Institutional side by side 4010A1 to 5010

INSTITUTIONAL CLAIM

4010A1 Element Identifier

Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

837-I 4010A1

ISA01 ISA02

ID 2-2 AN 10-10

R R

00, 03

ISA03 ISA04

Security Information Qualifier Security Information

ID 2-2 AN 10-10

R R

00, 01

ISA05 ISA06

Interchange ID Qualifier Interchange Sender ID

ID 2-2 AN 15-15

R R

ISA07 ISA08 ISA09 ISA10

ID 2-2 AN 15-15 DT 6-6 TM 4-4

R R R R

ISA12

Interchange ID Qualifier Interchange Receiver ID Interchange Date Interchange Time Interchange Control Standards ID Interchange Control Version Number

ISA13

Interchange Control Number

ISA11

ISA14 ISA15 ISA16

GS GS01 GS02 GS03 GS04

GS05 GS06 GS07 GS08

1

R

___

1

ISA03 ISA04

Security Information Qualifier Security Information

ID 2-2 AN 10-10

R R

00, 01

01, 14, 20, 27, 28, 29, 30, 33, ZZ

ISA05 ISA06

Interchange ID Qualifier Interchange Sender ID

ID 2-2 AN 15-15

R R

01, 14, 20, 27, 28, 29, 30, 33, ZZ

ISA07 ISA08 ISA09 ISA10

ID 2-2 AN 15-15 DT 6-6 TM 4-4

R R R R

5-5

R

ISA12

N0

9-9

R

ISA13


Acknowledgement Requested ID Usage Indicator ID Component Element Separator AN

1-1 1-1

R R

1-1

R

1 2-2 2-15 2-15 8-8

R R R R R

R R R R

1 00, 03

ID

4-8 1-9 1-2 1-12

___

Values

R R

ISA11

TM N0 ID AN

Loop Repeat

ID 2-2 AN 10-10

R

Time Group Control Number Responsible Agency Code Version Identifier Code

Loop

ISA01 ISA02

ISA

1-1

ID AN AN DT

Usage Reg.

INTERCHANGE CONTROL HEADER Authorization Information Qualifier Authorization Information

Interchange ID Qualifier Interchange Receiver ID Interchange Date Interchange Time Interchange Control Standards ID Interchange Control Version Number

FUNCTIONAL GROUP HEADER Functional Identifier Code Application Sender Code Application Receiver Code Date

Min. Max.

837-I 5010

INTERCHANGE CONTROL HEADER Authorization Information Qualifier Authorization Information

ISA

ID

YYMMDD HHMM

0, 1 P, T

ISA14 ISA15 ISA16

___

1

CCYYMMDD HHMM, HHMMSS, HHMMSSD, HHMMSSDD X 004010X096A1

GS GS01 GS02 GS03 GS04

GS05 GS06 GS07 GS08

1

R

1-1

R

ID

5-5

R

N0

9-9

R

Acknowledgement Requested ID Usage Indicator ID Component Element Separator AN

1-1 1-1

R R

1-1

R

1 2-2 2-15 2-15 8-8

R R R R R

FUNCTIONAL GROUP HEADER Functional Identifier Code Application Sender Code Application Receiver Code Date

Time Group Control Number Responsible Agency Code Version Identifier Code

Page 1 of 93

ID AN AN DT

TM N0 ID AN

4-8 1-9 1-2 1-12

R R R R

01, 14, 20, 27, 28, 29, 30, 33, ZZ

01, 14, 20, 27, 28, 29, 30, 33, ZZ YYMMDD HHMM

00501

0, 1 P, T

___

1

CCYYMMDD HHMM, HHMMSS, HHMMSSD, HHMMSSDD X 005010X223

Code Change

INