorizes service for a specific date or date range. If not required by this
implementation guide, do not send.
TR3 Notes:
1. The total number of DTP segments in the 2000E loop cannot exceed 9.
TR3 Example:
DTP*AAH*D8*20050516~
89
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Pos: 0700
DTP Admission Date
Max: 1
Detail - Optional
Loop:
2000E
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
IMPLEMENTATION NAME: Date Time Qualifier
CodeList Summary (Total Codes: 1280, 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: 42, Included: 2)
Code Name
D8
RD8
DTP03
1251
Date Expressed in Format CCYYMMDD
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
Use this for the range of dates when admission can occur. Use the HSD segment
for length of stay.
Date Time Period
M
AN
1/35
Required
Description: Expression of a date, a time, or range of dates, times or dates and times
IMPLEMENTATION NAME: Proposed or Actual Admission Date
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
Situational Rule:
Required when the UMO authorizes admission for a specific date or date range. If not required by this
implementation guide, do not send.
TR3 Notes:
1. The total number of DTP segments in the 2000E loop cannot exceed 9.
TR3 Example:
DTP*435*D8*20050505~
90
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Pos: 0700
DTP Discharge Date
Max: 1
Detail - Optional
Loop:
2000E
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
IMPLEMENTATION NAME: Date Time Qualifier
CodeList Summary (Total Codes: 1280, 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: 42, 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
IMPLEMENTATION NAME: Proposed or Actual Discharge Date
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
Situational Rule:
Required when the UMO authorizes services or admission based on the proposed or actual discharge date. If not
required by this implementation guide, do not send.
TR3 Notes:
1. The total number of DTP segments in the 2000E loop cannot exceed 9.
TR3 Example:
DTP*096*D8*20050509~
91
For internal use only
1/12/2012
Health Care Services Review Information - Response - 278
Pos: 0700
DTP Certification Issue Date
Max: 1
Detail - Optional
Loop:
2000E
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
IMPLEMENTATION NAME: Date Time Qualifier
CodeList Summary (Total Codes: 1280, Included: 1)
Code Name
102
DTP02
1250
Issue
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: 42, 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
IMPLEMENTATION NAME: Certification Issue Date
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
Situational Rule:
Required when the UMO assigns a certification issue date to this authorization. If not required by this
implementation guide, do not send.
TR3 Notes:
1. This is not the effective date of the authorization. The issue date is that date when the UMO issued the
authorization.
2. The total number of DTP segments in the 2000E loop cannot exceed 9.
TR3 Example:
DTP*102*D8820050502~
92
For internal use only
1/12/2012
Health Care Services Review Information - Response - 278
DTP Certification Expiration Date
Pos: 0700
Max: 1
Detail - Optional
Loop:
2000E
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
IMPLEMENTATION NAME: Date Time Qualifier
CodeList Summary (Total Codes: 1280, Included: 1)
Code Name
036
DTP02
1250
Expiration
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: 42, 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
IMPLEMENTATION NAME: Certification Expiration Date
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
Situational Rule:
Required when the authorization has an expiration date to indicate the date on which the authorization will expire.
If not required by this implementation guide, do not send.
TR3 Notes:
1. The total number of DTP segments in the 2000E loop cannot exceed 9.
TR3 Example:
DTP*036*D8*20050630~
93
For internal use only
1/12/2012
Health Care Services Review Information - Response - 278
DTP Certification Effective Date
Pos: 0700
Max: 1
Detail - Optional
Loop:
2000E
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
IMPLEMENTATION NAME: Date Time Qualifier
CodeList Summary (Total Codes: 1280, Included: 1)
Code Name
007
DTP02
1250
Effective
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: 42, Included: 2)
Code Name
D8
RD8
DTP03
1251
Date Expressed in Format CCYYMMDD
Range of Dates Expressed in Format CCYYMMDD-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
IMPLEMENTATION NAME: Certification Effective Date
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
Situational Rule:
Required when the authorization is limited by effective dates to indicate the date or date range when the
authorization is effective. If not required by this implementation guide, do not send.
TR3 Notes:
1. The total number of DTP segments in the 2000E loop cannot exceed 9.
TR3 Example:
DTP*007*RD8*20050502-20050630~
94
For internal use only
1/12/2012
Health Care Services Review Information - Response - 278
Pos: 0800
HI Patient Diagnosis
Max: 1
Detail - Optional
Loop:
2000E
Elements: 12
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
HI01-01
1270
Code List Qualifier Code
M
ID
1/3
Required
Description: Code identifying a specific industry code list
IMPLEMENTATION NAME: Diagnosis Type Code
CodeList Summary (Total Codes: 948, Included: 10)
Code Name
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
CODE SOURCE:
131: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
BJ
International Classification of Diseases Clinical Modification (ICD-9-CM) Admitting
Diagnosis
CODE SOURCE:
131: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
BK
International Classification of Diseases Clinical Modification (ICD-9-CM) Principal
Diagnosis
CODE SOURCE:
131: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
DR
Diagnosis Related Group (DRG)
CODE SOURCE:
229: Diagnosis Related Group Number (DRG)
PR
International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's
Reason for Visit
CODE SOURCE:
131: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
CODE SOURCE:
897: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
ABJ
International Classification of Diseases Clinical Modification (ICD-10-CM) Admitting
Diagnosis
CODE SOURCE:
897: International Classification of Diseases, 10th Revision, Clinical Modification
95
For internal use only
1/12/2012
Health Care Services Review Information - Response - 278
Code Name
(ICD-10-CM)
ABK
International Classification of Diseases Clinical Modification (ICD-10-CM) Principal
Diagnosis
CODE SOURCE:
897: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
APR
International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's
Reason for Visit
CODE SOURCE:
897: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
LOI
Logical Observation Identifier Names and Codes (LOINC) Codes
See Section 2.5 for information on using LOINC to request additional information.
CODE SOURCE:
663: Logical Observation Identifier Names and Codes (LOINC)
HI01-02
1271
Industry Code
M
AN
1/30
Required
Description: Code indicating a code from a specific industry code list
IMPLEMENTATION NAME: Diagnosis Code
ExternalCodeList
Name: 131D
Description: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
ExternalCodeList
Name: 229
Description: Diagnosis Related Group Number (DRG)
ExternalCodeList
Name: 663
Description: Logical Observation Identifier Names and Codes (LOINC)
ExternalCodeList
Name: 897
Description: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
HI01-03
1250
Date Time Period Format Qualifier
X
ID
2/3
Situational
Description: Code indicating the date format, time format, or date and time format
Situational Rule: Required when used by the UMO to render a medical decision. If not
required by this implementation guide, do not send.
CodeList Summary (Total Codes: 42, Included: 1)
Code Name
D8
HI01-04
1251
Date Expressed in Format CCYYMMDD
Date Time Period
X
AN
1/35
Situational
Description: Expression of a date, a time, or range of dates, times or dates and times
Situational Rule: Required when used by the UMO to render a medical decision. If not
required by this implementation guide, do not send.
IMPLEMENTATION NAME: Diagnosis Date
96
For internal use only
1/12/2012
Health Care Services Review Information - Response - 278
Ref
Id
Element Name
HI02
C022
Health Care Code Information
Req
Type
O
Comp
Min/Max
Usage
Situational
Description: To send health care codes and their associated dates, amounts and
quantities
Situational Rule: Required when used by the UMO to render a medical decision. If not
required by this implementation guide, do not send.
HI02-01
1270
Code List Qualifier Code
M
ID
1/3
Required
Description: Code identifying a specific industry code list
IMPLEMENTATION NAME: Diagnosis Type Code
CodeList Summary (Total Codes: 948, Included: 8)
Code Name
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
CODE SOURCE:
131: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
BJ
International Classification of Diseases Clinical Modification (ICD-9-CM) Admitting
Diagnosis
CODE SOURCE:
131: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
DR
Diagnosis Related Group (DRG)
CODE SOURCE:
229: Diagnosis Related Group Number (DRG)
PR
International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's
Reason for Visit
CODE SOURCE:
131: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
CODE SOURCE:
897: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
ABJ
International Classification of Diseases Clinical Modification (ICD-10-CM) Admitting
Diagnosis
CODE SOURCE:
897: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
APR
International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's
Reason for Visit
CODE SOURCE:
897: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
LOI
Logical Observation Identifier Names and Codes (LOINC) Codes
See Section 2.5 for information on using LOINC to request additional information.
CODE SOURCE:
663: Logical Observation Identifier Names and Codes (LOINC)
HI02-02
1271
Industry Code
M
97
AN
1/30
Required
For internal use only
1/12/2012
Ref
Health Care Services Review Information - Response - 278
Id
Element Name
Req
Type
Min/Max
Usage
Description: Code indicating a code from a specific industry code list
IMPLEMENTATION NAME: Diagnosis Code
ExternalCodeList
Name: 131D
Description: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
ExternalCodeList
Name: 229
Description: Diagnosis Related Group Number (DRG)
ExternalCodeList
Name: 663
Description: Logical Observation Identifier Names and Codes (LOINC)
ExternalCodeList
Name: 897
Description: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
HI02-03
1250
Date Time Period Format Qualifier
X
ID
2/3
Situational
Description: Code indicating the date format, time format, or date and time format
Situational Rule: Required when used by the UMO to render a medical decision. If not
required by this implementation guide, do not send.
CodeList Summary (Total Codes: 42, Included: 1)
Code Name
D8
HI02-04
1251
Date Expressed in Format CCYYMMDD
Date Time Period
X
AN
1/35
Situational
Description: Expression of a date, a time, or range of dates, times or dates and times
Situational Rule: Required when used by the UMO to render a medical decision. If not
required by this implementation guide, do not send.
IMPLEMENTATION NAME: Diagnosis Date
HI03
C022
Health Care Code Information
O
Comp
Situational
Description: To send health care codes and their associated dates, amounts and
quantities
Situational Rule: Required when used by the UMO to render a medical decision. If not
required by this implementation guide, do not send.
HI03-01
1270
Code List Qualifier Code
M
ID
1/3
Required
Description: Code identifying a specific industry code list
IMPLEMENTATION NAME: Diagnosis Type Code
CodeList Summary (Total Codes: 948, Included: 6)
Code Name
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
CODE SOURCE:
131: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
98
For internal use only
1/12/2012
Health Care Services Review Information - Response - 278
Code Name
DR
Diagnosis Related Group (DRG)
CODE SOURCE:
PR
International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's
Reason for Visit
CODE SOURCE:
229: Diagnosis Related Group Number (DRG)
131: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
CODE SOURCE:
897: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
APR
International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's
Reason for Visit
CODE SOURCE:
897: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
LOI
Logical Observation Identifier Names and Codes (LOINC) Codes
See Section 2.5 for information on using LOINC to request additional information.
CODE SOURCE:
663: Logical Observation Identifier Names and Codes (LOINC)
HI03-02
1271
Industry Code
M
AN
1/30
Required
Description: Code indicating a code from a specific industry code list
IMPLEMENTATION NAME: Diagnosis Code
ExternalCodeList
Name: 131D
Description: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
ExternalCodeList
Name: 229
Description: Diagnosis Related Group Number (DRG)
ExternalCodeList
Name: 663
Description: Logical Observation Identifier Names and Codes (LOINC)
ExternalCodeList
Name: 897
Description: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
HI03-03
1250
Date Time Period Format Qualifier
X
ID
2/3
Situational
Description: Code indicating the date format, time format, or date and time format
Situational Rule: Required when used by the UMO to render a medical decision. If not
required by this implementation guide, do not send.
CodeList Summary (Total Codes: 42, Included: 1)
Code Name
99
For internal use only
1/12/2012
Health Care Services Review Information - Response - 278
Code Name
D8
Date Expressed in Format CCYYMMDD
HI03-04
1251
Date Time Period
X
AN
1/35
Situational
Description: Expression of a date, a time, or range of dates, times or dates and times
Situational Rule: Required when used by the UMO to render a medical decision. If not
required by this implementation guide, do not send.
IMPLEMENTATION NAME: Diagnosis Date
HI04
C022
Health Care Code Information
O
Comp
Situational
Description: To send health care codes and their associated dates, amounts and
quantities
Situational Rule: Required when used by the UMO to render a medical decision. If not
required by this implementation guide, do not send.
HI04-01
1270
Code List Qualifier Code
M
ID
1/3
Required
Description: Code identifying a specific industry code list
IMPLEMENTATION NAME: Diagnosis Type Code
CodeList Summary (Total Codes: 948, Included: 6)
Code Name
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
CODE SOURCE:
131: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
DR
Diagnosis Related Group (DRG)
CODE SOURCE:
PR
International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's
Reason for Visit
CODE SOURCE:
229: Diagnosis Related Group Number (DRG)
131: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
CODE SOURCE:
897: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
APR
International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's
Reason for Visit
CODE SOURCE:
897: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
LOI
Logical Observation Identifier Names and Codes (LOINC) Codes
See Section 2.5 for information on using LOINC to request additional information.
CODE SOURCE:
663: Logical Observation Identifier Names and Codes (LOINC)
HI04-02
1271
Industry Code
M
AN
1/30
Required
Description: Code indicating a code from a specific industry code list
IMPLEMENTATION NAME: Diagnosis Code
100
For internal use only
1/12/2012
Ref
Health Care Services Review Information - Response - 278
Id
Element Name
Req
Type
Min/Max
Usage
ExternalCodeList
Name: 131D
Description: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
ExternalCodeList
Name: 229
Description: Diagnosis Related Group Number (DRG)
ExternalCodeList
Name: 663
Description: Logical Observation Identifier Names and Codes (LOINC)
ExternalCodeList
Name: 897
Description: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
HI04-03
1250
Date Time Period Format Qualifier
X
ID
2/3
Situational
Description: Code indicating the date format, time format, or date and time format
Situational Rule: Required when used by the UMO to render a medical decision. If not
required by this implementation guide, do not send.
CodeList Summary (Total Codes: 42, Included: 1)
Code Name
D8
HI04-04
1251
Date Expressed in Format CCYYMMDD
Date Time Period
X
AN
1/35
Situational
Description: Expression of a date, a time, or range of dates, times or dates and times
Situational Rule: Required when used by the UMO to render a medical decision. If not
required by this implementation guide, do not send.
IMPLEMENTATION NAME: Diagnosis Date
HI05
C022
Health Care Code Information
O
Comp
Situational
Description: To send health care codes and their associated dates, amounts and
quantities
Situational Rule: Required when used by the UMO to render a medical decision. If not
required by this implementation guide, do not send.
HI05-01
1270
Code List Qualifier Code
M
ID
1/3
Required
Description: Code identifying a specific industry code list
IMPLEMENTATION NAME: Diagnosis Type Code
CodeList Summary (Total Codes: 948, Included: 6)
Code Name
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
CODE SOURCE:
131: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
DR
Diagnosis Related Group (DRG)
CODE SOURCE:
101
For internal use only
1/12/2012
Health Care Services Review Information - Response - 278
Code Name
229: Diagnosis Related Group Number (DRG)
PR
International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's
Reason for Visit
CODE SOURCE:
131: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
CODE SOURCE:
897: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
APR
International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's
Reason for Visit
CODE SOURCE:
897: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
LOI
Logical Observation Identifier Names and Codes (LOINC) Codes
See Section 2.5 for information on using LOINC to request additional information.
CODE SOURCE:
663: Logical Observation Identifier Names and Codes (LOINC)
HI05-02
1271
Industry Code
M
AN
1/30
Required
Description: Code indicating a code from a specific industry code list
IMPLEMENTATION NAME: Diagnosis Code
ExternalCodeList
Name: 131D
Description: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
ExternalCodeList
Name: 229
Description: Diagnosis Related Group Number (DRG)
ExternalCodeList
Name: 663
Description: Logical Observation Identifier Names and Codes (LOINC)
ExternalCodeList
Name: 897
Description: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
HI05-03
1250
Date Time Period Format Qualifier
X
ID
2/3
Situational
Description: Code indicating the date format, time format, or date and time format
Situational Rule: Required when used by the UMO to render a medical decision. If not
required by this implementation guide, do not send.
CodeList Summary (Total Codes: 42, Included: 1)
Code Name
D8
HI05-04
1251
Date Expressed in Format CCYYMMDD
Date Time Period
X
102
AN
1/35
Situational
For internal use only
1/12/2012
Ref
Health Care Services Review Information - Response - 278
Id
Element Name
Req
Type
Min/Max
Usage
Description: Expression of a date, a time, or range of dates, times or dates and times
Situational Rule: Required when used by the UMO to render a medical decision. If not
required by this implementation guide, do not send.
IMPLEMENTATION NAME: Diagnosis Date
HI06
C022
Health Care Code Information
O
Comp
Situational
Description: To send health care codes and their associated dates, amounts and
quantities
Situational Rule: Required when used by the UMO to render a medical decision. If not
required by this implementation guide, do not send.
HI06-01
1270
Code List Qualifier Code
M
ID
1/3
Required
Description: Code identifying a specific industry code list
IMPLEMENTATION NAME: Diagnosis Type Code
CodeList Summary (Total Codes: 948, Included: 6)
Code Name
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
CODE SOURCE:
131: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
DR
Diagnosis Related Group (DRG)
CODE SOURCE:
PR
International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's
Reason for Visit
CODE SOURCE:
229: Diagnosis Related Group Number (DRG)
131: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
CODE SOURCE:
897: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
APR
International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's
Reason for Visit
CODE SOURCE:
897: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
LOI
Logical Observation Identifier Names and Codes (LOINC) Codes
See Section 2.5 for information on using LOINC to request additional information.
CODE SOURCE:
663: Logical Observation Identifier Names and Codes (LOINC)
HI06-02
1271
Industry Code
M
AN
1/30
Required
Description: Code indicating a code from a specific industry code list
IMPLEMENTATION NAME: Diagnosis Code
ExternalCodeList
Name: 131D
103
For internal use only
1/12/2012
Health Care Services Review Information - Response - 278
Description: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
ExternalCodeList
Name: 229
Description: Diagnosis Related Group Number (DRG)
ExternalCodeList
Name: 663
Description: Logical Observation Identifier Names and Codes (LOINC)
ExternalCodeList
Name: 897
Description: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
HI06-03
1250
Date Time Period Format Qualifier
X
ID
2/3
Situational
Description: Code indicating the date format, time format, or date and time format
Situational Rule: Required when used by the UMO to render a medical decision. If not
required by this implementation guide, do not send.
CodeList Summary (Total Codes: 42, Included: 1)
Code Name
D8
HI06-04
1251
Date Expressed in Format CCYYMMDD
Date Time Period
X
AN
1/35
Situational
Description: Expression of a date, a time, or range of dates, times or dates and times
Situational Rule: Required when used by the UMO to render a medical decision. If not
required by this implementation guide, do not send.
IMPLEMENTATION NAME: Diagnosis Date
HI07
C022
Health Care Code Information
O
Comp
Situational
Description: To send health care codes and their associated dates, amounts and
quantities
Situational Rule: Required when used by the UMO to render a medical decision. If not
required by this implementation guide, do not send.
HI07-01
1270
Code List Qualifier Code
M
ID
1/3
Required
Description: Code identifying a specific industry code list
IMPLEMENTATION NAME: Diagnosis Type Code
CodeList Summary (Total Codes: 948, Included: 6)
Code Name
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
CODE SOURCE:
131: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
DR
Diagnosis Related Group (DRG)
CODE SOURCE:
229: Diagnosis Related Group Number (DRG)
PR
International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's
Reason for Visit
CODE SOURCE:
104
For internal use only
1/12/2012
Health Care Services Review Information - Response - 278
Code Name
131: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
CODE SOURCE:
897: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
APR
International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's
Reason for Visit
CODE SOURCE:
897: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
LOI
Logical Observation Identifier Names and Codes (LOINC) Codes
See Section 2.5 for information on using LOINC to request additional information.
CODE SOURCE:
663: Logical Observation Identifier Names and Codes (LOINC)
HI07-02
1271
Industry Code
M
AN
1/30
Required
Description: Code indicating a code from a specific industry code list
IMPLEMENTATION NAME: Diagnosis Code
ExternalCodeList
Name: 131D
Description: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
ExternalCodeList
Name: 229
Description: Diagnosis Related Group Number (DRG)
ExternalCodeList
Name: 663
Description: Logical Observation Identifier Names and Codes (LOINC)
ExternalCodeList
Name: 897
Description: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
HI07-03
1250
Date Time Period Format Qualifier
X
ID
2/3
Situational
Description: Code indicating the date format, time format, or date and time format
Situational Rule: Required when used by the UMO to render a medical decision. If not
required by this implementation guide, do not send.
CodeList Summary (Total Codes: 42, Included: 1)
Code Name
D8
HI07-04
1251
Date Expressed in Format CCYYMMDD
Date Time Period
X
AN
1/35
Situational
Description: Expression of a date, a time, or range of dates, times or dates and times
Situational Rule: Required when used by the UMO to render a medical decision. If not
required by this implementation guide, do not send.
IMPLEMENTATION NAME: Diagnosis Date
105
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Ref
Id
Element Name
HI08
C022
Health Care Code Information
Req
Type
O
Comp
Min/Max
Usage
Situational
Description: To send health care codes and their associated dates, amounts and
quantities
Situational Rule: Required when used by the UMO to render a medical decision. If not
required by this implementation guide, do not send.
HI08-01
1270
Code List Qualifier Code
M
ID
1/3
Required
Description: Code identifying a specific industry code list
IMPLEMENTATION NAME: Diagnosis Type Code
CodeList Summary (Total Codes: 948, Included: 6)
Code Name
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
CODE SOURCE:
131: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
DR
Diagnosis Related Group (DRG)
CODE SOURCE:
229: Diagnosis Related Group Number (DRG)
PR
International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's
Reason for Visit
CODE SOURCE:
131: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
CODE SOURCE:
897: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
APR
International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's
Reason for Visit
CODE SOURCE:
897: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
LOI
Logical Observation Identifier Names and Codes (LOINC) Codes
See Section 2.5 for information on using LOINC to request additional information.
CODE SOURCE:
663: Logical Observation Identifier Names and Codes (LOINC)
HI08-02
1271
Industry Code
M
AN
1/30
Required
Description: Code indicating a code from a specific industry code list
IMPLEMENTATION NAME: Diagnosis Code
ExternalCodeList
Name: 131D
Description: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
ExternalCodeList
Name: 229
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Description: Diagnosis Related Group Number (DRG)
ExternalCodeList
Name: 663
Description: Logical Observation Identifier Names and Codes (LOINC)
ExternalCodeList
Name: 897
Description: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
HI08-03
1250
Date Time Period Format Qualifier
X
ID
2/3
Situational
Description: Code indicating the date format, time format, or date and time format
Situational Rule: Required when used by the UMO to render a medical decision. If not
required by this implementation guide, do not send.
CodeList Summary (Total Codes: 42, Included: 1)
Code Name
D8
HI08-04
1251
Date Expressed in Format CCYYMMDD
Date Time Period
X
AN
1/35
Situational
Description: Expression of a date, a time, or range of dates, times or dates and times
Situational Rule: Required when used by the UMO to render a medical decision. If not
required by this implementation guide, do not send.
IMPLEMENTATION NAME: Diagnosis Date
HI09
C022
Health Care Code Information
O
Comp
Situational
Description: To send health care codes and their associated dates, amounts and
quantities
Situational Rule: Required when used by the UMO to render a medical decision. If not
required by this implementation guide, do not send.
HI09-01
1270
Code List Qualifier Code
M
ID
1/3
Required
Description: Code identifying a specific industry code list
IMPLEMENTATION NAME: Diagnosis Type Code
CodeList Summary (Total Codes: 948, Included: 6)
Code Name
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
CODE SOURCE:
131: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
DR
Diagnosis Related Group (DRG)
CODE SOURCE:
229: Diagnosis Related Group Number (DRG)
PR
International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's
Reason for Visit
CODE SOURCE:
131: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
CODE SOURCE:
107
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Code Name
897: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
APR
International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's
Reason for Visit
CODE SOURCE:
897: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
LOI
Logical Observation Identifier Names and Codes (LOINC) Codes
See Section 2.5 for information on using LOINC to request additional information.
CODE SOURCE:
663: Logical Observation Identifier Names and Codes (LOINC)
HI09-02
1271
Industry Code
M
AN
1/30
Required
Description: Code indicating a code from a specific industry code list
IMPLEMENTATION NAME: Diagnosis Code
ExternalCodeList
Name: 131D
Description: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
ExternalCodeList
Name: 229
Description: Diagnosis Related Group Number (DRG)
ExternalCodeList
Name: 663
Description: Logical Observation Identifier Names and Codes (LOINC)
ExternalCodeList
Name: 897
Description: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
HI09-03
1250
Date Time Period Format Qualifier
X
ID
2/3
Situational
Description: Code indicating the date format, time format, or date and time format
Situational Rule: Required when used by the UMO to render a medical decision. If not
required by this implementation guide, do not send.
CodeList Summary (Total Codes: 42, Included: 1)
Code Name
D8
HI09-04
1251
Date Expressed in Format CCYYMMDD
Date Time Period
X
AN
1/35
Situational
Description: Expression of a date, a time, or range of dates, times or dates and times
Situational Rule: Required when used by the UMO to render a medical decision. If not
required by this implementation guide, do not send.
IMPLEMENTATION NAME: Diagnosis Date
HI10
C022
Health Care Code Information
O
Comp
Situational
Description: To send health care codes and their associated dates, amounts and
quantities
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Ref
Id
Element Name
Req
Type
Min/Max
Usage
Situational Rule: Required when used by the UMO to render a medical decision. If not
required by this implementation guide, do not send.
HI10-01
1270
Code List Qualifier Code
M
ID
1/3
Required
Description: Code identifying a specific industry code list
IMPLEMENTATION NAME: Diagnosis Type Code
CodeList Summary (Total Codes: 948, Included: 6)
Code Name
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
CODE SOURCE:
131: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
DR
Diagnosis Related Group (DRG)
CODE SOURCE:
229: Diagnosis Related Group Number (DRG)
PR
International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's
Reason for Visit
CODE SOURCE:
131: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
CODE SOURCE:
897: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
APR
International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's
Reason for Visit
CODE SOURCE:
897: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
LOI
Logical Observation Identifier Names and Codes (LOINC) Codes
See Section 2.5 for information on using LOINC to request additional information.
CODE SOURCE:
663: Logical Observation Identifier Names and Codes (LOINC)
HI10-02
1271
Industry Code
M
AN
1/30
Required
Description: Code indicating a code from a specific industry code list
IMPLEMENTATION NAME: Diagnosis Code
ExternalCodeList
Name: 131D
Description: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
ExternalCodeList
Name: 229
Description: Diagnosis Related Group Number (DRG)
ExternalCodeList
Name: 663
Description: Logical Observation Identifier Names and Codes (LOINC)
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ExternalCodeList
Name: 897
Description: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
HI10-03
1250
Date Time Period Format Qualifier
X
ID
2/3
Situational
Description: Code indicating the date format, time format, or date and time format
Situational Rule: Required when used by the UMO to render a medical decision. If not
required by this implementation guide, do not send.
CodeList Summary (Total Codes: 42, Included: 1)
Code Name
D8
HI10-04
1251
Date Expressed in Format CCYYMMDD
Date Time Period
X
AN
1/35
Situational
Description: Expression of a date, a time, or range of dates, times or dates and times
Situational Rule: Required when used by the UMO to render a medical decision. If not
required by this implementation guide, do not send.
IMPLEMENTATION NAME: Diagnosis Date
HI11
C022
Health Care Code Information
O
Comp
Situational
Description: To send health care codes and their associated dates, amounts and
quantities
Situational Rule: Required when used by the UMO to render a medical decision. If not
required by this implementation guide, do not send.
HI11-01
1270
Code List Qualifier Code
M
ID
1/3
Required
Description: Code identifying a specific industry code list
IMPLEMENTATION NAME: Diagnosis Type Code
CodeList Summary (Total Codes: 948, Included: 6)
Code Name
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
CODE SOURCE:
131: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
DR
Diagnosis Related Group (DRG)
CODE SOURCE:
PR
International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's
Reason for Visit
CODE SOURCE:
229: Diagnosis Related Group Number (DRG)
131: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
CODE SOURCE:
897: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
APR
International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's
Reason for Visit
CODE SOURCE:
110
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Code Name
897: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
LOI
Logical Observation Identifier Names and Codes (LOINC) Codes
CODE SOURCE:
663: Logical Observation Identifier Names and Codes (LOINC)
HI11-02
1271
Industry Code
M
AN
1/30
Required
Description: Code indicating a code from a specific industry code list
IMPLEMENTATION NAME: Diagnosis Code
ExternalCodeList
Name: 131D
Description: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
ExternalCodeList
Name: 229
Description: Diagnosis Related Group Number (DRG)
ExternalCodeList
Name: 663
Description: Logical Observation Identifier Names and Codes (LOINC)
ExternalCodeList
Name: 897
Description: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
HI11-03
1250
Date Time Period Format Qualifier
X
ID
2/3
Situational
Description: Code indicating the date format, time format, or date and time format
Situational Rule: Required when used by the UMO to render a medical decision. If not
required by this implementation guide, do not send.
CodeList Summary (Total Codes: 42, Included: 1)
Code Name
D8
HI11-04
1251
Date Expressed in Format CCYYMMDD
Date Time Period
X
AN
1/35
Situational
Description: Expression of a date, a time, or range of dates, times or dates and times
Situational Rule: Required when used by the UMO to render a medical decision. If not
required by this implementation guide, do not send.
IMPLEMENTATION NAME: Diagnosis Date
HI12
C022
Health Care Code Information
O
Comp
Situational
Description: To send health care codes and their associated dates, amounts and
quantities
Situational Rule: Required when used by the UMO to render a medical decision. If not
required by this implementation guide, do not send.
HI12-01
1270
Code List Qualifier Code
M
ID
1/3
Required
Description: Code identifying a specific industry code list
IMPLEMENTATION NAME: Diagnosis Type Code
111
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Id
Element Name
Req
Type
Min/Max
Usage
CodeList Summary (Total Codes: 948, Included: 6)
Code Name
BF
International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
CODE SOURCE:
131: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
DR
Diagnosis Related Group (DRG)
CODE SOURCE:
229: Diagnosis Related Group Number (DRG)
PR
International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's
Reason for Visit
CODE SOURCE:
131: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
ABF
International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
CODE SOURCE:
897: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
APR
International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's
Reason for Visit
CODE SOURCE:
897: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
LOI
Logical Observation Identifier Names and Codes (LOINC) Codes
See Section 2.5 for information on using LOINC to request additional information.
CODE SOURCE:
663: Logical Observation Identifier Names and Codes (LOINC)
HI12-02
1271
Industry Code
M
AN
1/30
Required
Description: Code indicating a code from a specific industry code list
IMPLEMENTATION NAME: Diagnosis Code
ExternalCodeList
Name: 131D
Description: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
ExternalCodeList
Name: 229
Description: Diagnosis Related Group Number (DRG)
ExternalCodeList
Name: 663
Description: Logical Observation Identifier Names and Codes (LOINC)
ExternalCodeList
Name: 897
Description: International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM)
HI12-03
1250
Date Time Period Format Qualifier
112
X
ID
2/3
Situational
For internal use only
1/12/2012
Ref
Health Care Services Review Information - Response - 278
Id
Element Name
Req
Type
Min/Max
Usage
Description: Code indicating the date format, time format, or date and time format
Situational Rule: Required when used by the UMO to render a medical decision. If not
required by this implementation guide, do not send.
CodeList Summary (Total Codes: 42, Included: 1)
Code Name
D8
HI12-04
1251
Date Expressed in Format CCYYMMDD
Date Time Period
X
AN
1/35
Situational
Description: Expression of a date, a time, or range of dates, times or dates and times
Situational Rule: Required when used by the UMO to render a medical decision. If not
required by this implementation guide, do not send.
IMPLEMENTATION NAME: Diagnosis Date
Situational Rule:
Required when used by the UMO to render a medical decision or if the UMO is requesting additional information.
If not required by this implementation guide, do not send.
TR3 Notes:
1. If the response has not been rendered and this segment is used to request additional information associated
with a specific diagnosis, place the specific diagnosis code in the HI C022 composite that precedes the HI C022
composite(s) containing the LOINC. If the original request contained more than six diagnosis codes and you are
using LOINC to request additional information for each of these diagnosis codes or if you need to specify multiple
questions/LOINC codes per diagnosis you cannot exceed the limit of 12 occurrences of the C022 composite.
2. The UMO can use each occurrence of the Health Care Code Information composite (C022) to specify codes
that identify the specific information that the UMO requires from the provider to complete the medical review. In
the C022 composite, data elements 1270 and 1271 support the use of codes supplied from the Logical
Observation Identifier Names and Codes (LOINC®) List. These codes identify high-level health care information
groupings, specific data elements, and associated modifiers.
Refer to Section 1.12.5.2 of this guide for more information on requesting additional information in the 278
response.
TR3 Example:
HI*BF:41090~
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Pos: 0900
HSD Health Care Services
Max: 1
Detail - Optional
Delivery
Loop:
2000E
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
X
ID
2/2
Situational
Description: Code specifying the type of quantity
Situational Rule: Required when the pattern of delivery has quantity of services
authorized. If not required by this implementation guide, do not send.
CodeList Summary (Total Codes: 1123, Included: 5)
Code Name
DY
FL
HS
MN
VS
HSD02
380
Days
Units
Hours
Month
Visits
Quantity
X
R
1/15
Situational
Description: Numeric value of quantity
Situational Rule: Required when the pattern of delivery has quantity of services
authorized. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Service Unit Count
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
Situational Rule: Required when HSD04 is valued to qualify the time frame in which the
quantity of services (HSD02) will be rendered. If not required by this implementation guide,
do not send.
CodeList Summary (Total Codes: 844, Included: 3)
Code Name
DA
MO
WK
HSD04
1167
Days
Months
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
Situational Rule: Required when the UMO authorizes patient events which must be
rendered within a specific timeframe. If not required by this implementation guide, do not
send.
HSD05
615
Time Period Qualifier
X
ID
1/2
Situational
Description: Code defining periods
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Id
Element Name
Req
Type
Min/Max
Usage
Situational Rule: Required when the UMO authorizes patient events which must be
rendered within a specific timeframe. If not required by this implementation guide, do not
send.
CodeList Summary (Total Codes: 38, Included: 7)
Code Name
6
7
21
26
27
34
35
HSD06
616
Hour
Day
Years
Episode
Visit
Month
Week
Number of Periods
O
N0
1/3
Situational
Description: Total number of periods
Situational Rule: Required when the UMO authorizes patient events which must be
rendered within a specific timeframe. If not required by this implementation guide, do not
send.
IMPLEMENTATION NAME: Period Count
HSD07
678
Ship/Delivery or Calendar Pattern Code
O
ID
1/2
Situational
Description: Code which specifies the routine shipments, deliveries, or calendar pattern
Situational Rule: Required when the UMO authorizes a specific calendar delivery pattern
for the patient event. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Delivery Frequency Code
CodeList Summary (Total Codes: 45, Included: 44)
Code Name
1
2
3
4
5
6
7
8
9
A
B
C
D
E
F
G
H
J
K
L
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
1st Working Day of Period
Last Working Day of Period
Monday through Friday
Monday through Saturday
Monday through Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Monday through Thursday
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Code Name
M
N
O
P
Q
R
S
T
U
V
W
X
Y
SA
SB
SC
SD
SG
SL
SP
SX
SY
SZ
WE
HSD08
679
Immediately
As Directed
Daily Mon. through Fri.
1/2 Mon. & 1/2 Thurs.
1/2 Tues. & 1/2 Thurs.
1/2 Wed. & 1/2 Fri.
Once Anytime Mon. through Fri.
1/2 Tue. & 1/2 Fri.
1/2 Mon. & 1/2 Wed.
1/3 Mon., 1/3 Wed., 1/3 Fri.
Whenever Necessary
1/2 By Wed., Bal. By Fri.
None (Also Used to Cancel or Override a Previous Pattern)
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
Monday, Wednesday and Thursday
Tuesday, Thursday and Friday
Weekend
Ship/Delivery Pattern Time Code
O
ID
1/1
Situational
Description: Code which specifies the time for routine shipments or deliveries
Situational Rule: Required when the UMO authorizes a specific time delivery pattern for
the services in this patient event. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Delivery Pattern Time Code
CodeList Summary (Total Codes: 9, Included: 8)
Code Name
A
B
C
D
E
F
G
Y
1st Shift (Normal Working Hours)
2nd Shift
3rd Shift
A.M.
P.M.
As Directed
Any Shift
None (Also Used to Cancel or Override a Previous Pattern)
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.
Situational Rule:
Required when the UMO authorizes services that have a specific pattern of delivery for the patient event. If not
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required by this implementation guide, do not send.
TR3 Notes:
1. Report authorized delivery patterns for specific services in the Service Level (Loop 2000F).
2. An explanation of the uses of this segment follows.
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 SD*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”.
TR3 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”.)
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Pos: 1100
CL1 Institutional Claim Code
Max: 1
Detail - Optional
Loop:
2000E
Elements: 3
User Option (Usage): Situational
Purpose: To supply information specific to hospital claims
Element Summary:
Ref
Id
Element Name
CL101
1315
Admission Type Code
Req
Type
Min/Max
Usage
O
ID
1/1
Situational
Description: Code indicating the priority of this admission
Situational Rule: Required when used by the UMO to render a medical decision. If not
required by this implementation guide, do not send.
CODE SOURCE: 231: Admission Type Code
ExternalCodeList
Name: 231
Description: Admission Type Code
CL102
1314
Admission Source Code
O
ID
1/1
Situational
Description: Code indicating the source of this admission
Situational Rule: Required when used by the UMO to render a medical decision. If not
required by this implementation guide, do not send.
CODE SOURCE: 230: Admission Source Code
ExternalCodeList
Name: 230
Description: Admission Source Code
CL103
1352
Patient Status Code
O
ID
1/2
Situational
Description: Code indicating patient status as of the "statement covers through date"
Situational Rule: Required when used by the UMO to render a medical decision. If not
required by this implementation guide, do not send.
CODE SOURCE: 239: Patient Status Code
ExternalCodeList
Name: 239
Description: Patient Status Code
Situational Rule:
Required when used by the UMO to render a medical decision. If not required by this implementation guide, do
not send.
TR3 Example:
CL1*3~
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Pos: 1200
CR1 Ambulance Transport
Max: 1
Detail - Optional
Information
Loop:
2000E
Elements: 3
User Option (Usage): Situational
Purpose: To supply information related to the ambulance service rendered to a patient
Element Summary:
Ref
Id
Element Name
CR103
1316
Ambulance Transport Code
Req
Type
Min/Max
Usage
O
ID
1/1
Required
2/2
Situational
Description: Code indicating the type of ambulance transport
CodeList Summary (Total Codes: 4, Included: 4)
Code Name
I
R
T
X
CR105
355
Initial Trip
Return Trip
Transfer Trip
Round Trip
Unit or Basis for Measurement Code
X
ID
Description: Code specifying the units in which a value is being expressed, or manner in
which a measurement has been taken
Situational Rule: Required when used by the UMO to authorize ambulance transport. If
not required by this implementation guide, do not send.
CodeList Summary (Total Codes: 844, Included: 2)
Code Name
DH
DK
CR106
380
Miles
Kilometers
Quantity
X
R
1/15
Situational
Description: Numeric value of quantity
Situational Rule: Required when used by the UMO to authorize ambulance transport. If
not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Transport Distance
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.
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Situational Rule:
Required when used by the UMO to authorize specific non-emergency transport services. If not required by this
implementation guide, do not send.
TR3 Notes:
1. Use this segment for certifications involving non-emergency transport of the patient.
TR3 Example:
CR1***T**DH*28~
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CR2 Spinal Manipulation Service
Information
Pos: 1300
Max: 1
Detail - Optional
Loop:
2000E
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
CR201
609
Count
Req
Type
Min/Max
Usage
X
N0
1/9
Situational
Description: Occurrence counter
Situational Rule: Required when used by the UMO to authorize Spinal Manipulation
Services. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Treatment Series Number
CR202
380
Quantity
X
R
1/15
Situational
Description: Numeric value of quantity
Situational Rule: Required when used by the UMO to authorize Spinal Manipulation
Services. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Treatment Count
CR203
1367
Subluxation Level Code
X
ID
2/3
Situational
Description: Code identifying the specific level of subluxation
Situational Rule: Required when used by the UMO to authorize Spinal Manipulation
Services. If not required by this implementation guide, do not send.
CodeList Summary (Total Codes: 28, Included: 28)
Code Name
C1
C2
C3
C4
C5
C6
C7
CO
IL
L1
L2
L3
L4
L5
OC
SA
T1
T2
T3
T4
Cervical 1
Cervical 2
Cervical 3
Cervical 4
Cervical 5
Cervical 6
Cervical 7
Coccyx
Ilium
Lumbar 1
Lumbar 2
Lumbar 3
Lumbar 4
Lumbar 5
Occiput
Sacrum
Thoracic 1
Thoracic 2
Thoracic 3
Thoracic 4
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Code Name
T5
T6
T7
T8
T9
T10
T11
T12
CR204
1367
Thoracic
Thoracic
Thoracic
Thoracic
Thoracic
Thoracic
Thoracic
Thoracic
5
6
7
8
9
10
11
12
Subluxation Level Code
O
ID
2/3
Situational
Description: Code identifying the specific level of subluxation
Situational Rule: Required when used by the UMO to authorize Spinal Manipulation
Services. If not required by this implementation guide, do not send.
CodeList Summary (Total Codes: 28, Included: 28)
Code Name
C1
C2
C3
C4
C5
C6
C7
CO
IL
L1
L2
L3
L4
L5
OC
SA
T1
T2
T3
T4
T5
T6
T7
T8
T9
T10
T11
T12
Cervical 1
Cervical 2
Cervical 3
Cervical 4
Cervical 5
Cervical 6
Cervical 7
Coccyx
Ilium
Lumbar 1
Lumbar 2
Lumbar 3
Lumbar 4
Lumbar 5
Occiput
Sacrum
Thoracic 1
Thoracic 2
Thoracic 3
Thoracic 4
Thoracic 5
Thoracic 6
Thoracic 7
Thoracic 8
Thoracic 9
Thoracic 10
Thoracic 11
Thoracic 12
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.
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3. P0506 - If either CR205 or CR206 is present, then the other is required.
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.
Situational Rule:
Required when used by the UMO to authorize spinal manipulation services that have a specific pattern of delivery
usage. If not required by this implementation guide, do not send.
TR3 Example:
CR2*1*5~
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Pos: 1400
CR5 Home Oxygen Therapy
Max: 1
Detail - Optional
Information
Loop:
2000E
Elements: 9
User Option (Usage): Situational
Purpose: To supply information regarding certification of medical necessity for home oxygen therapy
Element Summary:
Ref
Id
Element Name
CR503
1348
Oxygen Equipment Type Code
Req
Type
Min/Max
Usage
O
ID
1/1
Situational
Description: Code indicating the specific type of equipment being prescribed for the
delivery of oxygen
Situational Rule: Required when used by the UMO to authorize home oxygen therapy. If
not required by this implementation guide, do not send.
CodeList Summary (Total Codes: 6, Included: 6)
Code Name
A
B
C
D
E
O
CR504
1348
Concentrator
Liquid Stationary
Gaseous Stationary
Liquid Portable
Gaseous Portable
Other
Oxygen Equipment Type Code
O
ID
1/1
Situational
Description: Code indicating the specific type of equipment being prescribed for the
delivery of oxygen
Situational Rule: Required when used by the UMO to authorize home oxygen therapy. If
not required by this implementation guide, do not send.
CodeList Summary (Total Codes: 6, Included: 6)
Code Name
A
B
C
D
E
O
CR506
380
Concentrator
Liquid Stationary
Gaseous Stationary
Liquid Portable
Gaseous Portable
Other
Quantity
O
R
1/15
Required
R
1/15
Situational
Description: Numeric value of quantity
IMPLEMENTATION NAME: Oxygen Flow Rate
CR507
380
Quantity
O
Description: Numeric value of quantity
Situational Rule: Required when the UMO authorizes a daily home oxygen use count. If
not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Daily Oxygen Use Count
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Ref
CR508
Health Care Services Review Information - Response - 278
Id
380
Element Name
Quantity
Req
O
Type
R
Min/Max
1/15
Usage
Situational
Description: Numeric value of quantity
Situational Rule: Required when the UMO authorizes a daily home oxygen period hour
count. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Oxygen Use Period Hour Count
CR509
352
Description
O
AN
1/80
Situational
Description: A free-form description to clarify the related data elements and their content
Situational Rule: Required when the UMO must convey special orders to the respiratory
therapist that could not otherwise be codified within this transaction. If not required by this
implementation guide, do not send.
IMPLEMENTATION NAME: Respiratory Therapist Order Text
CR516
380
Quantity
O
R
1/15
Situational
Description: Numeric value of quantity
Situational Rule: Required when either CR503, CR505 or CR518 = “D” (Liquid Portable)
or “E” (Gaseous Portable). f not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Portable Oxygen System Flow Rate
CR517
1382
Oxygen Delivery System Code
O
ID
1/1
Required
Description: Code to indicate if a particular form of delivery was prescribed
CodeList Summary (Total Codes: 5, Included: 5)
Code Name
A
B
C
D
E
CR518
1348
Nasal Cannula
Oxygen Conserving Device
Oxygen Conserving Device with Oxygen Pulse System
Oxygen Conserving Device with Reservoir System
Transtracheal Catheter
Oxygen Equipment Type Code
O
ID
1/1
Situational
Description: Code indicating the specific type of equipment being prescribed for the
delivery of oxygen
Situational Rule: Required when used by the UMO to authorize home oxygen therapy. If
not required by this implementation guide, do not send.
CodeList Summary (Total Codes: 6, Included: 6)
Code Name
A
B
C
D
E
O
Concentrator
Liquid Stationary
Gaseous Stationary
Liquid Portable
Gaseous Portable
Other
Semantics:
1. CR502 is the number of months covered by this certification.
2. CR505 is the reason for equipment.
3. CR506 is the oxygen flow rate in liters per minute.
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4.
5.
6.
7.
8.
9.
Health Care Services Review Information - Response - 278
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.
Situational Rule:
Required when used by the UMO to authorize specific usage of home oxygen therapy. If not required by this
implementation guide, do not send.
TR3 Example:
CR5***D***1**********2*A~
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Pos: 1500
CR6 Home Health Care
Max: 1
Detail - Optional
Information
Loop:
2000E
Elements: 6
User Option (Usage): Situational
Purpose: To supply information related to the certification of a home health care patient
Element Summary:
Ref
Id
Element Name
CR601
923
Prognosis Code
Req
Type
Min/Max
Usage
M
ID
1/1
Required
Description: Code indicating physician's prognosis for the patient
CodeList Summary (Total Codes: 8, Included: 8)
Code Name
1
2
3
4
5
6
7
8
CR602
373
Poor
Guarded
Fair
Good
Very Good
Excellent
Less than 6 Months to Live
Terminal
Date
M
DT
8/8
Required
Description: Date expressed as CCYYMMDD where CC represents the first two digits of
the calendar year
IMPLEMENTATION NAME: Home Health Start Date
CR603
1250
Date Time Period Format Qualifier
X
ID
2/3
Situational
Description: Code indicating the date format, time format, or date and time format
Situational Rule: Required when the UMO authorizes a specific certification period for the
home health plan of treatment. If not required by this implementation guide, do not send.
CodeList Summary (Total Codes: 42, Included: 1)
Code Name
RD8
CR604
1251
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
Date Time Period
X
AN
1/35
Situational
Description: Expression of a date, a time, or range of dates, times or dates and times
Situational Rule: Required when the UMO authorizes a specific certification period for the
home health plan of treatment. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Home Health Certification Period
CR607
1073
Yes/No Condition or Response Code
M
ID
1/1
Required
Description: Code indicating a Yes or No condition or response
IMPLEMENTATION NAME: Medicare Coverage Indicator
CodeList Summary (Total Codes: 4, Included: 1)
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Code Name
W
CR608
1322
Not Applicable
Certification Type Code
M
ID
1/1
Required
Description: Code indicating the type of certification
This element must have the same value as UM02.
CodeList Summary (Total Codes: 15, Included: 9)
Code Name
1
Appeal - Immediate
Use this value only for appeals of review decisions where the level of service
required is emergency or urgent.
2
Appeal - Standard
Use this value for appeals of review decisions where the level of service required
is not emergency or urgent.
3
4
5
6
Cancel
Extension
Notification
Verification
This code is used to request the UMO to reconsider a previously denied referral or
certification request.
I
R
S
Initial
Renewal
Revised
Syntax Rules:
1. P0304 - If either CR603 or CR604 is present, then the other is required.
2. P091011 - If either CR609, CR610 or CR611 are present, then the others are required.
3. P151617 - If either CR615, CR616 or CR617 are present, then the others are required.
Semantics:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
CR602 is the date covered home health services began.
CR604 is the certification period covered by this plan of treatment.
CR605 is the date of onset or exacerbation of the principal diagnosis.
A "Y" value indicates patient is receiving care in a 1861J1 (skilled nursing) facility. An "N" value indicates
patient is not receiving care in a 1861J1 facility. A "U" value indicates it is unknown whether or not the patient
is receiving care in a 1861J1 facility.
CR607 indicates if the patient is covered by Medicare. A "Y" value indicates the patient is covered by
Medicare; an "N" value indicates patient is not covered by Medicare.
CR609 is the date that the surgery identified in CR611 was performed.
CR610 qualifies CR611.
CR611 is the surgical procedure most relevant to the care being rendered.
CR612 is the date the agency received the verbal orders from the physician for start of care.
CR613 is the date that the patient was last seen by the physician.
CR614 is the date of the home health agency's most recent contact with the physician.
CR616 is the date range of the most recent inpatient stay.
CR617 indicates the type of facility from which the patient was most recently discharged.
CR618 is the date of onset or exacerbation of the first secondary diagnosis.
CR619 is the date of onset or exacerbation of the second secondary diagnosis.
CR620 is the date of onset or exacerbation of the third secondary diagnosis.
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17. CR621 is the date of onset or exacerbation of the fourth secondary diagnosis.
Situational Rule:
Required when used by the UMO to render a medical decision. If not required by this implementation guide, do
not send.
TR3 Example:
CR6*7*20050429*****W*I~
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Pos: 1550
PWK Additional Patient
Max: 10
Detail - Optional
Information
Loop:
2000E
Elements: 5
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
IMPLEMENTATION NAME: Attachment Report Type Code
CodeList Summary (Total Codes: 541, Included: 66)
Code Name
03
04
05
06
07
Report Justifying Treatment Beyond Utilization Guidelines
Drugs Administered
Treatment Diagnosis
Initial Assessment
Functional Goals
Expected outcomes of rehabilitative services.
08
09
10
11
13
15
21
48
55
Plan of Treatment
Progress Report
Continued Treatment
Chemical Analysis
Certified Test Report
Justification for Admission
Recovery Plan
Social Security Benefit Letter
Rental Agreement
Use for medical or dental equipment rental.
59
77
A3
A4
AM
Benefit Letter
Support Data for Verification
Allergies/Sensitivities Document
Autopsy Report
Ambulance Certification
Information to support necessity of ambulance trip.
AS
Admission Summary
A brief patient summary; it lists the patient’s chief complaints and the reasons for
admitting the patient to the hospital.
AT
Purchase Order Attachment
Use for purchase of medical or dental equipment.
B2
B3
BR
BS
BT
Prescription
Physician Order
Benchmark Testing Results
Baseline
Blanket Test Results
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Code Name
PWK02
756
CB
Chiropractic Justification
Lists the reasons chiropractic is just and appropriate treatment.
CK
D2
DA
DB
DG
DJ
DS
FM
HC
HR
I5
IR
LA
M1
NN
OB
OC
OD
OE
OX
P4
P5
P6
P7
PE
PN
PO
PQ
PY
PZ
QC
QR
RB
RR
RT
RX
SG
V5
XP
Consent Form(s)
Drug Profile Document
Dental Models
Durable Medical Equipment Prescription
Diagnostic Report
Discharge Monitoring Report
Discharge Summary
Family Medical History Document
Health Certificate
Health Clinic Records
Immunization Record
State School Immunization Records
Laboratory Results
Medical Record Attachment
Nursing Notes
Operative Note
Oxygen Content Averaging Report
Orders and Treatments Document
Objective Physical Examination (including vital signs) Document
Oxygen Therapy Certification
Pathology Report
Patient Medical History Document
Periodontal Charts
Periodontal Reports
Parenteral or Enteral Certification
Physical Therapy Notes
Prosthetics or Orthotic Certification
Paramedical Results
Physician's Report
Physical Therapy Certification
Cause and Corrective Action Report
Quality Report
Radiology Films
Radiology Reports
Report of Tests and Analysis Report
Renewable Oxygen Content Averaging Report
Symptoms Document
Death Notification
Photographs
Report Transmission Code
O
ID
1/2
Required
Description: Code defining timing, transmission method or format by which reports are to
be sent
CodeList Summary (Total Codes: 55, Included: 5)
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Code Name
PWK05
66
BM
EL
By Mail
Electronically Only
Use to indicate that attachment is being transmitted in a separate X12 functional
group.
EM
FX
VO
E-Mail
By Fax
Voice
Use this for voicemail or phone communication.
Identification Code Qualifier
X
ID
1/2
Situational
Description: Code designating the system/method of code structure used for Identification
Code (67)
Situational Rule: Required when PWK02 equals BM, EL, EM or FX. If not required by this
implementation guide, do not send.
CodeList Summary (Total Codes: 241, Included: 1)
Code Name
AC
PWK06
67
Attachment Control Number
Identification Code
X
AN
2/80
Situational
Description: Code identifying a party or other code
Situational Rule: Required when PWK02 equals BM, EL, EM or FX. If not required by this
implementation guide, do not send.
IMPLEMENTATION NAME: Attachment Control Number
PWK07
352
Description
O
AN
1/80
Situational
Description: A free-form description to clarify the related data elements and their content
Situational Rule: Required when additional information requested can not be requested
using a LOINC code or other codified information within this transaction. If not required by
this implementation guide, do not send.
IMPLEMENTATION NAME: Attachment Description
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.
Situational Rule:
Required when the UMO requests additional patient information. If not required by this implementation guide, do
not send.
TR3 Notes:
1. If the UMO has pended the decision on this health care services review request (HCR01 = A4) because
additional medical necessity information is required (HCR03 = 90), the UMO uses this segment to identify the
type of documentation needed such as forms that the provider must complete. The UMO can also indicate what
medium it has used to send these forms.
2. Paperwork requested at the patient level should apply to the patient event and/or all the services requested.
Use the PWK segment in the appropriate Service loop if requesting medical necessity information for a specific
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service.
3. This PWK segment is required to identify requests for specific data that are sent electronically (PWK02 = EL)
but are transmitted in another X12 functional group rather than by paper or using LOINC in the HI segments of the
response. PWK06 is used to identify the attached electronic questionnaire. The number in PWK06 should be
referenced in the corresponding electronic attachment.
4. This PWK segment should not be used if
a. the requester should have provided the information within the 278 request (ST-SE) but failed to do so. In this
case the UMO should use the AAA segments in the 278 response to indicate the data that is missing or invalid.
b. the 278 request (ST-SE) does not support this information and the needed information pertains to a specific
service identified in Loop 2000F and not to all the services requested.
Refer to Section 2.5 for more information on using this segment.
TR3 Example:
PWK*OB*BM***AC*DMN0012~
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Pos: 1600
MSG Message Text
Max: 1
Detail - Optional
Loop:
2000E
Elements: 1
User Option (Usage): Situational
Purpose: To provide a free-form format that allows the transmission of text information
Element Summary:
Ref
Id
Element Name
MSG01
933
Free-form Message Text
Req
Type
Min/Max
Usage
M
AN
1/264
Required
Description: Free-form message text
IMPLEMENTATION NAME: Free Form Message Text
Syntax Rules:
1. C0302 - If MSG03 is present, then MSG02 is required.
Semantics:
1. MSG03 is the number of lines to advance before printing.
Comments:
1. MSG02 is not related to the specific characteristics of a printer, but identifies top of page, advance a line, etc.
2. If MSG02 is "AA - Advance the specified number of lines before print" then MSG03 is required.
Situational Rule:
Required when it is necessary to send additional information about the patient event that could not otherwise be
codified within the 2000E Loop. If not required by this implementation guide, do not send.
TR3 Example:
MSG*This is a free-form text message~
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Loop Patient Event Provider Name
Pos: 1700
Repeat: 14
Optional
Loop:
2010EA
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
1700
1800
NM1
REF
2000
2100
N3
N4
2200
2300
2400
PER
AAA
PRV
Patient Event Provider Name
Patient Event Provider Supplemental
Identification
Patient Event Provider Address
Patient Event Provider City, State, ZIP
Code
Provider Contact Information
Patient Event Provider Request Validation
Patient Event Provider Information
135
Req
Max Use
Repeat
Usage
O
O
1
7
Situational
Situational
O
O
1
1
Situational
Situational
O
O
O
1
9
1
Situational
Situational
Situational
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NM1 Patient Event Provider Name
Pos: 1700
Max: 1
Detail - Optional
Loop:
2010EA
Elements: 9
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: 1500, Included: 14)
Code Name
71
72
73
77
DD
DK
DN
FA
G3
P3
QB
QV
SJ
AAJ
NM102
1065
Attending Physician
Operating Physician
Other Physician
Service Location
Assistant Surgeon
Ordering Physician
Referring Provider
Facility
Clinic
Primary Care Provider
Purchase Service Provider
Group Practice
Service Provider
Admitting Services
Entity Type Qualifier
M
ID
1/1
Required
AN
1/60
Situational
Description: Code qualifying the type of entity
CodeList Summary (Total Codes: 16, Included: 2)
Code Name
1
2
NM103
1035
Person
Non-Person Entity
Name Last or Organization Name
X
Description: Individual last name or organizational name
Situational Rule: Required when valued on the request or when the UMO authorizes a
specific provider or specialty entity by name for this patient event. If not required by this
implementation guide, do not send.
IMPLEMENTATION NAME: Patient Event Provider Last or Organization Name
NM104
1036
Name First
O
AN
1/35
Situational
Description: Individual first name
Situational Rule: Required when NM103 is valued and NM102 = 1. If not required by this
implementation guide, do not send.
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Health Care Services Review Information - Response - 278
Id
Element Name
Req
Type
Min/Max
Usage
IMPLEMENTATION NAME: Patient Event Provider First Name
NM105
1037
Name Middle
O
AN
1/25
Situational
Description: Individual middle name or initial
Situational Rule: Required when NM104 is present and the middle name/initial of the
person is known. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Patient Event Provider Middle Name
NM106
1038
Name Prefix
O
AN
1/10
Situational
Description: Prefix to individual name
Situational Rule: Required when the UMO uses military title or rank to further identify the
individual provider. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Patient Event Provider Name Prefix
NM107
1039
Name Suffix
O
AN
1/10
Situational
Description: Suffix to individual name
Situational Rule: Required when the UMO uses the name suffix to further identify the
individual provider. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Patient Event Provider Name Suffix
NM108
66
Identification Code Qualifier
X
ID
1/2
Situational
Description: Code designating the system/method of code structure used for Identification
Code (67)
Situational Rule: Required when valued on the request or when the UMO authorizes a
specific provider or specialty entity for this patient event by provider ID. If not required by
this implementation guide, do not send.
CodeList Summary (Total Codes: 241, Included: 4)
Code Name
24
34
46
XX
Employer's Identification Number
Social Security Number
Electronic Transmitter Identification Number (ETIN)
Centers for Medicare and Medicaid Services National Provider Identifier
Required for providers on or after the mandated
HIPAA National Provider Identifier (NPI)
implementation date when the provider has an NPI and it is available to the UMO.
OR
Required for providers before the mandated HIPAA NPI implementation date when
the provider has an NPI and the UMO has the capability to send it.
If not required by this implementation guide, do not send.
CODE SOURCE:
537: Centers for Medicare and Medicaid Services National Provider Identifier
NM109
67
Identification Code
X
AN
2/80
Situational
Description: Code identifying a party or other code
Situational Rule: Required when valued on the request or when the UMO authorizes a
specific provider or specialty entity for this patient event by provider ID. If not required by
this implementation guide, do not send.
IMPLEMENTATION NAME: Patient Event Provider Identifier
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ExternalCodeList
Name: 537
Description: Centers for Medicare and Medicaid Services 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.
3. C1203 - If NM112 is present, then NM103 is required.
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
2. NM112 can identify a second surname.
Situational Rule:
Required when valued on the request or when the UMO authorizes a specific provider or specialty entity for this
patient event. If not required by this implementation guide, do not send.
TR3 Notes:
1. Use this segment to convey the name and identification number of the service provider (person, group, or
facility) specialist, or specialty entity to provide services to the patient.
TR3 Example:
NM1*SJ*1*WATSON*SUSAN****348987654321~
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Pos: 1800
REF Patient Event Provider
Max: 7
Detail - Optional
Supplemental Identification
Loop:
2010EA
Elements: 3
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: 1731, Included: 8)
Code Name
REF02
127
0B
1G
1J
EI
State License Number
Provider UPIN Number
Facility ID Number
Employer's Identification Number
Not used if NM108 = 24.
N5
N7
SY
Provider Plan Network Identification Number
Facility Network Identification Number
Social Security Number
The social security number must not be used for Medicare. Not used if NM108 =
34.
ZH
Carrier Assigned Reference Number
Use for the provider ID as assigned by the UMO identified in Loop 2000A.
Reference Identification
X
AN
1/50
Required
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
IMPLEMENTATION NAME: Patient Event Provider Supplemental Identifier
REF03
352
Description
X
AN
1/80
Situational
Description: A free-form description to clarify the related data elements and their content
Situational Rule: Required when REF01 = 0B to report the two character state ID of the
state assigning the State License Number. If not required by this implementation guide, do
not send. See Code Source 22: State and Outlying Areas of the US.
IMPLEMENTATION NAME: License Number State Code
ExternalCodeList
Name: 22C
Description: States and Provinces
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.
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Situational Rule:
Required when used by the UMO to identify the Patient Event Provider. If not required by this implementation
guide, do not send.
TR3 Notes:
1. Use the NM1 segment for the primary identifier.
TR3 Example:
REF*1G*123456~
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Pos: 2000
N3 Patient Event Provider
Max: 1
Detail - Optional
Address
Loop:
2010EA
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
Description: Address information
IMPLEMENTATION NAME: Patient Event Provider Address Line
Use this element for the first line of the service provider’s address.
N302
166
Address Information
O
AN
1/55
Situational
Description: Address information
Situational Rule: Required when a second address lines exists. If not required by this
implementation guide, do not send.
IMPLEMENTATION NAME: Patient Event Provider Address Line
Situational Rule:
Required when the UMO authorizes a specific location for a patient event provider that has multiple locations. If
not required by this implementation guide, do not send.
TR3 Example:
N3*77 HOLLY BLVD~
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Pos: 2100
N4 Patient Event Provider City,
Max: 1
Detail - Optional
State, ZIP Code
Loop:
2010EA
Elements: 5
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
2/2
Situational
Description: Free-form text for city name
IMPLEMENTATION NAME: Patient Event Provider City Name
N402
156
State or Province Code
X
ID
Description: Code (Standard State/Province) as defined by appropriate government
agency
Situational Rule: Required when the address is in the United States of America, including
its territories, or Canada. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Patient Event Provider State Code
CODE SOURCE: 22: States and Provinces
ExternalCodeList
Name: 22C
Description: States and Provinces
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)
Situational Rule: Required when the address is in the United States of America, including
its territories, or Canada, or when a postal code exists for the country in N404. If not
required by this implementation guide, do not send.
IMPLEMENTATION NAME: Patient Event Provider Postal Zone or ZIP Code
CODE SOURCE: 51: ZIP Code
932: Universal Postal Codes
ExternalCodeList
Name: 932
Description:
ExternalCodeList
Name: 51
Description: ZIP Code
N404
26
Country Code
X
ID
2/3
Situational
Description: Code identifying the country
Situational Rule: Required when the address is outside the United States of America. If
not required by this implementation guide, do not send.
CODE SOURCE: 5: Countries, Currencies and Funds
Use the alpha-2 country codes from Part 1 of ISO 3166.
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Id
Element Name
Req
Type
Min/Max
Usage
ID
1/3
Situational
ExternalCodeList
Name: 5
Description: Countries, Currencies and Funds
N407
1715
Country Subdivision Code
X
Description: Code identifying the country subdivision
Situational Rule: Required when the address is not in the United States of America,
including its territories, or Canada, and the country in N404 has administrative subdivisions
such as but not limited to states, provinces, cantons, etc. If not required by this
implementation guide, do not send.
CODE SOURCE: 5: Countries, Currencies and Funds
Use the country subdivision codes from Part 2 of ISO 3166.
ExternalCodeList
Name: 5
Description: Countries, Currencies and Funds
Syntax Rules:
1. E0207 - Only one of N402 or N407 may be present.
2. C0605 - If N406 is present, then N405 is required.
3. C0704 - If N407 is present, then N404 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.
Situational Rule:
Required when the UMO authorizes a specific location for a patient event provider that has multiple locations. If
not required by this implementation guide, do not send.
TR3 Example:
N4*KANSAS CITY*MO*64108~
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Pos: 2200
PER Provider Contact
Max: 1
Detail - Optional
Information
Loop:
2010EA
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: 238, Included: 1)
Code Name
IC
PER02
93
Information Contact
Name
O
AN
1/60
Situational
Description: Free-form name
Situational Rule: Required when the UMO needs to indicate a particular contact and the
name of the entity to contact is not already defined or is different than the name within the
prior name segment (e.g. N1 or NM1). If not required by this implementation guide, do not
send.
IMPLEMENTATION NAME: Patient Event Provider Contact Name
PER03
365
Communication Number Qualifier
X
ID
2/2
Situational
Description: Code identifying the type of communication number
Situational Rule: Required when PER02 is not valued or when the UMO needs to transmit
a contact communication number. If not required by this implementation guide, do not send.
CodeList Summary (Total Codes: 42, Included: 4)
Code Name
EM
FX
TE
UR
PER04
364
Electronic Mail
Facsimile
Telephone
Uniform Resource Locator (URL)
Communication Number
X
AN
1/256
Situational
Description: Complete communications number including country or area code when
applicable
Situational Rule: Required when PER02 is not valued or when the UMO needs to transmit
a contact communication number. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Patient Event Provider Contact Communications Number
PER05
365
Communication Number Qualifier
X
ID
2/2
Situational
Description: Code identifying the type of communication number
Situational Rule: Required when a telephone extension or multiple communication types
are available. If not required by this implementation guide, do not send.
CodeList Summary (Total Codes: 42, Included: 5)
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Code Name
PER06
364
EM
EX
Electronic Mail
Telephone Extension
When used, the value following this code is the extension for the preceding
communications contact number.
FX
TE
UR
Facsimile
Telephone
Uniform Resource Locator (URL)
Communication Number
X
AN
1/256
Situational
Description: Complete communications number including country or area code when
applicable
Situational Rule: Required when a telephone extension or multiple communication types
are available. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Patient Event Provider Contact Communications Number
PER07
365
Communication Number Qualifier
X
ID
2/2
Situational
Description: Code identifying the type of communication number
Situational Rule: Required when a telephone extension or multiple communication types
are available. If not required by this implementation guide, do not send.
CodeList Summary (Total Codes: 42, Included: 5)
Code Name
PER08
364
EM
EX
Electronic Mail
Telephone Extension
When used, the value following this code is the extension for the preceding
communications contact number.
FX
TE
UR
Facsimile
Telephone
Uniform Resource Locator (URL)
Communication Number
X
AN
1/256
Situational
Description: Complete communications number including country or area code when
applicable
Situational Rule: Required when a telephone extension or multiple communication types
are available. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Patient Event Provider Contact Communications Number
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.
Situational Rule:
Required when needed to identify a contact name and/or communications number for the provider. If not required
by this implementation guide, may be provided at the sender’s discretion but cannot be required by the receiver.
TR3 Notes:
1. When the communication number represents a telephone number in the United States and other countries
using the North American Dialing Plan (for voice, data, fax, etc), the communication number should always
include the area code and telephone number using the format AAABBBCCCC. Where AAA is the area code, BBB
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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. By definition of the standard, if PER03 is used, PER04 is required.
TR3 Example:
PER*IC*M TUCKER*TE*8189993456*FX*8188769304~
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Pos: 2300
AAA Patient Event Provider
Max: 9
Detail - Optional
Request Validation
Loop:
2010EA
Elements: 3
User Option (Usage): Situational
Purpose: To specify the validity of the request and indicate follow-up action authorized
Element Summary:
Ref
Id
Element Name
AAA01
1073
Yes/No Condition or Response Code
Req
Type
Min/Max
Usage
M
ID
1/1
Required
2/2
Required
Description: Code indicating a Yes or No condition or response
IMPLEMENTATION NAME: Valid Request Indicator
CodeList Summary (Total Codes: 4, Included: 1)
Code Name
N
AAA03
901
No
Reject Reason Code
O
ID
Description: Code assigned by issuer to identify reason for rejection
CodeList Summary (Total Codes: 204, Included: 15)
Code Name
AAA04
889
15
Required application data missing
Use when data is missing that is not covered by another reject reason code. Use
to indicate when there is not enough information to identify the provider.
33
Input Errors
Use for input errors not covered by another reject reason code.
35
41
43
44
45
46
47
49
51
52
Out of Network
Authorization/Access Restrictions
Invalid/Missing Provider Identification
Invalid/Missing Provider Name
Invalid/Missing Provider Specialty
Invalid/Missing Provider Phone Number
Invalid/Missing Provider State
Provider is Not Primary Care Physician
Provider Not on File
Service Dates Not Within Provider Plan Enrollment
Use for patient event dates.
79
Invalid Participant Identification
Use for invalid/missing provider supplemental identifier.
97
IP
Invalid or Missing Provider Address
Inappropriate Provider Role
Follow-up Action Code
O
ID
1/1
Required
Description: Code identifying follow-up actions allowed
CodeList Summary (Total Codes: 10, Included: 2)
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Code Name
C
N
Please Correct and Resubmit
Resubmission Not Allowed
Semantics:
1. AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N"
indicates that the code is invalid.
Comments:
1. If AAA02 is used, AAA03 contains a code from an industry code list.
Situational Rule:
Required when the request is not valid at this level to indicate the data condition that prohibits processing of the
original request. If not required by this implementation guide, do not send.
TR3 Example:
AAA*N**47*C~
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Pos: 2400
PRV Patient Event Provider
Max: 1
Detail - Optional
Information
Loop:
2010EA
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
1/50
Required
Description: Code identifying the type of provider
CodeList Summary (Total Codes: 26, Included: 9)
Code Name
PRV02
128
AD
Admitting
Use only when NM101 = AAJ.
AS
Assistant Surgeon
Use only when NM101 = DD.
AT
Attending
Use only when NM101 = 71.
OP
Operating
Use only when NM101 = 72.
OR
Ordering
Use only when NM101 = DK.
OT
Other Physician
Use only when NM101 = 73.
PC
Primary Care Physician
Use only when NM101 = P3.
PE
Performing
Use only when NM101 = SJ.
RF
Referring
Use only when NM101 = DN.
Reference Identification Qualifier
X
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1731, Included: 1)
Code Name
PXC
Health Care Provider Taxonomy Code
CODE SOURCE:
682: Health Care Provider Taxonomy
PRV03
127
Reference Identification
X
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
IMPLEMENTATION NAME: Provider Taxonomy Code
ExternalCodeList
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Name: 682
Description: Health Care Provider Taxonomy
Syntax Rules:
1. P0203 - If either PRV02 or PRV03 is present, then the other is required.
Situational Rule:
Required when used by the UMO to identify the provider. If not required by this implementation guide, do not
send.
TR3 Example:
PRV*PE*PXC*203BS0133X~
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Loop Additional Patient Information
Contact Name
Pos: 1700
Repeat: 1
Optional
Loop:
2010EB
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
1700
NM1
2000
N3
2100
N4
2200
PER
Additional Patient
Name
Additional Patient
Address
Additional Patient
State, ZIP Code
Additional Patient
Information
Req
Max Use
Information Contact
O
1
Situational
Information Contact
O
1
Situational
Information Contact City,
O
1
Situational
Information Contact
O
1
Situational
151
Repeat
Usage
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Pos: 1700
NM1 Additional Patient
Max: 1
Detail - Optional
Information Contact Name
Loop:
2010EB
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: 1500, Included: 1)
Code Name
L5
NM102
1065
Contact
Entity Type Qualifier
M
ID
1/1
Required
Description: Code qualifying the type of entity
CodeList Summary (Total Codes: 16, Included: 2)
Code Name
NM103
1035
1
Person
Use this name only if the destination is an individual, such as an individual primary
care physician.
2
Non-Person Entity
Name Last or Organization Name
X
AN
1/60
Situational
Description: Individual last name or organizational name
Situational Rule: Required when the responder needs to identify the destination by name.
If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Response Contact Last or Organization Name
NM104
1036
Name First
O
AN
1/35
Situational
Description: Individual first name
Situational Rule: Required when NM103 is valued and the destination is an individual
(NM102 = 1). If not required, do not send.
IMPLEMENTATION NAME: Response Contact First Name
NM105
1037
Name Middle
O
AN
1/25
Situational
Description: Individual middle name or initial
Situational Rule: Required when NM104 is valued and the middle name/initial of the
individual is known. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Response Contact Middle Name
NM107
1039
Name Suffix
O
AN
1/10
Situational
Description: Suffix to individual name
Situational Rule: Required when NM104 is valued and the suffix of the individual’s name
is known; e.g. Sr., Jr., or III. If not required by this implementation guide, do not send.
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Id
Element Name
Req
Type
Min/Max
Usage
1/2
Situational
IMPLEMENTATION NAME: Response Contact Name Suffix
NM108
66
Identification Code Qualifier
X
ID
Description: Code designating the system/method of code structure used for Identification
Code (67)
Situational Rule: Required when the responder needs to use an identifier to identify the
destination. If not required by this implementation guide, do not send.
CodeList Summary (Total Codes: 241, Included: 6)
Code Name
24
34
46
PI
Employer's Identification Number
Social Security Number
Electronic Transmitter Identification Number (ETIN)
Payor Identification
Use until the National PlanID is mandated if the destination is a payer.
XV
Centers for Medicare and Medicaid Services PlanID
Use if the destination is a payer.
CODE SOURCE:
540: Centers for Medicare and Medicaid Services PlanID
XX
Centers for Medicare and Medicaid Services National Provider Identifier
Use if the destination is a provider.
CODE SOURCE:
537: Centers for Medicare and Medicaid Services National Provider Identifier
NM109
67
Identification Code
X
AN
2/80
Situational
Description: Code identifying a party or other code
Situational Rule: Required when the responder needs to use an identifier to identify the
destination. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Response Contact Identifier
ExternalCodeList
Name: 537
Description: Centers for Medicare and Medicaid Services National Provider Identifier
ExternalCodeList
Name: 540
Description: Centers for Medicare and Medicaid Services 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.
3. C1203 - If NM112 is present, then NM103 is required.
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
2. NM112 can identify a second surname.
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Situational Rule:
Required when this Loop 2000E contains a request for additional information and the destination for that
additional information differs from the UMO Name information in the NM1 loop (Loop 2010A) of the 278 response.
If not required by this implementation guide, do not send.
TR3 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.
Refer to Section 2.5 for more information on this NM1 loop.
TR3 Example:
NM1*L5*2*ACME THIRD PARTY ADMINISTRATOR~
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N3 Additional Patient Information
Contact Address
Pos: 2000
Max: 1
Detail - Optional
Loop:
2010EB
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
1/55
Situational
Description: Address information
IMPLEMENTATION NAME: Response Contact Address Line
Use this element for the first line of the requester’s address.
N302
166
Address Information
O
AN
Description: Address information
Situational Rule: Required when a second address lines exists. If not required by this
implementation guide, do not send.
IMPLEMENTATION NAME: Response Contact Address Line
Situational Rule:
Required when the response to the request for additional patient information must be routed to a specific office
location. If not required by this implementation guide, do not send.
TR3 Notes:
1. This segment identifies the office location to route the response to the request for additional patient information.
TR3 Example:
N3*43 SUNRISE BLVD*SUITE 1000~
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N4 Additional Patient Information
Contact City, State, ZIP Code
Pos: 2100
Max: 1
Detail - Optional
Loop:
2010EB
Elements: 5
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
Description: Free-form text for city name
IMPLEMENTATION NAME: Additional Patient Information Contact City Name
N402
156
State or Province Code
X
ID
2/2
Situational
Description: Code (Standard State/Province) as defined by appropriate government
agency
Situational Rule: Required when the address is in the United States of America, including
its territories, or Canada. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Additional Patient Information Contact State Code
CODE SOURCE: 22: States and Provinces
ExternalCodeList
Name: 22C
Description: States and Provinces
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)
Situational Rule: Required when the address is in the United States of America, including
its territories, or Canada, or when a postal code exists for the country in N404. If not
required by this implementation guide, do not send.
IMPLEMENTATION NAME: Additional Patient Information Contact Postal
Zone or ZIP Code
CODE SOURCE: 51: ZIP Code
ExternalCodeList
Name: 51
Description: ZIP Code
N404
26
Country Code
X
ID
2/3
Situational
Description: Code identifying the country
Situational Rule: Required when the address is outside the United States of America. If
not required by this implementation guide, do not send.
CODE SOURCE: 5: Countries, Currencies and Funds
Use the alpha-2 country codes from Part 1 of ISO 3166.
ExternalCodeList
Name: 5
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Description: Countries, Currencies and Funds
N407
1715
Country Subdivision Code
X
ID
1/3
Situational
Description: Code identifying the country subdivision
Situational Rule: Required when the address is not in the United States of America,
including its territories, or Canada, and the country in N404 has administrative subdivisions
such as but not limited to states, provinces, cantons, etc. If not required by this
implementation guide, do not send.
CODE SOURCE: 5: Countries, Currencies and Funds
Use the country subdivision codes from Part 2 of ISO 3166.
ExternalCodeList
Name: 5
Description: Countries, Currencies and Funds
Syntax Rules:
1. E0207 - Only one of N402 or N407 may be present.
2. C0605 - If N406 is present, then N405 is required.
3. C0704 - If N407 is present, then N404 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.
Situational Rule:
Required when the response to the request for additional patient information must be routed to a specific office
location. If not required by this implementation guide, do not send.
TR3 Example:
N4*KANSAS CITY*MO*64108~
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Pos: 2200
PER Additional Patient
Max: 1
Detail - Optional
Information Contact
Information
Loop:
2010EB
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: 238, Included: 1)
Code Name
IC
PER02
93
Information Contact
Name
O
AN
1/60
Situational
Description: Free-form name
Situational Rule: Required when the response must be directed to a particular contact
and when the name of the entity to contact is not already defined or is different than the
name within the prior name segment (e.g. N1 or NM1). If not required by this
implementation guide, do not send.
IMPLEMENTATION NAME: Response Contact Name
PER03
365
Communication Number Qualifier
X
ID
2/2
Situational
Description: Code identifying the type of communication number
Situational Rule: Required when PER02 is not valued or when the UMO needs to transmit
a contact communication number. If not required by this implementation guide, do not send.
CodeList Summary (Total Codes: 42, Included: 4)
Code Name
EM
FX
TE
UR
PER04
364
Electronic Mail
Facsimile
Telephone
Uniform Resource Locator (URL)
Must not contain any characters used as delimiters in this transaction.
Communication Number
X
AN
1/256
Situational
Description: Complete communications number including country or area code when
applicable
Situational Rule: Required when PER02 is not valued or when the UMO needs to transmit
a contact communication number. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Response Contact Communication Number
PER05
365
Communication Number Qualifier
X
ID
2/2
Situational
Description: Code identifying the type of communication number
Situational Rule: Required when a telephone extension or multiple communication types
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Id
Element Name
Req
Type
Min/Max
are available. If not required by this implementation guide, do not send.
Usage
CodeList Summary (Total Codes: 42, Included: 4)
Code Name
EM
EX
FX
TE
PER06
364
Electronic Mail
Telephone Extension
Facsimile
Telephone
Communication Number
X
AN
1/256
Situational
Description: Complete communications number including country or area code when
applicable
Situational Rule: Required when a telephone extension or multiple communication types
are available. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Response Contact Communication Number
PER07
365
Communication Number Qualifier
X
ID
2/2
Situational
Description: Code identifying the type of communication number
Situational Rule: Required when a telephone extension or multiple communication types
are available. If not required by this implementation guide, do not send.
CodeList Summary (Total Codes: 42, Included: 4)
Code Name
EM
EX
FX
TE
PER08
364
Electronic Mail
Telephone Extension
Facsimile
Telephone
Communication Number
X
AN
1/256
Situational
Description: Complete communications number including country or area code when
applicable
Situational Rule: Required when a telephone extension or multiple communication types
are available. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Response Contact Communication Number
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.
Situational Rule:
Required when the provider must direct the response to the request for additional patient information to a specific
requester contact, electronic mail, facsimile, or phone number other than the contact provided in the PER
segment in the UMO Name loop (Loop 2010A) PER segment of this 278 response. If not required by this
implementation guide, do not send.
TR3 Notes:
1. When the communication number represents a telephone number in the United States and other countries
using the North American Dialing Plan (for voice, data, fax, etc), the communication number should always
include the area code and telephone 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
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5342242525). The extension, when applicable, should be included in the communication number immediately
after the telephone number.
2. By definition of the standard, if PER03 is used, PER04 is required.
TR3 Example:
PER*IC*MARY*FX*3135554321~
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Pos: 1700
Loop Patient Event Transport
Information
Repeat: 5
Optional
Loop:
2010EC
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
1700
2000
2100
NM1
N3
N4
2300
AAA
Patient Event Transport
Patient Event Transport
Patient Event Transport
City/State/ZIP Code
Patient Event Transport
Validation
Req
Max Use
Information
Location Address
Location
O
O
O
1
1
1
Situational
Required
Required
Location Request
O
9
Situational
161
Repeat
Usage
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Pos: 1700
NM1 Patient Event Transport
Max: 1
Detail - Optional
Information
Loop:
2010EC
Elements: 3
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: 1500, Included: 5)
Code Name
45
FS
ND
PW
R3
NM102
1065
Drop-off Location
Final Scheduled Destination
Next Destination
Pickup Address
Next Scheduled Destination
Entity Type Qualifier
M
ID
1/1
Required
AN
1/60
Required
Description: Code qualifying the type of entity
CodeList Summary (Total Codes: 16, Included: 1)
Code Name
2
NM103
1035
Non-Person Entity
Name Last or Organization Name
X
Description: Individual last name or organizational name
IMPLEMENTATION NAME: Patient Event Transport Location Name
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.
3. C1203 - If NM112 is present, then NM103 is required.
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
2. NM112 can identify a second surname.
Situational Rule:
Required when used by the UMO to authorize specific transport services. If not required by this implementation
guide, do not send.
TR3 Example:
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NM1*PW*2*PATIENT DIALYSIS CENT~
NM1*FS*2*PATIENT’S HOME~
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Pos: 2000
N3 Patient Event Transport
Max: 1
Detail - Optional
Location Address
Loop:
2010EC
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
IMPLEMENTATION NAME: Patient Event Transport Location Address Line
Use this element for the first line of the transport location address.
N302
166
Address Information
O
AN
1/55
Situational
Description: Address information
Situational Rule: Required when a second address lines exists. If not required by this
implementation guide, do not send.
IMPLEMENTATION NAME: Patient Event Transport Location Address Line
TR3 Example:
N3*77 HOLLY BLVD~
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Pos: 2100
N4 Patient Event Transport
Max: 1
Detail - Optional
Location City/State/ZIP Code
Loop:
2010EC
Elements: 3
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
Situational
Description: Free-form text for city name
Situational Rule: Required when used by the UMO to authorize specific transport services.
If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Patient Event Transport Location City Name
N402
156
State or Province Code
X
ID
2/2
Situational
Description: Code (Standard State/Province) as defined by appropriate government
agency
Situational Rule: Required when used by the UMO to authorize specific transport services.
If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Patient Event Transport Location State or Province Code
CODE SOURCE: 22: States and Provinces
ExternalCodeList
Name: 22C
Description: States and Provinces
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)
Situational Rule: Required when used by the UMO to authorize specific transport services.
If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Patient Event Transport Location Postal Zone or ZIP Code
CODE SOURCE: 51: ZIP Code
ExternalCodeList
Name: 51
Description: ZIP Code
Syntax Rules:
1. E0207 - Only one of N402 or N407 may be present.
2. C0605 - If N406 is present, then N405 is required.
3. C0704 - If N407 is present, then N404 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.
TR3 Example:
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N4*HOLLYWOOD*CA*90214~
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Pos: 2300
AAA Patient Event Transport
Max: 9
Detail - Optional
Location Request Validation
Loop:
2010EC
Elements: 3
User Option (Usage): Situational
Purpose: To specify the validity of the request and indicate follow-up action authorized
Element Summary:
Ref
Id
Element Name
AAA01
1073
Yes/No Condition or Response Code
Req
Type
Min/Max
Usage
M
ID
1/1
Required
2/2
Required
Description: Code indicating a Yes or No condition or response
IMPLEMENTATION NAME: Valid Request Indicator
CodeList Summary (Total Codes: 4, Included: 1)
Code Name
N
AAA03
901
No
Reject Reason Code
O
ID
Description: Code assigned by issuer to identify reason for rejection
CodeList Summary (Total Codes: 204, Included: 4)
Code Name
AAA04
889
15
Required application data missing
Use when data is missing that is not covered by another reject reason code. Use
to indicate when there is not enough information to identify the transport
information.
33
Input Errors
Use for input errors not covered by another reject reason code.
47
Invalid/Missing Provider State
Use to code to indicate that the transport location state is invalid or missing.
97
Invalid or Missing Provider Address
Use this code to indicate that the transport location address is invalid or missing.
Follow-up Action Code
O
ID
1/1
Required
Description: Code identifying follow-up actions allowed
CodeList Summary (Total Codes: 10, Included: 2)
Code Name
C
N
Please Correct and Resubmit
Resubmission Not Allowed
Semantics:
1. AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N"
indicates that the code is invalid.
Comments:
1. If AAA02 is used, AAA03 contains a code from an industry code list.
Situational Rule:
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Required when the request is not valid at this level to indicate the data condition that prohibits processing of the
original request. If not required by this implementation guide, do not send.
TR3 Example:
AAA*N**47*C~
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Pos: 0100
Loop Service Level
Repeat: >1
Optional
Loop:
2000F
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
0100
0200
0300
0400
0500
0600
0600
0700
0700
0700
0700
0800
0810
0820
0830
0840
0900
1550
1600
1700
1700
HL
TRN
AAA
UM
HCR
REF
REF
DTP
DTP
DTP
DTP
HI
SV1
SV2
SV3
TOO
HSD
PWK
MSG
Service Level
Service Trace Number
Service Request Validation
Health Care Services Review Information
Health Care Services Review
Administrative Reference Number
Previous Review Authorization Number
Service Date
Certification Issue Date
Certification Expiration Date
Certification Effective Date
Request For Additional Information
Professional Service
Institutional Service Line
Dental Service
Tooth Information
Health Care Services Delivery
Additional Service Information
Message Text
Loop 2010FA
Loop 2010FB
169
Req
Max Use
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
1
3
9
1
1
1
1
1
1
1
1
1
1
1
1
32
1
10
1
Repeat
Usage
12
1
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
Situational
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Pos: 0100
HL Service Level
Max: 1
Detail - Optional
Loop:
2000F
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: 250, Included: 1)
Code Name
SS
HL04
736
Services
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.
Situational Rule:
Required when the UMO system processed any of the information contained in Loop 2000F of the request. If not
required by this implementation guide, do not send.
TR3 Notes:
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1. This segment identifies the service(s) requested and conveys the review outcome related to that service(s).
2. If the UMO was unable to process any data beyond Loop 2000C or Loop 2000D of the request, this loop and
any subordinate loops are not required.
TR3 Example:
HL*6*5*SS*0~
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Pos: 0200
TRN Service Trace Number
Max: 3
Detail - Optional
Loop:
2000F
Elements: 4
User Option (Usage): Situational
Purpose: To uniquely identify a transaction to an application
Element Summary:
Ref
Id
Element Name
TRN01
481
Trace Type Code
Req
Type
Min/Max
Usage
M
ID
1/2
Required
Description: Code identifying which transaction is being referenced
CodeList Summary (Total Codes: 3, Included: 2)
Code Name
TRN02
127
1
Current Transaction Trace Numbers
The term “Current Transaction Trace Number” refers to the trace number assigned
by the creator of the 278 response transaction (the UMO).
2
Referenced Transaction Trace Numbers
The term “Referenced Transaction Trace Number” refers to the trace number
originally sent in the 278 request transaction.
Reference Identification
M
AN
1/50
Required
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
IMPLEMENTATION NAME: Service Trace Number
TRN03
509
Originating Company Identifier
O
AN
10/10
Required
Description: A unique identifier designating the company initiating the funds transfer
instructions, business transaction or assigning tracking reference identification.
IMPLEMENTATION NAME: Trace Assigning Entity Identifier
Use this element to identify the organization that assigned this trace number. If TRN01 is
“2", this is the value received in the original 278 request transaction. If TRN01 is ”1", use
this information to identify the UMO organization that assigned this trace number.
The first position must be either a “1" if an EIN is used, a ”3" if a DUNS is used or a “9" if a
user assigned identifier is used.
TRN04
127
Reference Identification
O
AN
1/50
Situational
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Situational Rule: Required when TRN01 = 2 and TRN04 was valued on the request or
when TRN01 = 1 and a specific division or group, of the company identified in the previous
data element (TRN03) is needed by the sender to further identify a specific component of
the entity. If not required by this implementation guide, may be provided at the sender’s
discretion, but can not be required by the receiver.
IMPLEMENTATION NAME: Trace Assigning Entity Additional Identifier
Semantics:
1. TRN02 provides unique identification for the transaction.
2. TRN03 identifies an organization.
3. TRN04 identifies a further subdivision within the organization.
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Situational Rule:
Required when this loop is returned and the request contained a tracking number at this level on the request, or
when the UMO or clearinghouse assigns a trace number to this service in the response for tracking purposes. If
not required by this implementation guide, do not send.
TR3 Notes:
1. Any trace numbers provided at this level on the request must be returned by the UMO at this level of the 278
response.
2. If the 278 request transaction passes through more than one clearinghouse, the second (and subsequent)
clearinghouse may choose one of the following options:
If the second or subsequent clearinghouse needs to assign their own TRN segment they may replace the
received TRN segment belonging to the sending clearinghouse with their own TRN segment. Upon returning a
278 response to the sending clearinghouse, they must remove their TRN segment and replace it with the sending
clearinghouse’s TRN segment.
If the second or subsequent clearinghouse does not need to assign their own TRN segment, they should merely
pass all TRN segments received in the 278 response transaction.
3. If the 278 request passes through a clearinghouse that adds their own TRN in addition to a requester TRN, the
clearinghouse will receive a response from the UMO containing two TRN segments that contain the value “2"
(Referenced Transaction Trace Number) in TRN01. If the UMO has assigned a TRN, the UMO’s TRN will contain
the value ”1" (Current Transaction Trace Number) in TRN01. If the clearinghouse chooses to pass their own TRN
values to the requester, the clearinghouse must change the value in their TRN01 to “1" because, from the
requester’s perspective, this is not a referenced transaction trace number.
TR3 Example:
TRN*2*111099*9012345678*RADIOLOGY~
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Pos: 0300
AAA Service Request Validation
Max: 9
Detail - Optional
Loop:
2000F
Elements: 3
User Option (Usage): Situational
Purpose: To specify the validity of the request and indicate follow-up action authorized
Element Summary:
Ref
Id
Element Name
AAA01
1073
Yes/No Condition or Response Code
Req
Type
Min/Max
Usage
M
ID
1/1
Required
2/2
Required
Description: Code indicating a Yes or No condition or response
IMPLEMENTATION NAME: Valid Request Indicator
CodeList Summary (Total Codes: 4, Included: 1)
Code Name
N
AAA03
901
No
Reject Reason Code
O
ID
Description: Code assigned by issuer to identify reason for rejection
CodeList Summary (Total Codes: 204, Included: 10)
Code Name
AAA04
889
15
Required application data missing
Use when data is missing that is not covered by another Reject Reason Code. For
example, use for missing procedure codes and procedure dates.
33
Input Errors
Use for input errors in the service data not covered by the other reject reason
codes listed. For example, use for invalid place of service codes and invalid
procedure codes and procedure dates.
52
57
Service Dates Not Within Provider Plan Enrollment
Invalid/Missing Date(s) of Service
Use for invalid/missing service, admission, surgery, or discharge dates.
60
61
62
AA
AG
T5
Date of Birth Follows Date(s) of Service
Date of Death Precedes Date(s) of Service
Date of Service Not Within Allowable Inquiry Period
Authorization Number Not Found
Invalid/Missing Procedure Code(s)
Certification Information Missing
Use to indicate missing previous certification number information.
Follow-up Action Code
O
ID
1/1
Required
Description: Code identifying follow-up actions allowed
CodeList Summary (Total Codes: 10, Included: 2)
Code Name
C
N
Please Correct and Resubmit
Resubmission Not Allowed
Semantics:
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1. AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N"
indicates that the code is invalid.
Comments:
1. If AAA02 is used, AAA03 contains a code from an industry code list.
Situational Rule:
Required when the request is not valid at this level. If not required by this implementation guide, do not send.
TR3 Notes:
1. If the non-certification is related to a medical necessity/benefits decision, use the HCR segment.
2. If Loop 2000F is present in the response, either the AAA segment or the HCR segment must be returned.
TR3 Example:
AAA*N**52*C~
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UM Health Care Services Review
Information
Pos: 0400
Max: 1
Detail - Optional
Loop:
2000F
Elements: 4
User Option (Usage): Situational
Purpose: To specify health care services review information
Element Summary:
Ref
Id
Element Name
UM01
1525
Request Category Code
Req
Type
Min/Max
Usage
M
ID
1/2
Required
Description: Code indicating a type of request
CodeList Summary (Total Codes: 7, Included: 2)
Code Name
UM02
1322
HS
Health Services Review
Required when this is a response to a request for review of services related to an
episode of care.
SC
Specialty Care Review
Required when this is a response to a request for a referral to a specialty provider.
Certification Type Code
O
ID
1/1
Situational
Description: Code indicating the type of certification
Situational Rule: Required when different from the UM02 value at the Patient Event level
(Loop 2000E). If not required, do not send.
CodeList Summary (Total Codes: 15, Included: 8)
Code Name
1
Appeal - Immediate
Use this value only for appeals of review decisions where the level of service
required is emergency or urgent.
2
Appeal - Standard
Use this value for appeals of review decisions where the level of service is not
emergency or urgent.
3
4
Cancel
Extension
A “UM02 = 4" indicates that this is an extension request to a prior approved
service.
I
N
R
Initial
Reconsideration
Renewal
Various services, such as physical therapy, spinal manipulation, and allergy
treatment, have both a delivery pattern and a time span of authorization. Many
UMOs place time limits - as in will not authorize anything for more than 30 days at
a time. For example, blanket authorization for allergy treatments as required for 30
days. At the end of the 30 days, the provider must request to renew the
certification - not extend it - because the UMO authorizes for 30 day intervals, one
interval at a time.
S
Revised
Use if the requester is revising the specifics of a certification for which services
have not been rendered. For example, the requester may be requesting additional
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Code Name
procedures or other procedures for the same patient event.
UM03
1365
Service Type Code
O
ID
1/2
Situational
Description: Code identifying the classification of service
Situational Rule: Required when valued on the request and used by the UMO to render a
medical decision. If not required by this implementation guide, do not send.
CodeList Summary (Total Codes: 190, Included: 102)
Code Name
1
2
3
4
5
6
7
8
11
12
14
15
16
17
18
20
21
23
24
25
Medical Care
Surgical
Consultation
Diagnostic X-Ray
Diagnostic Lab
Radiation Therapy
Anesthesia
Surgical Assistance
Used Durable Medical Equipment
Durable Medical Equipment Purchase
Renal Supplies in the Home
Alternate Method Dialysis
Chronic Renal Disease (CRD) Equipment
Pre-Admission Testing
Durable Medical Equipment Rental
Second Surgical Opinion
Third Surgical Opinion
Diagnostic Dental
Periodontics
Restorative
Use for restorative dental services.
26
27
28
33
35
36
37
38
39
40
42
44
45
46
54
56
61
Endodontics
Maxillofacial Prosthetics
Adjunctive Dental Services
Chiropractic
Dental Care
Dental Crowns
Dental Accident
Orthodontics
Prosthodontics
Oral Surgery
Home Health Care
Home Health Visits
Hospice
Respite Care
Long Term Care
Medically Related Transportation
In-vitro Fertilization
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Code
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
82
83
84
85
86
87
88
93
A4
A6
A9
AD
AE
AF
AG
AI
AJ
AK
AL
AR
B1
BB
BC
BD
BE
BF
BG
BL
Name
MRI/CAT Scan
Donor Procedures
Acupuncture
Newborn Care
Pathology
Smoking Cessation
Well Baby Care
Maternity
Transplants
Audiology Exam
Inhalation Therapy
Diagnostic Medical
Private Duty Nursing
Prosthetic Device
Dialysis
Otological Exam
Chemotherapy
Allergy Testing
Immunizations
Family Planning
Infertility
Abortion
AIDS
Emergency Services
Cancer
Pharmacy
Podiatry
Psychiatric
Psychotherapy
Rehabilitation
Occupational Therapy
Physical Medicine
Speech Therapy
Skilled Nursing Care
Substance Abuse
Alcoholism
Drug Addiction
Vision (Optometry)
Experimental Drug Therapy
Burn Care
Partial Hospitalization (Psychiatric)
Day Care (Psychiatric)
Cognitive Therapy
Massage Therapy
Pulmonary Rehabilitation
Cardiac Rehabilitation
Cardiac
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Code Name
BN
BP
BQ
BS
BY
BZ
C1
GY
IC
MH
NI
ON
PT
PU
RN
RT
TC
TN
UM04
C023
Gastrointestinal
Endocrine
Neurology
Invasive Procedures
Physician Visit - Office: Sick
Physician Visit - Office: Well
Coronary Care
Allergy
Intensive Care
Mental Health
Neonatal Intensive Care
Oncology
Physical Therapy
Pulmonary
Renal
Residential Psychiatric Treatment
Transitional Care
Transitional Nursery Care
Health Care Service Location
Information
O
Comp
Situational
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
Situational Rule: Required when valued on the request and used by the UMO to render a
medical decision. If not required by this implementation guide, do not send.
UM04-01
1331
Facility Code Value
M
AN
1/2
Required
Description: Code identifying where services were, or may be, performed; the first and
second positions of the Uniform Bill Type Code for Institutional Services or the Place of
Service Codes for Professional or Dental Services.
IMPLEMENTATION NAME: Facility Type Code
Use to indicate a facility code value from the code source referenced in UM04-2.
ExternalCodeList
Name: 236
Description: Uniform Billing Claim Form Bill Type
ExternalCodeList
Name: 237
Description: Place of Service Codes for Professional Claims
UM04-02
1332
Facility Code Qualifier
O
ID
1/2
Required
Description: Code identifying the type of facility referenced
CodeList Summary (Total Codes: 2, Included: 2)
Code Name
A
Uniform Billing Claim Form Bill Type
CODE SOURCE:
236: Uniform Billing Claim Form Bill Type
B
Place of Service Codes for Professional or Dental Services
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Code Name
CODE SOURCE:
237: Place of Service Codes for Professional Claims
Situational Rule:
Required when valued on the request and used by the UMO to render a medical decision. If not required by this
implementation guide, do not send.
TR3 Example:
UM*SC*I*3~
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Pos: 0500
HCR Health Care Services
Max: 1
Detail - Optional
Review
Loop:
2000F
Elements: 4
User Option (Usage): Situational
Purpose: To specify the outcome of a health care services review
Element Summary:
Ref
Id
Element Name
HCR01
306
Action Code
Req
Type
Min/Max
Usage
M
ID
1/2
Required
AN
1/50
Situational
Description: Code indicating type of action
CodeList Summary (Total Codes: 320, Included: 7)
Code Name
C
A1
A3
A4
A6
CT
NA
HCR02
127
Cancelled
Certified in total
Not Certified
Pended
Modified
Contact Payer
No Action Required
Use only if certification is not required.
Reference Identification
O
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Situational Rule: Required when HCR01 = A1 or A6. If not required by this implementation
guide, do not send.
IMPLEMENTATION NAME: Review Identification Number
HCR03
1271
Industry Code
O
AN
1/30
Situational
Description: Code indicating a code from a specific industry code list
Situational Rule: Required when HCR01=A3 or A4. If not required by this implementation
guide, may be provided at the sender’s discretion but cannot be required by the receiver.
IMPLEMENTATION NAME: Review Decision Reason Code
This data element is a repeating data element and can be repeated the maximum number
allowed by the standard in this implementation guide.
HCR04
1073
Yes/No Condition or Response Code
O
ID
1/1
Situational
Description: Code indicating a Yes or No condition or response
Situational Rule: Required when certification pertains to a surgical procedure and the
contract under which the patient is covered has provisions regarding a second surgical
opinion. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Second Surgical Opinion Indicator
CodeList Summary (Total Codes: 4, Included: 2)
Code Name
N
Y
No
Yes
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Semantics:
1. HCR02 is the number assigned by the information source to this review outcome.
2. HCR03 is the code assigned by the information source to identify the reason for the health care service review
outcome indicated in HCR01.See Code Source 886
3. HCR04 is the second surgical opinion indicator. A "Y" value indicates a second surgical opinion is required; an
"N" value indicates a second surgical opinion is not required for this request.
Situational Rule:
Required when the UMO has reviewed the request at this level, and the UMO renders a decision at both the
Patient Event level and at the Service level, to provide service review outcome information and an associated
reference number. If not required by this implementation guide, do not send.
TR3 Notes:
1. If the UMO for this service was unable to review the request due to missing or invalid application data at this
level, the UMO must return a 278 response containing a AAA segment at this level.
2. If the review outcome is pending additional medical information and the 278 response includes a request for
additional information using either a PWK segment or an HI segment that specifies LOINC values, then the
associated HCR segment must be valued with HCR01 = A4 (pended) and HCR03 must be valued with the
appropriate health care services review decision reason code to indicate that additional information is required.
Refer to Section 2.5 for more information.
3. If the HCR segment is sent in this 2000F Service level loop, it will override an HCR segment sent in the Patient
Event loop (2000E) for this service only.
TR3 Example:
HCR*A1*20020713~
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Pos: 0600
REF Administrative Reference
Max: 1
Detail - Optional
Number
Loop:
2000F
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
1/50
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1731, Included: 1)
Code Name
NT
REF02
127
Administrator's Reference Number
Reference Identification
X
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
IMPLEMENTATION NAME: Administrative 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.
Situational Rule:
Required when the HCR segment is valued in this loop and HCR01 = A3, A4 or CT, and the response does not
carry an administrative reference number at the parent Patient Event level to assign an administrative reference
number associated with this service line. If not required by this implementation guide, may be provided at the
sender’s discretion but cannot be required by the receiver.
TR3 Notes:
1. This number can be used by the requester on a follow up request, such as an appeal (UM02=1) or request for
reconsideration (UM02=6), to reference this UMO response.
TR3 Example:
REF*NT*Y789~
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Pos: 0600
REF Previous Review
Max: 1
Detail - Optional
Authorization Number
Loop:
2000F
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
1/50
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1731, Included: 1)
Code Name
BB
REF02
127
Authorization Number
Reference Identification
X
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
IMPLEMENTATION NAME: Previous Review 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.
Situational Rule:
Required when the certification number assigned by the UMO to the original service review outcome associated
with this service review was used by the UMO to determine the outcome of this service review. If not required by
this implementation guide, do not send.
TR3 Example:
REF*BB*123A~
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Pos: 0700
DTP Service Date
Max: 1
Detail - Optional
Loop:
2000F
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
IMPLEMENTATION NAME: Date Time Qualifier
CodeList Summary (Total Codes: 1280, Included: 1)
Code Name
472
DTP02
1250
Service
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: 42, Included: 2)
Code Name
D8
RD8
DTP03
1251
Date Expressed in Format CCYYMMDD
Range of Dates Expressed in Format CCYYMMDD-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
IMPLEMENTATION NAME: Proposed or Actual Service Date
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
Situational Rule:
Required when the UMO authorizes service for a specific date or date range. If not required by this
implementation guide, do not send.
TR3 Notes:
1. Use this segment for the valid date(s) during which the service can be performed.
TR3 Example:
DTP*472*D8*20050516~
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Pos: 0700
DTP Certification Issue Date
Max: 1
Detail - Optional
Loop:
2000F
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
IMPLEMENTATION NAME: Date Time Qualifier
CodeList Summary (Total Codes: 1280, Included: 1)
Code Name
102
DTP02
1250
Issue
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: 42, 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
IMPLEMENTATION NAME: Certification Issue Date
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
Situational Rule:
Required when the UMO assigns a certification issue date to this authorization. If not required by this
implementation guide, do not send.
TR3 Notes:
1. This is not the effective date of the authorization. The issue date is that date when the UMO issued the
authorization.
TR3 Example:
DTP*102*D8*20050502~
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DTP Certification Expiration Date
Pos: 0700
Max: 1
Detail - Optional
Loop:
2000F
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
IMPLEMENTATION NAME: Date Time Qualifier
CodeList Summary (Total Codes: 1280, Included: 1)
Code Name
036
DTP02
1250
Expiration
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: 42, 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
IMPLEMENTATION NAME: Certification Expiration Date
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
Situational Rule:
Required when the authorization has an expiration date to indicate the date on which the authorization will expire.
If not required by this implementation guide, do not send.
TR3 Example:
DTP*036*D8*20050630~
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DTP Certification Effective Date
Pos: 0700
Max: 1
Detail - Optional
Loop:
2000F
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
IMPLEMENTATION NAME: Date Time Qualifier
CodeList Summary (Total Codes: 1280, Included: 1)
Code Name
007
DTP02
1250
Effective
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: 42, Included: 2)
Code Name
D8
RD8
DTP03
1251
Date Expressed in Format CCYYMMDD
Range of Dates Expressed in Format CCYYMMDD-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
IMPLEMENTATION NAME: Certification Effective Date
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
Situational Rule:
Required when the authorization is limited by effective dates to indicate the date or date range when the
authorization is effective. If not required by this implementation guide, do not send.
TR3 Example:
DTP*007*RD8*20050502-20050630~
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Pos: 0800
HI Request For Additional
Max: 1
Detail - Optional
Information
Loop:
2000F
Elements: 12
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
HI01-01
1270
Code List Qualifier Code
M
ID
1/3
Required
Description: Code identifying a specific industry code list
CodeList Summary (Total Codes: 948, Included: 1)
Code Name
LOI
Logical Observation Identifier Names and Codes (LOINC) Codes
See Section 2.5 for information on using LOINC to request additional information.
CODE SOURCE:
663: Logical Observation Identifier Names and Codes (LOINC)
HI01-02
1271
Industry Code
M
AN
1/30
Required
Description: Code indicating a code from a specific industry code list
IMPLEMENTATION NAME: LOINC Code
Code identifying the beginning procedure in a procedure code range or the information
requested.
ExternalCodeList
Name: 663
Description: Logical Observation Identifier Names and Codes (LOINC)
HI02
C022
Health Care Code Information
O
Comp
Situational
Description: To send health care codes and their associated dates, amounts and
quantities
Situational Rule: Required when requesting additional information. If not required by this
implementation guide, do not send.
HI02-01
1270
Code List Qualifier Code
M
ID
1/3
Required
Description: Code identifying a specific industry code list
CodeList Summary (Total Codes: 948, Included: 1)
Code Name
LOI
Logical Observation Identifier Names and Codes (LOINC) Codes
See Section 2.5 for information on using LOINC to request additional information.
CODE SOURCE:
663: Logical Observation Identifier Names and Codes (LOINC)
HI02-02
1271
Industry Code
M
189
AN
1/30
Required
For internal use only
1/12/2012
Ref
Health Care Services Review Information - Response - 278
Id
Element Name
Req
Type
Min/Max
Usage
Description: Code indicating a code from a specific industry code list
IMPLEMENTATION NAME: LOINC Code
ExternalCodeList
Name: 663
Description: Logical Observation Identifier Names and Codes (LOINC)
HI03
C022
Health Care Code Information
O
Comp
Situational
Description: To send health care codes and their associated dates, amounts and
quantities
Situational Rule: Required when requesting additional information. If not required by this
implementation guide, do not send.
HI03-01
1270
Code List Qualifier Code
M
ID
1/3
Required
Description: Code identifying a specific industry code list
CodeList Summary (Total Codes: 948, Included: 1)
Code Name
LOI
Logical Observation Identifier Names and Codes (LOINC) Codes
See Section 2.5 for information on using LOINC to request additional information.
CODE SOURCE:
663: Logical Observation Identifier Names and Codes (LOINC)
HI03-02
1271
Industry Code
M
AN
1/30
Required
Description: Code indicating a code from a specific industry code list
IMPLEMENTATION NAME: LOINC Code
ExternalCodeList
Name: 663
Description: Logical Observation Identifier Names and Codes (LOINC)
HI04
C022
Health Care Code Information
O
Comp
Situational
Description: To send health care codes and their associated dates, amounts and
quantities
Situational Rule: Required when requesting additional information. If not required by this
implementation guide, do not send.
HI04-01
1270
Code List Qualifier Code
M
ID
1/3
Required
Description: Code identifying a specific industry code list
CodeList Summary (Total Codes: 948, Included: 1)
Code Name
LOI
Logical Observation Identifier Names and Codes (LOINC) Codes
See Section 2.5 for information on using LOINC to request additional information.
CODE SOURCE:
663: Logical Observation Identifier Names and Codes (LOINC)
HI04-02
1271
Industry Code
M
AN
1/30
Required
Description: Code indicating a code from a specific industry code list
IMPLEMENTATION NAME: LOINC Code
190
For internal use only
1/12/2012
Ref
Health Care Services Review Information - Response - 278
Id
Element Name
Req
Type
Min/Max
Usage
ExternalCodeList
Name: 663
Description: Logical Observation Identifier Names and Codes (LOINC)
HI05
C022
Health Care Code Information
O
Comp
Situational
Description: To send health care codes and their associated dates, amounts and
quantities
Situational Rule: Required when requesting additional information. If not required by this
implementation guide, do not send.
HI05-01
1270
Code List Qualifier Code
M
ID
1/3
Required
Description: Code identifying a specific industry code list
CodeList Summary (Total Codes: 948, Included: 1)
Code Name
LOI
Logical Observation Identifier Names and Codes (LOINC) Codes
See Section 2.5 for information on using LOINC to request additional information.
CODE SOURCE:
663: Logical Observation Identifier Names and Codes (LOINC)
HI05-02
1271
Industry Code
M
AN
1/30
Required
Description: Code indicating a code from a specific industry code list
IMPLEMENTATION NAME: LOINC Code
ExternalCodeList
Name: 663
Description: Logical Observation Identifier Names and Codes (LOINC)
HI06
C022
Health Care Code Information
O
Comp
Situational
Description: To send health care codes and their associated dates, amounts and
quantities
Situational Rule: Required when requesting additional information. If not required by this
implementation guide, do not send.
HI06-01
1270
Code List Qualifier Code
M
ID
1/3
Required
Description: Code identifying a specific industry code list
CodeList Summary (Total Codes: 948, Included: 1)
Code Name
LOI
Logical Observation Identifier Names and Codes (LOINC) Codes
See Section 2.5 for information on using LOINC to request additional information.
CODE SOURCE:
663: Logical Observation Identifier Names and Codes (LOINC)
HI06-02
1271
Industry Code
M
AN
1/30
Required
Description: Code indicating a code from a specific industry code list
IMPLEMENTATION NAME: LOINC Code
ExternalCodeList
191
For internal use only
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Name: 663
Description: Logical Observation Identifier Names and Codes (LOINC)
HI07
C022
Health Care Code Information
O
Comp
Situational
Description: To send health care codes and their associated dates, amounts and
quantities
Situational Rule: Required when requesting additional information. If not required by this
implementation guide, do not send.
HI07-01
1270
Code List Qualifier Code
M
ID
1/3
Required
Description: Code identifying a specific industry code list
CodeList Summary (Total Codes: 948, Included: 1)
Code Name
LOI
Logical Observation Identifier Names and Codes (LOINC) Codes
See Section 2.5 for information on using LOINC to request additional information.
CODE SOURCE:
663: Logical Observation Identifier Names and Codes (LOINC)
HI07-02
1271
Industry Code
M
AN
1/30
Required
Description: Code indicating a code from a specific industry code list
IMPLEMENTATION NAME: LOINC Code
ExternalCodeList
Name: 663
Description: Logical Observation Identifier Names and Codes (LOINC)
HI08
C022
Health Care Code Information
O
Comp
Situational
Description: To send health care codes and their associated dates, amounts and
quantities
Situational Rule: Required when requesting additional information. If not required by this
implementation guide, do not send.
HI08-01
1270
Code List Qualifier Code
M
ID
1/3
Required
Description: Code identifying a specific industry code list
CodeList Summary (Total Codes: 948, Included: 1)
Code Name
LOI
Logical Observation Identifier Names and Codes (LOINC) Codes
See Section 2.5 for information on using LOINC to request additional information.
CODE SOURCE:
663: Logical Observation Identifier Names and Codes (LOINC)
HI08-02
1271
Industry Code
M
AN
1/30
Required
Description: Code indicating a code from a specific industry code list
IMPLEMENTATION NAME: LOINC Code
ExternalCodeList
Name: 663
Description: Logical Observation Identifier Names and Codes (LOINC)
HI09
C022
Health Care Code Information
O
192
Comp
Situational
For internal use only
1/12/2012
Ref
Health Care Services Review Information - Response - 278
Id
Element Name
Req
Type
Min/Max
Usage
Description: To send health care codes and their associated dates, amounts and
quantities
Situational Rule: Required when requesting additional information. If not required by this
implementation guide, do not send.
HI09-01
1270
Code List Qualifier Code
M
ID
1/3
Required
Description: Code identifying a specific industry code list
CodeList Summary (Total Codes: 948, Included: 1)
Code Name
LOI
Logical Observation Identifier Names and Codes (LOINC) Codes
See Section 2.5 for information on using LOINC to request additional information.
CODE SOURCE:
663: Logical Observation Identifier Names and Codes (LOINC)
HI09-02
1271
Industry Code
M
AN
1/30
Required
Description: Code indicating a code from a specific industry code list
IMPLEMENTATION NAME: LOINC Code
ExternalCodeList
Name: 663
Description: Logical Observation Identifier Names and Codes (LOINC)
HI10
C022
Health Care Code Information
O
Comp
Situational
Description: To send health care codes and their associated dates, amounts and
quantities
Situational Rule: Required when requesting additional information. If not required by this
implementation guide, do not send.
HI10-01
1270
Code List Qualifier Code
M
ID
1/3
Required
Description: Code identifying a specific industry code list
CodeList Summary (Total Codes: 948, Included: 1)
Code Name
LOI
Logical Observation Identifier Names and Codes (LOINC) Codes
See Section 2.5 for information on using LOINC to request additional information.
CODE SOURCE:
663: Logical Observation Identifier Names and Codes (LOINC)
HI10-02
1271
Industry Code
M
AN
1/30
Required
Description: Code indicating a code from a specific industry code list
IMPLEMENTATION NAME: LOINC Code
ExternalCodeList
Name: 663
Description: Logical Observation Identifier Names and Codes (LOINC)
HI11
C022
Health Care Code Information
O
Comp
Situational
Description: To send health care codes and their associated dates, amounts and
quantities
193
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Ref
Id
Element Name
Req
Type
Min/Max
Usage
Situational Rule: Required when requesting additional information. If not required by this
implementation guide, do not send.
HI11-01
1270
Code List Qualifier Code
M
ID
1/3
Required
Description: Code identifying a specific industry code list
CodeList Summary (Total Codes: 948, Included: 1)
Code Name
LOI
Logical Observation Identifier Names and Codes (LOINC) Codes
See Section 2.5 for information on using LOINC to request additional information.
CODE SOURCE:
663: Logical Observation Identifier Names and Codes (LOINC)
HI11-02
1271
Industry Code
M
AN
1/30
Required
Description: Code indicating a code from a specific industry code list
IMPLEMENTATION NAME: LOINC Code
ExternalCodeList
Name: 663
Description: Logical Observation Identifier Names and Codes (LOINC)
HI12
C022
Health Care Code Information
O
Comp
Situational
Description: To send health care codes and their associated dates, amounts and
quantities
Situational Rule: Required when requesting additional information. If not required by this
implementation guide, do not send.
HI12-01
1270
Code List Qualifier Code
M
ID
1/3
Required
Description: Code identifying a specific industry code list
CodeList Summary (Total Codes: 948, Included: 1)
Code Name
LOI
Logical Observation Identifier Names and Codes (LOINC) Codes
See Section 2.5 for information on using LOINC to request additional information.
CODE SOURCE:
663: Logical Observation Identifier Names and Codes (LOINC)
HI12-02
1271
Industry Code
M
AN
1/30
Required
Description: Code indicating a code from a specific industry code list
IMPLEMENTATION NAME: LOINC Code
ExternalCodeList
Name: 663
Description: Logical Observation Identifier Names and Codes (LOINC)
Situational Rule:
Required when using LOINC to request additional information about this service. If not required by this
implementation guide, do not send.
TR3 Notes:
1. The UMO can use each occurrence of the Health Care Code Information composite (C022) to specify codes
194
For internal use only
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that identify the specific information that the UMO requires from the provider to complete the medical review. In
the C022 composite, data elements 1270 and 1271 support the use of codes supplied from the Logical
Observation Identifier Names and Codes (LOINC®) List. These codes identify high-level health care information
groupings, specific data elements, and associated modifiers.
Refer to Section 1.12.5.2 of this guide for more information on requesting additional information.
TR3 Example:
HI*LOI:18584-3~
195
For internal use only
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Pos: 0810
SV1 Professional Service
Max: 1
Detail - Optional
Loop:
2000F
Elements: 6
User Option (Usage): Situational
Purpose: To specify the service line item 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
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)
IMPLEMENTATION NAME: Product or Service ID Qualifier
CodeList Summary (Total Codes: 519, Included: 4)
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:
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. Use
only in non-HIPAA
implementations.
130: Health Care Financing Administration Common Procedural Coding System
CODE SOURCE:
513: Home Infusion EDI Coalition (HIEC) Product/Service Code List
N4
National Drug Code in 5-4-2 Format
CODE SOURCE:
240: National Drug Code by Format
WK
Advanced Billing Concepts (ABC) Codes
This code set is not allowed for use under HIPAA at the time of this writing. The
qualifier can only be used:
If a new rule names the Complimentary, Alternative, or Holistic Procedure Codes
as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as
allowed under the law,
OR
For service reviews which are not covered under HIPAA.
CODE SOURCE:
843: Advanced Billing Concepts (ABC) Codes
SV101-02
234
Product/Service ID
M
196
AN
1/48
Required
For internal use only
1/12/2012
Ref
Health Care Services Review Information - Response - 278
Id
Element Name
Req
Type
Description: Identifying number for a product or service
IMPLEMENTATION NAME: Procedure Code
Min/Max
Usage
ExternalCodeList
Name: 130
Description: Health Care Financing Administration Common Procedural Coding System
ExternalCodeList
Name: 240
Description: National Drug Code by Format
ExternalCodeList
Name: 513
Description: Home Infusion EDI Coalition (HIEC) Product/Service Code List
ExternalCodeList
Name: 843
Description: Advanced Billing Concepts (ABC) Codes
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
Situational Rule: Required when valued on the request and used by the UMO to render a
decision. If not required by this implementation guide, do not send.
ExternalCodeList
Name: 130
Description: Health Care Financing Administration Common Procedural Coding System
ExternalCodeList
Name: 513
Description: Home Infusion EDI Coalition (HIEC) Product/Service Code List
ExternalCodeList
Name: 843
Description: Advanced Billing Concepts (ABC) Codes
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
Situational Rule: Required when valued on the request and used by the UMO to render a
decision. If not required by this implementation guide, do not send.
ExternalCodeList
Name: 130
Description: Health Care Financing Administration Common Procedural Coding System
ExternalCodeList
Name: 513
Description: Home Infusion EDI Coalition (HIEC) Product/Service Code List
ExternalCodeList
Name: 843
Description: Advanced Billing Concepts (ABC) Codes
SV101-05
1339
Procedure Modifier
O
197
AN
2/2
Situational
For internal use only
1/12/2012
Ref
Health Care Services Review Information - Response - 278
Id
Element Name
Req
Type
Min/Max
Usage
Description: This identifies special circumstances related to the performance of the
service, as defined by trading partners
Situational Rule: Required when valued on the request and used by the UMO to render a
decision. If not required by this implementation guide, do not send.
ExternalCodeList
Name: 130
Description: Health Care Financing Administration Common Procedural Coding System
ExternalCodeList
Name: 513
Description: Home Infusion EDI Coalition (HIEC) Product/Service Code List
ExternalCodeList
Name: 843
Description: Advanced Billing Concepts (ABC) Codes
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
Situational Rule: Required when valued on the request and used by the UMO to render a
decision. If not required by this implementation guide, do not send.
ExternalCodeList
Name: 130
Description: Health Care Financing Administration Common Procedural Coding System
ExternalCodeList
Name: 513
Description: Home Infusion EDI Coalition (HIEC) Product/Service Code List
ExternalCodeList
Name: 843
Description: Advanced Billing Concepts (ABC) Codes
SV101-07
352
Description
O
AN
1/80
Situational
Description: A free-form description to clarify the related data elements and their content
Situational Rule: Required when necessary to provide further clarification on the
procedure for this service. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Procedure Code Description
SV101-08
234
Product/Service ID
O
AN
1/48
Situational
Description: Identifying number for a product or service
Situational Rule: Required when valued on the request and the UMO has authorized a
range of procedures. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Procedure Code
Use SV101-2 to represent the beginning value in the procedure range and this data
element to represent the ending value in a range of codes.
ExternalCodeList
Name: 130
Description: Health Care Financing Administration Common Procedural Coding System
ExternalCodeList
198
For internal use only
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Name: 240
Description: National Drug Code by Format
ExternalCodeList
Name: 513
Description: Home Infusion EDI Coalition (HIEC) Product/Service Code List
ExternalCodeList
Name: 843
Description: Advanced Billing Concepts (ABC) Codes
SV102
782
Monetary Amount
O
R
1/18
Situational
Description: Monetary amount
Situational Rule: Required when the UMO has approved the health care service with
monetary limitations. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Service Line Amount
SV103
355
Unit or Basis for Measurement Code
X
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
Situational Rule: Required when service units were not provided in the HSD segment and
a specific number of services are being authorized for this procedure. If not required by this
implementation guide, do not send.
CodeList Summary (Total Codes: 844, 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
X
R
1/15
Situational
Description: Numeric value of quantity
Situational Rule: Required when service units were not provided in the HSD segment and
a specific number of services are being authorized for this procedure. If not required by this
implementation guide, do not send.
IMPLEMENTATION NAME: Service Unit Count
SV111
1073
Yes/No Condition or Response Code
O
ID
1/1
Situational
Description: Code indicating a Yes or No condition or response
Situational Rule: Required when the review decision is based on EPSDT. If not required
by this implementation guide, do not send.
IMPLEMENTATION NAME: EPSDT Indicator
CodeList Summary (Total Codes: 4, Included: 2)
Code Name
N
Y
SV120
1337
No
Yes
Level of Care Code
O
199
ID
1/1
Situational
For internal use only
1/12/2012
Ref
Health Care Services Review Information - Response - 278
Id
Element Name
Req
Type
Min/Max
Usage
Description: Code specifying the level of care provided by a nursing home facility
Situational Rule: Required when used by the UMO to render a decision. If not required by
this implementation guide, do not send.
IMPLEMENTATION NAME: Nursing Home Level of Care
CodeList Summary (Total Codes: 8, Included: 8)
Code Name
1
2
3
4
5
6
7
8
Skilled Nursing Facility (SNF)
Intermediate Care Facility (ICF)
Intermediate Care Facility - Mentally Retarded (ICF-MR)
Chronic Disease Hospital (CD)
Intermediate Care Facility (ICF) Level II
Special Skilled Nursing Facility (SNF)
Nursing Facility (NF)
Hospice
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 service line item 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 non-covered service amount.
Comments:
1. If SV113 is equal to "L" or "N", then SV114 is required.
Situational Rule:
Required when authorizing a specific Professional Service. If not required by this implementation guide, do not
send.
TR3 Example:
SV1*HC:99211:25*12.25*UN*1*******N~
200
For internal use only
1/12/2012
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Pos: 0820
SV2 Institutional Service Line
Max: 1
Detail - Optional
Loop:
2000F
Elements: 7
User Option (Usage): Situational
Purpose: To specify the service line item detail for a health care institution
Element Summary:
Ref
Id
Element Name
SV201
234
Product/Service ID
Req
Type
Min/Max
Usage
X
AN
1/48
Situational
Description: Identifying number for a product or service
Situational Rule: Required when the UMO authorizes a revenue code. If not required by
this implementation guide, do not send.
IMPLEMENTATION NAME: Service Line Revenue Code
See Code Source 132: National Uniform Billing Committee (NUBC) Codes.
ExternalCodeList
Name: 132
Description: National Uniform Billing Committee (NUBC) Codes
SV202
C003
Composite Medical Procedure
Identifier
X
Comp
Situational
Description: To identify a medical procedure by its standardized codes and applicable
modifiers
Situational Rule: Required when authorizing a specific procedure code. If not required by
this implementation guide, do not send.
SV202-01
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)
IMPLEMENTATION NAME: Product or Service ID Qualifier
CodeList Summary (Total Codes: 519, Included: 6)
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
ID
International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM) - Procedure
CODE SOURCE:
131: International Classification of Diseases, 9th
Revision, Clinical Modification (ICD-9-CM)
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. Use
only in non-HIPAA
implementations.
CODE SOURCE:
201
For internal use only
1/12/2012
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Code Name
513: Home Infusion EDI Coalition (HIEC) Product/Service Code List
N4
National Drug Code in 5-4-2 Format
CODE SOURCE:
240: National Drug Code by Format
WK
Advanced Billing Concepts (ABC) Codes
This code set is not allowed for use under HIPAA at the time of this writing. The
qualifier can only be used:
If a new rule names the Complimentary, Alternative, or Holistic Procedure Codes
as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as
allowed under the law,
OR
For service reviews which are not covered under HIPAA.
CODE SOURCE:
843: Advanced Billing Concepts (ABC) Codes
ZZ
Mutually Defined
Use this code when reporting ICD-10-PCS. This code can only be used if
mandated by HIPAA or for services not covered under HIPAA.
CODE SOURCE:
896 International Classification of Diseases, 10th Revision, Procedure Coding
System (ICD-10-PCS)
SV202-02
234
Product/Service ID
M
AN
1/48
Required
Description: Identifying number for a product or service
IMPLEMENTATION NAME: Procedure Code
ExternalCodeList
Name: 130
Description: Health Care Financing Administration Common Procedural Coding System
ExternalCodeList
Name: 131P
Description: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
ExternalCodeList
Name: 240
Description: National Drug Code by Format
ExternalCodeList
Name: 513
Description: Home Infusion EDI Coalition (HIEC) Product/Service Code List
ExternalCodeList
Name: 843
Description: Advanced Billing Concepts (ABC) Codes
ExternalCodeList
Name: 896
Description: International Classification of Diseases, 10th Revision, Procedure Coding
System (ICD-10-PCS)
SV202-03
1339
Procedure Modifier
O
202
AN
2/2
Situational
For internal use only
1/12/2012
Ref
Health Care Services Review Information - Response - 278
Id
Element Name
Req
Type
Min/Max
Usage
Description: This identifies special circumstances related to the performance of the
service, as defined by trading partners
Situational Rule: Required when used by the UMO to render a decision. If not required by
this implementation guide, do not send.
ExternalCodeList
Name: 130
Description: Health Care Financing Administration Common Procedural Coding System
ExternalCodeList
Name: 513
Description: Home Infusion EDI Coalition (HIEC) Product/Service Code List
ExternalCodeList
Name: 843
Description: Advanced Billing Concepts (ABC) Codes
SV202-04
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
Situational Rule: Required when used by the UMO to render a decision. If not required by
this implementation guide, do not send.
ExternalCodeList
Name: 130
Description: Health Care Financing Administration Common Procedural Coding System
ExternalCodeList
Name: 513
Description: Home Infusion EDI Coalition (HIEC) Product/Service Code List
ExternalCodeList
Name: 843
Description: Advanced Billing Concepts (ABC) Codes
SV202-05
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
Situational Rule: Required when used by the UMO to render a decision. If not required by
this implementation guide, do not send.
ExternalCodeList
Name: 130
Description: Health Care Financing Administration Common Procedural Coding System
ExternalCodeList
Name: 513
Description: Home Infusion EDI Coalition (HIEC) Product/Service Code List
ExternalCodeList
Name: 843
Description: Advanced Billing Concepts (ABC) Codes
SV202-06
1339
Procedure Modifier
O
203
AN
2/2
Situational
For internal use only
1/12/2012
Ref
Health Care Services Review Information - Response - 278
Id
Element Name
Req
Type
Min/Max
Usage
Description: This identifies special circumstances related to the performance of the
service, as defined by trading partners
Situational Rule: Required when used by the UMO to render a decision. If not required by
this implementation guide, do not send.
ExternalCodeList
Name: 130
Description: Health Care Financing Administration Common Procedural Coding System
ExternalCodeList
Name: 513
Description: Home Infusion EDI Coalition (HIEC) Product/Service Code List
ExternalCodeList
Name: 843
Description: Advanced Billing Concepts (ABC) Codes
SV202-07
352
Description
O
AN
1/80
Situational
Description: A free-form description to clarify the related data elements and their content
Situational Rule: Required when necessary to provide further clarification on the
procedure for this service. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Procedure Code Description
SV202-08
234
Product/Service ID
O
AN
1/48
Situational
Description: Identifying number for a product or service
Situational Rule: Required when valued on the request and the UMO has authorized a
range of procedures. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Procedure Code
Use SV202-2 to represent the beginning value in the procedure range and this data
element to represent the ending value in a range of codes.
ExternalCodeList
Name: 130
Description: Health Care Financing Administration Common Procedural Coding System
ExternalCodeList
Name: 131P
Description: International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
ExternalCodeList
Name: 240
Description: National Drug Code by Format
ExternalCodeList
Name: 513
Description: Home Infusion EDI Coalition (HIEC) Product/Service Code List
ExternalCodeList
Name: 843
Description: Advanced Billing Concepts (ABC) Codes
ExternalCodeList
Name: 896
Description: International Classification of Diseases, 10th Revision, Procedure Coding
204
For internal use only
1/12/2012
Health Care Services Review Information - Response - 278
System (ICD-10-PCS)
SV203
782
Monetary Amount
O
R
1/18
Situational
Description: Monetary amount
Situational Rule: Required when the UMO has approved the health care service with
monetary limitations. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Service Line Amount
SV204
355
Unit or Basis for Measurement Code
X
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
Situational Rule: Required when service units were not provided in the HSD segment and
a specific number of services are being authorized for this procedure. If not required by this
implementation guide, do not send.
CodeList Summary (Total Codes: 844, Included: 3)
Code Name
SV205
380
DA
F2
Days
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).
UN
Unit
Quantity
X
R
1/15
Situational
Description: Numeric value of quantity
Situational Rule: Required when service units were not provided in the HSD segment and
a specific number of services are being authorized for this procedure. If not required by this
implementation guide, do not send.
IMPLEMENTATION NAME: Service Unit Count
SV206
1371
Unit Rate
O
R
1/10
Situational
Description: The rate per unit of associate revenue for hospital accommodation
Situational Rule: Required when SV201 is used and the UMO has approved the health
care service with monetary limitations on the accommodation rate. If not required by this
implementation guide, do not send.
IMPLEMENTATION NAME: Service Line Rate
SV210
1337
Level of Care Code
O
ID
1/1
Situational
Description: Code specifying the level of care provided by a nursing home facility
Situational Rule: Required when used by the UMO to render a decision. If not required by
this implementation guide, do not send.
IMPLEMENTATION NAME: Nursing Home Level of Care
CodeList Summary (Total Codes: 8, Included: 8)
Code Name
1
2
3
4
5
Skilled Nursing Facility (SNF)
Intermediate Care Facility (ICF)
Intermediate Care Facility - Mentally Retarded (ICF-MR)
Chronic Disease Hospital (CD)
Intermediate Care Facility (ICF) Level II
205
For internal use only
1/12/2012
Health Care Services Review Information - Response - 278
Code Name
6
7
8
Special Skilled Nursing Facility (SNF)
Nursing Facility (NF)
Hospice
Syntax Rules:
1. R0102 - At least one of SV201 or SV202 is required.
2. P0405 - If either SV204 or SV205 is present, then the other is required.
Semantics:
1.
2.
3.
4.
SV201 is the revenue code.
SV203 is the submitted service line item amount.
SV207 is a non-covered service amount.
SV208 is the detail service line indicator. A "Y" value indicates a detail service line; an "N" value indicates a
summary service line.
Situational Rule:
Required when authorizing a specific Institutional Service. If not required by this implementation guide, do not
send.
TR3 Notes:
1. Use this segment to authorize a specific Revenue Code.
TR3 Example:
SV2*3008HC:80019*73.42*UN*1~
SV2*120**1500*DA*5*300~
206
For internal use only
1/12/2012
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Pos: 0830
SV3 Dental Service
Max: 1
Detail - Optional
Loop:
2000F
Elements: 5
User Option (Usage): Situational
Purpose: To specify the service line item detail for dental work
Element Summary:
Ref
Id
Element Name
SV301
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
SV301-01
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)
IMPLEMENTATION NAME: Product or Service ID Qualifier
CodeList Summary (Total Codes: 519, Included: 1)
Code Name
AD
American Dental Association Codes
CODE SOURCE:
135: American Dental Association
SV301-02
234
Product/Service ID
M
AN
1/48
Required
2/2
Situational
Description: Identifying number for a product or service
IMPLEMENTATION NAME: Procedure Code
ExternalCodeList
Name: 135
Description: American Dental Association
SV301-03
1339
Procedure Modifier
O
AN
Description: This identifies special circumstances related to the performance of the
service, as defined by trading partners
Situational Rule: Required when used by the UMO to render a decision. If not required by
this implementation guide, do not send.
A modifier must be from code source 135 (American Dental Association) found in the ’Code
on Dental Procedures and Nomenclature’, if such modifier is available.
ExternalCodeList
Name: 135
Description: American Dental Association
SV301-04
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
Situational Rule: Required when used by the UMO to render a decision. If not required by
this implementation guide, do not send.
207
For internal use only
1/12/2012
Ref
Health Care Services Review Information - Response - 278
Id
Element Name
Req
Type
Min/Max
Usage
A modifier must be from code source 135 (American Dental Association) found in the ’Code
on Dental Procedures and Nomenclature’, if such modifier is available.
ExternalCodeList
Name: 135
Description: American Dental Association
SV301-05
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
Situational Rule: Required when used by the UMO to render a decision. If not required by
this implementation guide, do not send.
A modifier must be from code source 135 (American Dental Association) found in the ’Code
on Dental Procedures and Nomenclature’, if such modifier is available.
ExternalCodeList
Name: 135
Description: American Dental Association
SV301-06
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
Situational Rule: Required when used by the UMO to render a decision. If not required by
this implementation guide, do not send.
CODE SOURCE: A modifier must be from code source 135 (American Dental Association)
found in the ’Code on Dental Procedures and Nomenclature’, if such modifier is available.
ExternalCodeList
Name: 135
Description: American Dental Association
SV301-07
352
Description
O
AN
1/80
Situational
Description: A free-form description to clarify the related data elements and their content
Situational Rule: Required when necessary to provide further clarification on the
procedure for this service. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Procedure Code Description
SV301-08
234
Product/Service ID
O
AN
1/48
Situational
Description: Identifying number for a product or service
Situational Rule: Required when valued on the request and the UMO has authorized a
range of procedures. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Procedure Code
Use SV301-2 to represent the beginning value in the procedure range and this data
element to represent the ending value in a range of codes.
ExternalCodeList
Name: 135
Description: American Dental Association
SV302
782
Monetary Amount
O
R
1/18
Situational
Description: Monetary amount
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Id
Element Name
Req
Type
Min/Max
Usage
Situational Rule: Required when the UMO has approved the health care service with
monetary limitations. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Service Line Amount
SV304
C006
Oral Cavity Designation
O
Comp
Situational
Description: To identify one or more areas of the oral cavity
Situational Rule: Required when used by the UMO to render a decision. If not required by
this implementation guide, do not send.
SV304-01
1361
Oral Cavity Designation Code
M
ID
1/3
Required
Description: Code Identifying the area of the oral cavity in which service is rendered
CODE SOURCE: 135: American Dental Association
ExternalCodeList
Name: 135C
Description: ADA Oral Cavity Designation Codes
SV304-02
1361
Oral Cavity Designation Code
O
ID
1/3
Situational
Description: Code Identifying the area of the oral cavity in which service is rendered
Situational Rule: Required when used by the UMO to render a decision. If not required by
this implementation guide, do not send.
CODE SOURCE: 135: American Dental Association
Use this code for the additional oral cavity designation codes. The code values in SV304-1
apply to all occurrences of the oral cavity designation code.
ExternalCodeList
Name: 135C
Description: ADA Oral Cavity Designation Codes
SV304-03
1361
Oral Cavity Designation Code
O
ID
1/3
Situational
Description: Code Identifying the area of the oral cavity in which service is rendered
Situational Rule: Required when used by the UMO to render a decision. If not required by
this implementation guide, do not send.
CODE SOURCE: 135: American Dental Association
Use this code for the additional oral cavity designation codes. The code values in SV304-1
apply to all occurrences of the oral cavity designation code.
ExternalCodeList
Name: 135C
Description: ADA Oral Cavity Designation Codes
SV304-04
1361
Oral Cavity Designation Code
O
ID
1/3
Situational
Description: Code Identifying the area of the oral cavity in which service is rendered
Situational Rule: Required when used by the UMO to render a decision. If not required by
this implementation guide, do not send.
CODE SOURCE: 135: American Dental Association
Use this code for the additional oral cavity designation codes. The code values in SV304-1
apply to all occurrences of the oral cavity designation code.
ExternalCodeList
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Name: 135C
Description: ADA Oral Cavity Designation Codes
SV304-05
1361
Oral Cavity Designation Code
O
ID
1/3
Situational
Description: Code Identifying the area of the oral cavity in which service is rendered
Situational Rule: Required when used by the UMO to render a decision. If not required by
this implementation guide, do not send.
CODE SOURCE: 135: American Dental Association
Use this code for the additional oral cavity designation codes. The code values in SV304-1
apply to all occurrences of the oral cavity designation code.
ExternalCodeList
Name: 135C
Description: ADA Oral Cavity Designation Codes
SV305
1358
Prosthesis, Crown or Inlay Code
O
ID
1/1
Situational
Description: Code specifying the placement status for the dental work
Situational Rule: Required when used by the UMO to render a decision. If not required by
this implementation guide, do not send.
IMPLEMENTATION NAME: Prosthesis, Crown, or Inlay Code
CodeList Summary (Total Codes: 2, Included: 2)
Code Name
I
R
SV306
380
Initial Placement
Replacement
If the SV305 = R, then the DTP segment in the 2400 loop for Prior Placement is
Required.
Quantity
O
R
1/15
Required
Description: Numeric value of quantity
IMPLEMENTATION NAME: Service Unit Count
Number of procedures.
Semantics:
1.
2.
3.
4.
5.
SV302 is the submitted service line item amount.
SV303 is the place of service code representing the location where the dental treatment was rendered.
SV306 is the number of procedures.
SV307 is the reason for replacement.
SV310 is the predetermination of benefits indicator. A "Y" value indicates that this service is being submitted
for predetermination of benefits.
Situational Rule:
Required if authorizing a specific Dental Service. If not required by this implementation guide, do not send.
TR3 Notes:
1. This segment is not used when the HI segment has been used to authorize a range of services in the same
iteration of the 2000F loop.
TR3 Example:
SV3*AD:D2150*80****1~
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Pos: 0840
TOO Tooth Information
Max: 32
Detail - Optional
Loop:
2000F
Elements: 3
User Option (Usage): Situational
Purpose: To identify a tooth by number and, if applicable, one or more tooth surfaces
Element Summary:
Ref
Id
Element Name
TOO01
1270
Code List Qualifier Code
Req
Type
Min/Max
Usage
X
ID
1/3
Required
1/30
Required
Description: Code identifying a specific industry code list
CodeList Summary (Total Codes: 948, Included: 1)
Code Name
JP
Universal National Tooth Designation System
CODE SOURCE:
135: American Dental Association
TOO02
1271
Industry Code
X
AN
Description: Code indicating a code from a specific industry code list
IMPLEMENTATION NAME: Tooth Code
See Code Source 135: American Dental Association Codes.
TOO03
C005
Tooth Surface
O
Comp
Situational
Description: To identify one or more tooth surface codes
Situational Rule: Required when used by the UMO to render a medical decision. If not
required by this implementation guide, do not send.
TOO03-01 1369
Tooth Surface Code
M
ID
1/2
Required
Description: Code identifying the area of the tooth that was treated
CodeList Summary (Total Codes: 7, Included: 7)
Code Name
B
D
F
I
L
M
O
TOO03-02 1369
Buccal
Distal
Facial
Incisal
Lingual
Mesial
Occlusal
Tooth Surface Code
O
ID
1/2
Situational
Description: Code identifying the area of the tooth that was treated
Situational Rule: Required when used by the UMO to render a medical decision. If not
required by this implementation guide, do not send.
Use code values from TOO03-1.
CodeList Summary (Total Codes: 7, Included: 7)
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Code Name
B
D
F
I
L
M
O
TOO03-03 1369
Buccal
Distal
Facial
Incisal
Lingual
Mesial
Occlusal
Tooth Surface Code
O
ID
1/2
Situational
Description: Code identifying the area of the tooth that was treated
Situational Rule: Required when used by the UMO to render a medical decision. If not
required by this implementation guide, do not send.
Use code values from TOO03-1.
CodeList Summary (Total Codes: 7, Included: 7)
Code Name
B
D
F
I
L
M
O
TOO03-04 1369
Buccal
Distal
Facial
Incisal
Lingual
Mesial
Occlusal
Tooth Surface Code
O
ID
1/2
Situational
Description: Code identifying the area of the tooth that was treated
Situational Rule: Required when used by the UMO to render a medical decision. If not
required by this implementation guide, do not send.
Use code values from TOO03-1.
CodeList Summary (Total Codes: 7, Included: 7)
Code Name
B
D
F
I
L
M
O
TOO03-05 1369
Buccal
Distal
Facial
Incisal
Lingual
Mesial
Occlusal
Tooth Surface Code
O
ID
1/2
Situational
Description: Code identifying the area of the tooth that was treated
Situational Rule: Required when used by the UMO to render a medical decision. If not
required by this implementation guide, do not send.
Use code values from TOO03-1.
CodeList Summary (Total Codes: 7, Included: 7)
Code Name
B
Buccal
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Code Name
D
F
I
L
M
O
Distal
Facial
Incisal
Lingual
Mesial
Occlusal
Syntax Rules:
1. P0102 - If either TOO01 or TOO02 is present, then the other is required.
Situational Rule:
Required when used by the UMO to render a medical decision. If not required by this implementation guide, do
not send.
TR3 Example:
TOO*JP*12*L:O~
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Pos: 0900
HSD Health Care Services
Max: 1
Detail - Optional
Delivery
Loop:
2000F
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
X
ID
2/2
Situational
Description: Code specifying the type of quantity
Situational Rule: Required when the pattern of delivery has quantity of services
authorized. If not required by this implementation guide, do not send.
CodeList Summary (Total Codes: 1123, Included: 5)
Code Name
DY
FL
HS
MN
VS
HSD02
380
Days
Units
Hours
Month
Visits
Quantity
X
R
1/15
Situational
Description: Numeric value of quantity
Situational Rule: Required when the pattern of delivery has quantity of services
authorized. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Service Unit Count
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
Situational Rule: Required when HSD04 is valued to qualify the time frame in which the
quantity of services (HSD02) will be rendered. If not required by this implementation guide,
do not send.
CodeList Summary (Total Codes: 844, Included: 3)
Code Name
DA
MO
WK
HSD04
1167
Days
Months
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
Situational Rule: Required when the UMO authorizes services which must be rendered
within a specific time frame. If not required by this implementation guide, do not send.
HSD05
615
Time Period Qualifier
X
ID
1/2
Situational
Description: Code defining periods
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Id
Element Name
Req
Type
Min/Max
Usage
Situational Rule: Required when the UMO authorizes services which can be continued for
a specific time period. If not required by this implementation guide, do not send.
CodeList Summary (Total Codes: 38, Included: 8)
Code Name
6
7
21
26
27
29
34
35
HSD06
616
Hour
Day
Years
Episode
Visit
Remaining
Month
Week
Number of Periods
O
N0
1/3
Situational
Description: Total number of periods
Situational Rule: Required when the UMO authorizes services which can be continued for
a specific time period. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Period Count
HSD07
678
Ship/Delivery or Calendar Pattern Code
O
ID
1/2
Situational
Description: Code which specifies the routine shipments, deliveries, or calendar pattern
Situational Rule: Required when the UMO authorizes a specific calendar delivery pattern
for the service. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Delivery Frequency Code
CodeList Summary (Total Codes: 45, Included: 43)
Code Name
1
2
3
4
5
6
7
8
9
A
B
C
D
E
F
G
H
J
K
L
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
1st Working Day of Period
Last Working Day of Period
Monday through Friday
Monday through Saturday
Monday through Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Monday through Thursday
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Code Name
M
N
O
P
Q
R
S
T
U
V
W
X
Y
SA
SB
SC
SD
SG
SL
SP
SX
SY
SZ
HSD08
679
Immediately
As Directed
Daily Mon. through Fri.
1/2 Mon. & 1/2 Thurs.
1/2 Tues. & 1/2 Thurs.
1/2 Wed. & 1/2 Fri.
Once Anytime Mon. through Fri.
1/2 Tue. & 1/2 Fri.
1/2 Mon. & 1/2 Wed.
1/3 Mon., 1/3 Wed., 1/3 Fri.
Whenever Necessary
1/2 By Wed., Bal. By Fri.
None (Also Used to Cancel or Override a Previous Pattern)
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
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
Situational Rule: Required when the UMO authorizes a specific time delivery pattern for
the service. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Delivery Pattern Time Code
CodeList Summary (Total Codes: 9, Included: 8)
Code Name
A
B
C
D
E
F
G
Y
1st Shift (Normal Working Hours)
2nd Shift
3rd Shift
A.M.
P.M.
As Directed
Any Shift
None (Also Used to Cancel or Override a Previous Pattern)
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.
Situational Rule:
Required when the UMO authorizes services that have a specific pattern of delivery and the pattern of delivery or
usage for this service is different from the pattern of delivery or usage (HSD) in the Patient Event (Loop 2000E or
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when identifying the number of medical services reservations remaining. If not required by this implementation
guide, do not send.
TR3 Notes:
1. An explanation of the uses of this segment or delivery pattern is as follows.
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. An explanation of the use of this segment for identifying the number of medical service reservations remaining
is as follows:
HSD05 qualifies HSD06. If the value in HSD06=5 and the value in HSD05=29, this means there are 5 service
reservations remaining.
TR3 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”.)
HSD*****29*5~
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Pos: 1550
PWK Additional Service
Max: 10
Detail - Optional
Information
Loop:
2000F
Elements: 5
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
IMPLEMENTATION NAME: Attachment Report Type Code
CodeList Summary (Total Codes: 541, Included: 66)
Code Name
03
04
05
06
07
Report Justifying Treatment Beyond Utilization Guidelines
Drugs Administered
Treatment Diagnosis
Initial Assessment
Functional Goals
Expected outcomes of rehabilitative services.
08
09
10
11
13
15
21
48
55
Plan of Treatment
Progress Report
Continued Treatment
Chemical Analysis
Certified Test Report
Justification for Admission
Recovery Plan
Social Security Benefit Letter
Rental Agreement
Use for medical or dental equipment rental.
59
77
A3
A4
AM
Benefit Letter
Support Data for Verification
Allergies/Sensitivities Document
Autopsy Report
Ambulance Certification
Information to support necessity of ambulance trip.
AS
Admission Summary
A brief patient summary; it lists the patient’s chief complaints and the reasons for
admitting the patient to the hospital.
AT
Purchase Order Attachment
Use for purchase of medical or dental equipment.
B2
B3
BR
BS
BT
Prescription
Physician Order
Benchmark Testing Results
Baseline
Blanket Test Results
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Code Name
PWK02
756
CB
Chiropractic Justification
Lists the reasons chiropractic is just and appropriate treatment.
CK
D2
DA
DB
DG
DJ
DS
FM
HC
HR
I5
IR
LA
M1
NN
OB
OC
OD
OE
OX
P4
P5
P6
P7
PE
PN
PO
PQ
PY
PZ
QC
QR
RB
RR
RT
RX
SG
V5
XP
Consent Form(s)
Drug Profile Document
Dental Models
Durable Medical Equipment Prescription
Diagnostic Report
Discharge Monitoring Report
Discharge Summary
Family Medical History Document
Health Certificate
Health Clinic Records
Immunization Record
State School Immunization Records
Laboratory Results
Medical Record Attachment
Nursing Notes
Operative Note
Oxygen Content Averaging Report
Orders and Treatments Document
Objective Physical Examination (including vital signs) Document
Oxygen Therapy Certification
Pathology Report
Patient Medical History Document
Periodontal Charts
Periodontal Reports
Parenteral or Enteral Certification
Physical Therapy Notes
Prosthetics or Orthotic Certification
Paramedical Results
Physician's Report
Physical Therapy Certification
Cause and Corrective Action Report
Quality Report
Radiology Films
Radiology Reports
Report of Tests and Analysis Report
Renewable Oxygen Content Averaging Report
Symptoms Document
Death Notification
Photographs
Report Transmission Code
O
ID
1/2
Required
Description: Code defining timing, transmission method or format by which reports are to
be sent
CodeList Summary (Total Codes: 55, Included: 5)
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Code Name
PWK05
66
BM
EL
By Mail
Electronically Only
Use to indicate that attachment is being transmitted in a separate X12 functional
group.
EM
FX
VO
E-Mail
By Fax
Voice
Use this for voicemail or phone communication.
Identification Code Qualifier
X
ID
1/2
Situational
Description: Code designating the system/method of code structure used for Identification
Code (67)
Situational Rule: Required when PWK02 equals BM, EL, EM or FX. If not required by this
implementation guide, may be provided at the sender’s discretion but cannot be required
by the receiver.
CodeList Summary (Total Codes: 241, Included: 1)
Code Name
AC
PWK06
67
Attachment Control Number
Identification Code
X
AN
2/80
Situational
Description: Code identifying a party or other code
Situational Rule: Required when PWK02 equals BM, EL, EM or FX. If not required by this
implementation guide, may be provided at the sender’s discretion but cannot be required
by the receiver.
IMPLEMENTATION NAME: Attachment Control Number
PWK07
352
Description
O
AN
1/80
Situational
Description: A free-form description to clarify the related data elements and their content
Situational Rule: Required when additional information requested can not be requested
using a LOINC code or other codified information within this transaction. If not required by
this implementation guide, do not send.
IMPLEMENTATION NAME: Attachment Description
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.
Situational Rule:
Required when the UMO needs to request additional information that applies to the service(s) requested in this
Service loop. If not required by this implementation guide, do not send.
TR3 Notes:
1. If the UMO has pended the decision on this health care services review request (HCR01 = A4) because
additional medical necessity information is required (HCR03 = 90), the UMO uses this segment to identify the
type of documentation needed such as forms that the provider must complete. The UMO can also indicate what
medium it has used to send these forms.
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2. Additional information requested at the Service level should apply to a specific service and/or all the services
requested in this service loop.
3. This PWK segment is required to identify requests for specific data that are sent electronically (PWK02 = EL)
but are transmitted in another X12 functional group rather than by paper or using LOINC in the HI segments of the
response. PWK06 is used to identify the attached electronic questionnaire. The number in PWK06 should be
referenced in the corresponding electronic attachment.
4. This PWK segment should not be used if
a. the requester should have provided the information within the 278 request (ST-SE) but failed to do so. In this
case the UMO should use the AAA segments in the 278 response to indicate the data that is missing or invalid.
b. the 278 request (ST-SE) does not support this information and the needed information pertains to all the
services requested and not to a specific service. Use the PWK segment at the Patient Event level (Loop 2000E) if
requesting medical necessity information that applies to all the services requested.
Refer to Section 2.5 for more information on using this segment.
TR3 Example:
PWK*OB*BM***AC*DMN0012~
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Pos: 1600
MSG Message Text
Max: 1
Detail - Optional
Loop:
2000F
Elements: 1
User Option (Usage): Situational
Purpose: To provide a free-form format that allows the transmission of text information
Element Summary:
Ref
Id
Element Name
MSG01
933
Free-form Message Text
Req
Type
Min/Max
Usage
M
AN
1/264
Required
Description: Free-form message text
IMPLEMENTATION NAME: Free Form Message Text
Syntax Rules:
1. C0302 - If MSG03 is present, then MSG02 is required.
Semantics:
1. MSG03 is the number of lines to advance before printing.
Comments:
1. MSG02 is not related to the specific characteristics of a printer, but identifies top of page, advance a line, etc.
2. If MSG02 is "AA - Advance the specified number of lines before print" then MSG03 is required.
Situational Rule:
Required when it is necessary to send additional information about the Service which could not otherwise be
codified within the 2000F Loop. If not required by this implementation guide, do not send.
TR3 Example:
MSG*This is a free-form text message~
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Pos: 1700
Loop Service Provider Name
Repeat: 12
Optional
Loop:
2010FA
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
1700
1800
NM1
REF
2000
2100
2200
2300
2400
N3
N4
PER
AAA
PRV
Service Provider Name
Service Provider Supplemental
Identification
Service Provider Address
Service Provider City, State, ZIP Code
Service Provider Contact Information
Service Provider Request Validation
Service Provider Information
223
Req
Max Use
Repeat
Usage
O
O
1
8
Situational
Situational
O
O
O
O
O
1
1
1
9
1
Situational
Situational
Situational
Situational
Situational
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Pos: 1700
NM1 Service Provider Name
Max: 1
Detail - Optional
Loop:
2010FA
Elements: 9
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: 1500, Included: 12)
Code Name
72
73
77
DD
DK
DQ
FA
G3
P3
QB
QV
SJ
NM102
1065
Operating Physician
Other Physician
Service Location
Assistant Surgeon
Ordering Physician
Supervising Physician
Facility
Clinic
Primary Care Provider
Purchase Service Provider
Group Practice
Service Provider
Entity Type Qualifier
M
ID
1/1
Required
AN
1/60
Situational
Description: Code qualifying the type of entity
CodeList Summary (Total Codes: 16, Included: 2)
Code Name
1
2
NM103
1035
Person
Non-Person Entity
Name Last or Organization Name
X
Description: Individual last name or organizational name
Situational Rule: Required when valued on the request or when the UMO authorizes a
specific provider or specialty entity for this service. If not required by this implementation
guide, do not send.
IMPLEMENTATION NAME: Service Provider Last or Organization Name
NM104
1036
Name First
O
AN
1/35
Situational
Description: Individual first name
Situational Rule: Required when NM103 is valued and NM102 = 1. If not required by this
implementation guide, do not send.
IMPLEMENTATION NAME: Service Provider First Name
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Ref
Id
Element Name
NM105
1037
Name Middle
Req
Type
Min/Max
Usage
O
AN
1/25
Situational
Description: Individual middle name or initial
Situational Rule: Required when NM104 is present and the middle name/initial of the
person is known. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Service Provider Middle Name
NM106
1038
Name Prefix
O
AN
1/10
Situational
Description: Prefix to individual name
Situational Rule: Required when the UMO uses military title or rank to further identify the
individual provider. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Service Provider Name Prefix
NM107
1039
Name Suffix
O
AN
1/10
Situational
Description: Suffix to individual name
Situational Rule: Required when the UMO uses the name suffix to further identify the
individual provider. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Service Provider Name Suffix
NM108
66
Identification Code Qualifier
X
ID
1/2
Situational
Description: Code designating the system/method of code structure used for Identification
Code (67)
Situational Rule: Required when valued on the request or when the UMO authorizes a
specific provider or specialty entity for this service by provider ID. If not required by this
implementation guide, do not send.
CodeList Summary (Total Codes: 241, Included: 4)
Code Name
24
34
46
XX
Employer's Identification Number
Social Security Number
Electronic Transmitter Identification Number (ETIN)
Centers for Medicare and Medicaid Services National Provider Identifier
Required for providers on or after the mandated
HIPAA National Provider Identifier (NPI) implementation date when the provider
has an NPI and it is available to the UMO.
OR
Required for providers before the mandated HIPAA NPI implementation date when
the provider has an NPI and the UMO has the capability to send it.
If not required by this implementation guide, do not send.
CODE SOURCE:
537: Centers for Medicare and Medicaid Services National Provider Identifier
NM109
67
Identification Code
X
AN
2/80
Situational
Description: Code identifying a party or other code
Situational Rule: Required when valued on the request or when the UMO authorizes a
specific provider or specialty entity for this service by provider ID. If not required by this
implementation guide, do not send.
IMPLEMENTATION NAME: Service Provider Identifier
ExternalCodeList
Name: 537
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Description: Centers for Medicare and Medicaid Services 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.
3. C1203 - If NM112 is present, then NM103 is required.
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
2. NM112 can identify a second surname.
Situational Rule:
Required when valued on the request or when the UMO authorizes a specific provider or specialty entity for this
service. If not required by this implementation guide, do not send.
TR3 Notes:
1. Use this segment to convey the name and identification number of the service provider (person, group, or
facility) or to identify the specialty entity.
TR3 Example:
NM1*SJ*1*WATSON*SUSAN****34*987654321~
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Pos: 1800
REF Service Provider
Max: 8
Detail - Optional
Supplemental Identification
Loop:
2010FA
Elements: 3
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: 1731, Included: 9)
Code Name
REF02
127
0B
1G
1J
EI
State License Number
Provider UPIN Number
Facility ID Number
Employer's Identification Number
Not used if NM108 = 24.
G5
N5
N7
SY
Provider Site Number
Provider Plan Network Identification Number
Facility Network Identification Number
Social Security Number
The social security number must not be used for any Federally administered
programs such as Medicare or CHAMPUS. Not used if NM108 = 34.
ZH
Carrier Assigned Reference Number
Use for the provider ID as assigned by the UMO identified in Loop 2000A.
Reference Identification
X
AN
1/50
Required
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
IMPLEMENTATION NAME: Service Provider Supplemental Identifier
REF03
352
Description
X
AN
1/80
Situational
Description: A free-form description to clarify the related data elements and their content
Situational Rule: Required when REF01 = 0B to report the two character state ID of the
state assigning the State License Number. If not required by this implementation guide, do
not send.
IMPLEMENTATION NAME: License Number State Code
See code source 22: State and Outlying Areas of the US.
ExternalCodeList
Name: 22C
Description: States and Provinces
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
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1. REF04 contains data relating to the value cited in REF02.
Situational Rule:
Required when used by the UMO to identify the Service Provider. If not required by this implementation guide, do
not send.
TR3 Notes:
1. Use the NM1 segment for the primary identifier.
TR3 Example:
REF*1G*123456~
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Pos: 2000
N3 Service Provider Address
Max: 1
Detail - Optional
Loop:
2010FA
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
Description: Address information
IMPLEMENTATION NAME: Service Provider Address Line
Use this element for the first line of the service provider’s address.
N302
166
Address Information
O
AN
1/55
Situational
Description: Address information
Situational Rule: Required when a second address lines exists. If not required by this
implementation guide, do not send.
IMPLEMENTATION NAME: Service Provider Address Line
Situational Rule:
Required when the UMO authorizes a specific location for a service provider that has multiple locations. If not
required by this implementation guide, do not send.
TR3 Example:
N3*77 HOLLY BLVD~
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N4 Service Provider City, State,
ZIP Code
Pos: 2100
Max: 1
Detail - Optional
Loop:
2010FA
Elements: 5
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
2/2
Situational
Description: Free-form text for city name
IMPLEMENTATION NAME: Service Provider City Name
N402
156
State or Province Code
X
ID
Description: Code (Standard State/Province) as defined by appropriate government
agency
Situational Rule: Required when the address is in the United States of America, including
its territories, or Canada. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Service Provider State or Province Code
CODE SOURCE: 22: States and Provinces
ExternalCodeList
Name: 22C
Description: States and Provinces
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)
Situational Rule: Required when the address is in the United States of America, including
its territories, or Canada, or when a postal code exists for the country in N404. If not
required by this implementation guide, do not send.
IMPLEMENTATION NAME: Service Provider Postal Zone or ZIP Code
CODE SOURCE: 51: ZIP Code
ExternalCodeList
Name: 51
Description: ZIP Code
N404
26
Country Code
X
ID
2/3
Situational
Description: Code identifying the country
Situational Rule: Required when the address is outside the United States of America. If
not required by this implementation guide, do not send.
CODE SOURCE: 5: Countries, Currencies and Funds
Use the alpha-2 country codes from Part 1 of ISO 3166.
ExternalCodeList
Name: 5
Description: Countries, Currencies and Funds
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N407
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Id
1715
Element Name
Country Subdivision Code
Req
X
Type
ID
Min/Max
1/3
Usage
Situational
Description: Code identifying the country subdivision
Situational Rule: Required when the address is not in the United States of America,
including its territories, or Canada, and the country in N404 has administrative subdivisions
such as but not limited to states, provinces, cantons, etc. If not required by this
implementation guide, do not send.
CODE SOURCE: 5: Countries, Currencies and Funds
Use the country subdivision codes from Part 2 of ISO 3166.
ExternalCodeList
Name: 5
Description: Countries, Currencies and Funds
Syntax Rules:
1. E0207 - Only one of N402 or N407 may be present.
2. C0605 - If N406 is present, then N405 is required.
3. C0704 - If N407 is present, then N404 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.
Situational Rule:
Required when the UMO authorizes a specific location for a service provider that has multiple locations. If not
required by this implementation guide, do not send.
TR3 Example:
N4*KANSAS CITY*MO*64108~
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Pos: 2200
PER Service Provider Contact
Max: 1
Detail - Optional
Information
Loop:
2010FA
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: 238, Included: 1)
Code Name
IC
PER02
93
Information Contact
Name
O
AN
1/60
Situational
Description: Free-form name
Situational Rule: Required when the UMO wishes to indicate a particular contact and the
name of the entity to contact is not already defined or is different than the name within the
prior name segment (e.g. N1 or NM1). If not required by this implementation guide, do not
send.
IMPLEMENTATION NAME: Service Provider Contact Name
PER03
365
Communication Number Qualifier
X
ID
2/2
Situational
Description: Code identifying the type of communication number
Situational Rule: Required when PER02 is not valued or when the UMO needs to transmit
a contact communication number. If not required by this implementation guide, do not send.
CodeList Summary (Total Codes: 42, Included: 4)
Code Name
EM
FX
TE
UR
PER04
364
Electronic Mail
Facsimile
Telephone
Uniform Resource Locator (URL)
Communication Number
X
AN
1/256
Situational
Description: Complete communications number including country or area code when
applicable
Situational Rule: Required when PER02 is not valued or when the UMO needs to transmit
a contact communication number. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Service Provider Contact Communication Number
PER05
365
Communication Number Qualifier
X
ID
2/2
Situational
Description: Code identifying the type of communication number
Situational Rule: Required when a telephone extension or multiple communication types
are available. If not required by this implementation guide, do not send.
CodeList Summary (Total Codes: 42, Included: 5)
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Code Name
PER06
364
EM
EX
Electronic Mail
Telephone Extension
When used, the value following this code is the extension for the preceding
communications contact number.
FX
TE
UR
Facsimile
Telephone
Uniform Resource Locator (URL)
Communication Number
X
AN
1/256
Situational
Description: Complete communications number including country or area code when
applicable
Situational Rule: Required when a telephone extension or multiple communication types
are available. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Service Provider Contact Communication Number
PER07
365
Communication Number Qualifier
X
ID
2/2
Situational
Description: Code identifying the type of communication number
Situational Rule: Required when a telephone extension or multiple communication types
are available. If not required by this implementation guide, do not send.
CodeList Summary (Total Codes: 42, Included: 5)
Code Name
PER08
364
EM
EX
Electronic Mail
Telephone Extension
When used, the value following this code is the extension for the preceding
communications contact number.
FX
TE
UR
Facsimile
Telephone
Uniform Resource Locator (URL)
Communication Number
X
AN
1/256
Situational
Description: Complete communications number including country or area code when
applicable
Situational Rule: Required when a telephone extension or multiple communication types
are available. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Service Provider Contact Communication Number
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.
Situational Rule:
Required when needed to identify a contact name and/or communications number for the provider. If not required
by this implementation guide, may be provided at the sender’s discretion but cannot be required by the receiver.
TR3 Notes:
1. When the communication number represents a telephone number in the United States and other countries
using the North American Dialing Plan (for voice, data, fax, etc), the communication number should always
include the area code and telephone number using the format AAABBBCCCC. Where AAA is the area code, BBB
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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.
TR3 Example:
PER*IC*M TUCKER*TE*8189993456*FX*8185551212~
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Pos: 2300
AAA Service Provider Request
Max: 9
Detail - Optional
Validation
Loop:
2010FA
Elements: 3
User Option (Usage): Situational
Purpose: To specify the validity of the request and indicate follow-up action authorized
Element Summary:
Ref
Id
Element Name
AAA01
1073
Yes/No Condition or Response Code
Req
Type
Min/Max
Usage
M
ID
1/1
Required
2/2
Required
Description: Code indicating a Yes or No condition or response
IMPLEMENTATION NAME: Valid Request Indicator
CodeList Summary (Total Codes: 4, Included: 1)
Code Name
N
AAA03
901
No
Reject Reason Code
O
ID
Description: Code assigned by issuer to identify reason for rejection
CodeList Summary (Total Codes: 204, Included: 15)
Code Name
AAA04
889
15
Required application data missing
Use when data is missing that is not covered by another reject reason code. Use
to indicate when there is not enough information to identify the service provider.
33
Input Errors
Use for input errors not covered by another reject reason code.
35
41
43
44
45
46
47
49
51
52
79
97
IP
Out of Network
Authorization/Access Restrictions
Invalid/Missing Provider Identification
Invalid/Missing Provider Name
Invalid/Missing Provider Specialty
Invalid/Missing Provider Phone Number
Invalid/Missing Provider State
Provider is Not Primary Care Physician
Provider Not on File
Service Dates Not Within Provider Plan Enrollment
Invalid Participant Identification
Invalid or Missing Provider Address
Inappropriate Provider Role
Follow-up Action Code
O
ID
1/1
Required
Description: Code identifying follow-up actions allowed
CodeList Summary (Total Codes: 10, Included: 2)
Code Name
C
N
Please Correct and Resubmit
Resubmission Not Allowed
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Semantics:
1. AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N"
indicates that the code is invalid.
Comments:
1. If AAA02 is used, AAA03 contains a code from an industry code list.
Situational Rule:
Required when the request is not valid at this level to indicate the data condition that prohibits processing of the
original request. If not required by this implementation guide, do not send.
TR3 Example:
AAA*N**47*C~
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PRV Service Provider Information
Pos: 2400
Max: 1
Detail - Optional
Loop:
2010FA
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
1/50
Required
Description: Code identifying the type of provider
CodeList Summary (Total Codes: 26, Included: 6)
Code Name
PRV02
128
AS
Assistant Surgeon
Use only when NM101 = DD.
OP
Operating
Use only when NM101 = 72.
OR
Ordering
Use only when NM101 = DK.
OT
Other Physician
Use only when NM101 = 73.
PC
Primary Care Physician
Use only when NM101 = P3.
PE
Performing
Use only when NM101 = SJ.
Reference Identification Qualifier
X
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1731, Included: 1)
Code Name
PXC
Health Care Provider Taxonomy Code
CODE SOURCE:
682: Health Care Provider Taxonomy
PRV03
127
Reference Identification
X
AN
Description: Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
IMPLEMENTATION NAME: Provider Taxonomy Code
ExternalCodeList
Name: 682
Description: Health Care Provider Taxonomy
Syntax Rules:
1. P0203 - If either PRV02 or PRV03 is present, then the other is required.
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Situational Rule:
Required when used by the UMO to identify the provider. If not required by this implementation guide, do not
send.
TR3 Example:
PRV*PE*PXC*203BS0133X~
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Pos: 1700
Loop Additional Service
Information Contact Name
Repeat: 1
Optional
Loop:
2010FB
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
1700
NM1
2000
N3
2100
N4
2200
PER
Additional Service Information
Name
Additional Service Information
Address
Additional Service Information
City, State, ZIP Code
Additional Service Information
Information
Req
Max Use
Contact
O
1
Situational
Contact
O
1
Situational
Contact
O
1
Required
Contact
O
1
Situational
239
Repeat
Usage
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Pos: 1700
NM1 Additional Service
Max: 1
Detail - Optional
Information Contact Name
Loop:
2010FB
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: 1500, Included: 1)
Code Name
L5
NM102
1065
Contact
Entity Type Qualifier
M
ID
1/1
Required
Description: Code qualifying the type of entity
CodeList Summary (Total Codes: 16, Included: 2)
Code Name
NM103
1035
1
Person
Use this name only if the destination is an individual, such as an individual primary
care physician.
2
Non-Person Entity
Name Last or Organization Name
X
AN
1/60
Situational
Description: Individual last name or organizational name
Situational Rule: Required when the responder needs to identify the destination by name.
If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Response Contact Last or Organization Name
NM104
1036
Name First
O
AN
1/35
Situational
Description: Individual first name
Situational Rule: Required when NM103 is valued and the destination is an individual
(NM102 = 1). If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Response Contact First Name
NM105
1037
Name Middle
O
AN
1/25
Situational
Description: Individual middle name or initial
Situational Rule: Required when NM104 is valued and the middle name/initial of the
individual is known. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Response Contact Middle Name
NM107
1039
Name Suffix
O
AN
1/10
Situational
Description: Suffix to individual name
Situational Rule: Required when NM104 is valued and the suffix of the individual’s name
is known; e.g. Sr., Jr., or III. If not required by this implementation guide, do not send.
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Id
Element Name
Req
Type
Min/Max
Usage
1/2
Situational
IMPLEMENTATION NAME: Response Contact Name Suffix
NM108
66
Identification Code Qualifier
X
ID
Description: Code designating the system/method of code structure used for Identification
Code (67)
Situational Rule: Required when the responder needs to use an identifier to identify the
destination. If not required by this implementation guide, do not send.
CodeList Summary (Total Codes: 241, Included: 6)
Code Name
24
34
46
PI
Employer's Identification Number
Social Security Number
Electronic Transmitter Identification Number (ETIN)
Payor Identification
Use until the National PlanID is mandated if the destination is a payer.
XV
Centers for Medicare and Medicaid Services PlanID
Use if the destination is a payer.
CODE SOURCE:
540: Centers for Medicare and Medicaid Services PlanID
XX
Centers for Medicare and Medicaid Services National Provider Identifier
Use if the destination is a provider.
CODE SOURCE:
537: Centers for Medicare and Medicaid Services National Provider Identifier
NM109
67
Identification Code
X
AN
2/80
Situational
Description: Code identifying a party or other code
Situational Rule: Required when the responder needs to use an identifier to identify the
destination. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Response Contact Identifier
ExternalCodeList
Name: 537
Description: Centers for Medicare and Medicaid Services National Provider Identifier
ExternalCodeList
Name: 540
Description: Centers for Medicare and Medicaid Services 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.
3. C1203 - If NM112 is present, then NM103 is required.
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
2. NM112 can identify a second surname.
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Situational Rule:
Required when Loop 2000F contains a request for additional information and the destination for that additional
information differs from the UMO Name information in the NM1 loop (Loop 2010A) of the 278 response. If not
required by this implementation guide, do not send.
TR3 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.
Refer to Section 2.5 for more information on this NM1 loop.
TR3 Example:
NM1*L5*2*ACME THIRD PARTY ADMINISTRATOR~
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N3 Additional Service Information
Contact Address
Pos: 2000
Max: 1
Detail - Optional
Loop:
2010FB
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
1/55
Situational
Description: Address information
IMPLEMENTATION NAME: Response Contact Address Line
Use this element for the first line of the requester’s address.
N302
166
Address Information
O
AN
Description: Address information
Situational Rule: Required when a second address lines exists. If not required by this
implementation guide, do not send.
IMPLEMENTATION NAME: Response Contact Address Line
Situational Rule:
Required when the response to the request for additional service information must be routed to a specific office
location. If not required by this implementation guide, do not send.
TR3 Notes:
1. This segment identifies the office location to route the response to the request for additional service
information.
TR3 Example:
N3*43 SUNRISE BLVD*SUITE 1000~
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N4 Additional Service Information
Contact City, State, ZIP Code
Pos: 2100
Max: 1
Detail - Optional
Loop:
2010FB
Elements: 5
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
IMPLEMENTATION NAME: Additional Service Information Contact City Name
N402
156
State or Province Code
X
ID
2/2
Situational
Description: Code (Standard State/Province) as defined by appropriate government
agency
Situational Rule: Required when the address is in the United States of America, including
its territories, or Canada. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Additional Service Information Contact City Name
CODE SOURCE: 22: States and Provinces
ExternalCodeList
Name: 22C
Description: States and Provinces
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)
Situational Rule: Required when the address is in the United States of America, including
its territories, or Canada, or when a postal code exists for the country in N404. If not
required by this implementation guide, do not send.
IMPLEMENTATION NAME: Additional Service Information Contact City Name
CODE SOURCE: 51: ZIP Code
ExternalCodeList
Name: 51
Description: ZIP Code
N404
26
Country Code
X
ID
2/3
Situational
Description: Code identifying the country
Situational Rule: Required when the address is outside the United States of America. If
not required by this implementation guide, do not send.
CODE SOURCE: 5: Countries, Currencies and Funds
Use the alpha-2 country codes from Part 1 of ISO 3166.
ExternalCodeList
Name: 5
Description: Countries, Currencies and Funds
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Ref
N407
Health Care Services Review Information - Response - 278
Id
1715
Element Name
Country Subdivision Code
Req
X
Type
ID
Min/Max
1/3
Usage
Situational
Description: Code identifying the country subdivision
Situational Rule: Required when the address is not in the United States of America,
including its territories, or Canada, and the country in N404 has administrative subdivisions
such as but not limited to states, provinces, cantons, etc. If not required by this
implementation guide, do not send.
CODE SOURCE: 5: Countries, Currencies and Funds
Use the country subdivision codes from Part 2 of ISO 3166.
ExternalCodeList
Name: 5
Description: Countries, Currencies and Funds
Syntax Rules:
1. E0207 - Only one of N402 or N407 may be present.
2. C0605 - If N406 is present, then N405 is required.
3. C0704 - If N407 is present, then N404 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.
Situational Rule:
Required when the response to the request for additional service information must be routed to a specific office
location. If not required by this implementation guide, do not send.
TR3 Example:
N4*KANSAS CITY*MO*64108~
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Pos: 2200
PER Additional Service
Max: 1
Detail - Optional
Information Contact
Information
Loop:
2010FB
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: 238, Included: 1)
Code Name
IC
PER02
93
Information Contact
Name
O
AN
1/60
Situational
Description: Free-form name
Situational Rule: Required when the response must be directed to a particular contact
and when the name of the entity to contact is not already defined or is different than the
name within the prior name segment (e.g. N1 or NM1). If not required by this
implementation guide, do not send.
IMPLEMENTATION NAME: Response Contact Name
PER03
365
Communication Number Qualifier
X
ID
2/2
Situational
Description: Code identifying the type of communication number
Situational Rule: Required when PER02 is not valued or when the UMO needs to transmit
a contact communication number. If not required by this implementation guide, do not send.
CodeList Summary (Total Codes: 42, Included: 4)
Code Name
EM
FX
TE
UR
PER04
364
Electronic Mail
Facsimile
Telephone
Uniform Resource Locator (URL)
Communication Number
X
AN
1/256
Situational
Description: Complete communications number including country or area code when
applicable
Situational Rule: Required when PER02 is not valued or when the UMO needs to transmit
a contact communication number. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Response Contact Communication Number
PER05
365
Communication Number Qualifier
X
ID
2/2
Situational
Description: Code identifying the type of communication number
Situational Rule: Required when a telephone extension or multiple communication types
are available. If not required by this implementation guide, do not send.
246
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Ref
Health Care Services Review Information - Response - 278
Id
Element Name
Req
Type
Min/Max
Usage
AN
1/256
Situational
CodeList Summary (Total Codes: 42, Included: 5)
Code Name
EM
EX
FX
TE
UR
PER06
364
Electronic Mail
Telephone Extension
Facsimile
Telephone
Uniform Resource Locator (URL)
Communication Number
X
Description: Complete communications number including country or area code when
applicable
Situational Rule: Required when a telephone extension or multiple communication types
are available. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Response Contact Communication Number
PER07
365
Communication Number Qualifier
X
ID
2/2
Situational
Description: Code identifying the type of communication number
Situational Rule: Required when a telephone extension or multiple communication types
are available. If not required by this implementation guide, do not send.
CodeList Summary (Total Codes: 42, Included: 5)
Code Name
EM
EX
FX
TE
UR
PER08
364
Electronic Mail
Telephone Extension
Facsimile
Telephone
Uniform Resource Locator (URL)
Communication Number
X
AN
1/256
Situational
Description: Complete communications number including country or area code when
applicable
Situational Rule: Required when a telephone extension or multiple communication types
are available. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Response Contact Communication Number
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.
Situational Rule:
Required when the provider must direct the response to the request for additional service information to a specific
requester contact, electronic mail, facsimile, or phone number other than the contact provided in the PER
segment in the UMO Name loop (Loop 2010A) PER segment of this 278 response. If not required by this
implementation guide, do not send.
TR3 Notes:
1. Do not use if the request for additional service information is in another X12 functional group.
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
247
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Health Care Services Review Information - Response - 278
include the area code and telephone 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.
TR3 Example:
PER*IC*MARY*FX*3135551212~
248
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Pos: 2800
SE Transaction Set Trailer
Max: 1
Detail - Mandatory
Loop: N/A
Elements: 2
User Option (Usage): Required
Purpose: To indicate the end of the transaction set and provide the count of the transmitted segments (including the
beginning (ST) and ending (SE) segments)
Element Summary:
Ref
Id
Element Name
SE01
96
Number of Included Segments
Req
Type
Min/Max
Usage
M
N0
1/10
Required
Description: Total number of segments included in a transaction set including ST and SE
segments
IMPLEMENTATION NAME: Transaction Segment Count
SE02
329
Transaction Set Control Number
M
AN
4/9
Required
Description: Identifying control number that must be unique within the transaction set
functional group assigned by the originator for a transaction set
The Transaction Set Control Numbers in ST02 and SE02 must be identical. The number is
assigned by the originator and must be unique within a functional group (GS-GE). For
example, start with the number 0001 and increment from there. The number also aids in
error resolution research.
Comments:
1. SE is the last segment of each transaction set.
TR3 Example:
SE*24*0001~
249
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Pos:
GE Functional Group Trailer
Max: 1
Not Defined - Mandatory
Loop: N/A
Elements: 2
User Option (Usage): Required
Purpose: To indicate the end of a functional group and to provide control information
Element Summary:
Ref
Id
Element Name
GE01
97
Number of Transaction Sets Included
Req
Type
Min/Max
Usage
M
N0
1/6
Required
Description: Total number of transaction sets included in the functional group or
interchange (transmission) group terminated by the trailer containing this data element
GE02
28
Group Control Number
M
N0
1/9
Required
Description: Assigned number originated and maintained by the sender
Semantics:
1. The data interchange control number GE02 in this trailer must be identical to the same data element in the
associated functional group header, GS06.
Comments:
1. The use of identical data interchange control numbers in the associated functional group header and trailer is
designed to maximize functional group integrity. The control number is the same as that used in the
corresponding header.
TR3 Example:
GE*1*1~
250
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IEA Interchange Control Trailer
Pos:
Max: 1
Not Defined - Mandatory
Loop: N/A
Elements: 2
User Option (Usage): Required
Purpose: To define the end of an interchange of zero or more functional groups and interchange-related control
segments
Element Summary:
Ref
Id
Element Name
IEA01
I16
Number of Included Functional Groups
Req
Type
Min/Max
Usage
M
N0
1/5
Required
Description: A count of the number of functional groups included in an interchange
IEA02
I12
Interchange Control Number
M
N0
9/9
Required
Description: A control number assigned by the interchange sender
TR3 Example:
IEA*1*000000905~
251
For internal use only
Blue Shield of California
Electronic Data Exchange
Trading Partner Agreement
This Trading Partner Agreement (“Agreement”) is made as of __________________, between
California Physicians’ Service dba Blue Shield of California, for and on behalf of itself and its
subsidiaries including Blue Shield of California Life & Health Insurance Company (collectively
“Blue Shield”) and
______________________________________________________ (“Trading Partner”).
Trading Partner Name (please print)
A.
Conducting Transactions
1.
The parties shall use the standard data content, data conditions, and format to
conduct electronic transactions for which the Department of Health and Human
Services has established a standard under the HIPAA Transactions Rule (45
C.F.R. Parts 160, 162). The transactions the parties may conduct include claim
submissions, remittance advice, electronic funds transfer, eligibility inquiries and
responses, claims status inquiries and responses, and requests to authorize
health care and responses to such requests. To the extent not inconsistent with
the applicable standards under the Transactions Rule, the parties shall conduct
all such transactions in accordance with the applicable Blue Shield Companion
Guide. Blue Shield may modify its Companion Guides at any time without
amending this Agreement.
2.
Blue Shield may reject any transaction that does not conform to the applicable
HIPAA standard and applicable Companion Guide.
3.
Trading Partner and Blue Shield shall cooperate in testing the exchange of
transactions, as Blue Shield deems appropriate. Testing will be designed to
ensure the accuracy, timeliness, completeness, and security of each data
transmission.
4.
The parties shall take reasonable care to ensure that transactions conducted
pursuant to this Agreement are timely, complete, and secure. Trading Partner
shall ensure the accuracy of all information it provides to Blue Shield in such
transactions and shall research and correct any billing discrepancy caused by
inaccurate information. For purposes of this paragraph, if Trading Partner is an
intermediary (rather than the entity that originates the transaction), information is
“accurate” if it is not materially changed from the information that Trading Partner
received from (a) the originator of the transaction or (b) another intermediary, as
the case may be.
5.
In the event a party receives an electronic transaction under this Agreement that
is (i) garbled or incomplete, regardless of how or why the electronic transaction
was rendered garbled or incomplete, or (ii) not intended for the receiving party,
the receiving party shall immediately notify the sending party to arrange for the
return or destruction of the transaction, as the sending party directs.
6.
Each party is responsible for all costs, charges, or fees it may incur by
transmitting electronic transactions to, or receiving electronic transactions from,
the other party.
1
B.
7.
Blue Shield will not conduct transactions that Trading Partner submits or receives
on behalf of a health care provider unless Trading Partner is (a) the health care
provider or (b) named in a “Provider Authorization Form” as an authorized
recipient of the health care provider’s transactions.
8.
Blue Shield will only make electronic funds transfers to an authorized financial
institution.
9.
Blue Shield shall provide Trading Partner security access codes that will allow
Trading Partner access to Blue Shield’s electronic data systems. Blue Shield
may change security access codes at any time and in such manner as Blue
Shield, in its sole discretion, deems necessary.
Privacy and Security
1.
Each party shall develop, implement, and maintain safeguards reasonably
necessary to ensure the privacy and security of (a) protected health information
transmitted or maintained by the party and (b) each party’s own Information
Systems (as that term is defined in 45 C.F.R. § 164.304).
2.
Each party shall maintain policies and procedures reasonably designed to:
o
Prevent unauthorized access to (i) transactions conducted pursuant to
this Agreement, (ii) security access codes, (iii) backup files, and (iv)
Information Systems;
o
Assure data are not inappropriately modified, deleted, or destroyed; and
o
Assure the availability of data.
Each party shall document and keep current its security measures. Each party’s
security measures will include, at a minimum, the safeguards required by the
HIPAA Security Rule (45 C.F.R. Part 164, Subpart C).
3.
Trading Partner shall use the Blue Shield-issued security access codes as an
electronic signature to authenticate and verify that Trading Partner sent each
transaction it submits to Blue Shield pursuant to this Agreement and that the data
in the transaction are valid. Trading Partner shall protect and maintain the
confidentiality of the security access codes and limit disclosure of the codes to
authorized personnel on a need-to-know basis. Trading Partner shall promptly
request Blue Shield to terminate any security access code to which an
unauthorized person, including a former employee, has access.
4.
Each party shall comply with the requirements of the HIPAA Privacy, Security,
and Breach Notification Rules (45 C.F.R. Parts 160-164) with respect to
protected health information the party maintains or transmits. Trading Partner
shall promptly notify Blue Shield of any infringement of security access codes or
other circumstances that may cause (or may have already caused) a breach of
Blue Shield’s protected health information or a Security Incident (as that term is
defined in 45 C.F.R. § 164.304).
2
C.
General Terms
1.
Trading Partner agrees to require its employees and agents to comply with the
terms of this Agreement.
2.
This Agreement is effective when Blue Shield receives a copy of the Agreement
signed by Trading Partner.
3.
Each party shall establish and maintain a “Trade Data Log,” in which the party
shall record all transactions exchanged with the other party under this
Agreement. Each party shall take reasonable steps to ensure that the Trade
Data Log is a current, accurate, complete, and unaltered record of all data
transmissions between the parties. Each party shall maintain accurate,
complete, and unaltered copies of the Trade Data Log for ten (10) years. This
paragraph will survive the termination of the Agreement for any reason.
4.
Trading Partner shall allow and shall require its agents to allow Blue Shield to
audit Trading Partner’s and Trading Partner’s agents’ Trade Data Log,
Information Systems, and relevant business records to assess Trading Partner’s
compliance with this Agreement. Blue Shield’s audit may evaluate security
precautions implemented by Trading Partner and Trading Partner’s agents.
Trading Partner shall cooperate and shall require the cooperation of its agents
with any audit related to this Agreement by a governmental agency, licensing
body, or accreditation body.
5.
Should one party materially breach this Agreement, the other party may give the
breaching party written notice of the breach and the breaching party shall have
thirty (30) days to cure the breach. If the breaching party does not cure the
breach within the thirty (30) day period, the non-breaching party may, in its sole
discretion, either extend the cure period or give a written termination notice that
becomes effective five (5) working days thereafter.
The parties acknowledge, agree to and shall be bound by all of the terms, provisions and
conditions of the Agreement with the execution hereof by duly authorized representatives:
TRADING PARTNER
By:
CALIFORNIA PHYSICIANS’ SERVICE dba
BLUE SHIELD OF CALIFORNIA
______
By:
Title:
Title:
Date:
Date:
TIN:
Manager, eBusiness EDI
______
Telephone:
Telephone: 800-480-1221
Fax:
Fax: 530-351-6150
E-Mail:
E-mail: [email protected]
3
Trading Partner Enrollment Form
Trading Partner will exchange transactions directly with Blue Shield of California using sFTP or Http/s
Transactions
Elected:
837 Claims/Encounter Submission
276/277Claims Status
835 ERA/EFT
270/271 Eligibility
278 Authorizations
Blue Shield of California providers must use the Provider Authorization Form to enroll in electronic
remittance advice and provide bank routing information for electronic funds transfer (EFT). Additional
copies of this form are available online at blueshieldca.com/provider/edi.
During exchange of electronic transactions, each party will comply with all applicable requirements of
the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and regulations promulgated
thereunder.
For Claim 837 enrollment, clearinghouses representing multiple providers or providers with multiple
Tax Identification Numbers (TINS) or Type II NPI(s) must use the Tax Identification Detail form to
indicate all Tax Identification numbers for which data will be included in EDI transmissions.
Business Type:
Clearinghouse
Institutional provider
Billing Service
Vendor
MSO/CBO
Professional provider
IPA
Trading partner name:
Tax ID:
National Provider Identifier (NPI) Type 2:
Street Address:
City:
State:
Zip:
Mailing address:
State:
Contact name:
Phone:
Contact title:
Email:
Zip:
Fax:
Software Vendor Information (if applicable)
Software vendor contact name:
Vendor address
Blue Shield of California
Attn: EDI
4700 Bechelli Lane
Redding, CA 96002
Fax to: EDI/Blue Shield at (530) 351-6150
Email: [email protected]
Trading Partner Enrollment Form
An Independent Member of the Blue Shield Association
City:
Blue Shield of California
Attn: EDI
4700 Bechelli Lane
Redding, CA 96002
Fax to: EDI/Blue Shield at (530) 351-6150
Email: [email protected]
Trading Partner Enrollment Form
Connectivity Detail Form
Complete this form to establish a direct connection with Blue Shield.
Contact Information (at least two contacts are required):
Contact Type
Name
Phone
Email
Business
Technical Lead
Primary User
Backup User
COMPLETE INFORMATION BELOW FOR SECURE FILE TRANSFER PROTOCOL (sFTP)
Data Integrity Protocol (select one):
Not Required
SHA-1
MD5
RIPEMD-160
Transport Method & Data Encryption (select one):
Secure FTP over SSH with no PGP data
encryption 
Secure FTP over SSH with PGP encryption of data
PGP Encryption Method (please select only one):
AES (128 bit)
Diffie-Hellman (1024 bit)
RSA (1024 bit)
AES (192 bit)
Diffie-Hellman (2048 bit)
RSA (2048 bit)
AES (256 bit)
Diffie-Hellman (4096 bit)
RSA (4096 bit)
Cast 5 (128 bit)
El Gamal (1024 bit)
Triple DES (168 bit)
DSA v3 & v4 (1024 bit)
El Gamal (2048 bit)
Two Fish (256 bit )
DSA v3 & v4 (2048 bit)
El Gamal (4096 bit)
DSA v3 & v4 (4096 bit)
IDEA (128 bit)
Static DNS Name and/or Static IP Address & Data Delivery Method (select one):
Primary DNS Name and/or IP address: (
).(
).(
).(
)
Secondary DNS Name and/or IP address:
(
).(
).(
).(
)
IP addresses must be static. For IP address not registered in the name of the trading partner, complete the IP Ownership
Verification Form.
NOTE: Notify Blue Shield of California at (800) 480-1221 two weeks prior to any IP address change to avoid interruption in
service.
Inbound to BSC:
Customer pushes file to BSC
BSC FTP Server pulls file from customer
Outbound to
customer:
Source Directory:
Customer pulls from the BSC SFTP server
BSC FTP Server pushes to customer
Source Directory:
Note: Blue Shield will email with your login ID and password for our secure FTP server, with a copy of our PGP public key,
if applicable. Blue Shield will also request a login ID and Password if BSC will push or pull from the customer’s server.
Blue Shield of California
Attn: EDI
4700 Bechelli Lane
Redding, CA 96002
Page 1
Fax to: EDI BSC at (530)351-6150
Email: [email protected]
COMPLETE INFORMATION BELOW FOR HTTP/s CONNECTIVITY
Transmission Mode:
Batch
Real Time
HTTP/s Connectivity Standards:
SOAP
MIME
Static DNS Name and/or Static IP Address & Data Delivery Method
Primary DNS Name and/or IP address: (
Secondary DNS Name and/or IP address:
(
).(
).(
).(
).(
).(
).(
)
)
IP addresses must be static. For IP address not registered in the name of the trading partner, complete the IP Ownership
Verification Form.
Static DNS Name and/or Static IP Address & Data Delivery Method
Primary DNS Name and/or IP address: (
).(
).(
Secondary DNS Name and/or IP address:
(
).(
).(
).(
).(
)
)
IP addresses must be static. For IP address not registered in the name of the trading partner, complete the IP Ownership
Verification Form.
NOTE: Notify Blue Shield of California at (800) 480-1221 two weeks prior to any IP address change to avoid interruption in
service.
Note: Blue Shield will email with your login ID and password for our secure FTP server, with a copy of our PGP public key,
if applicable. Blue Shield will also request a login ID and Password if BSC will push or pull from the customer’s server.
Blue Shield of California
Attn: EDI
4700 Bechelli Lane
Redding, CA 96002
Page 2
Fax to: EDI BSC at (530) 351-6150
Email: [email protected]
IP Ownership Verification Form
If the DNS Name / IP address is not registered in the name of the trading partner, please complete this
form to verify ownership.
This DNS Name / IP address is static and for the trading partner’s sole purpose.
Trading Partner Name:
Static IP Address: (primary)
(secondary)
DNS Name: (primary)
(secondary)
Check one:
DNS Name / IP address allocated by my Hosting Provider
Name of Hosting Provider
DNS Name / IP address provided by my ISP
Name of ISP
Other:
Please explain:
Authorized Signature
Signature:
Print Name:
Title:
Address:
Telephone:
Blue Shield of California Fax to: EDI /Blue Shield at (530) 351-6150
Attn: EDI Email: [email protected]
4700 Bechelli Lane Redding, CA 96002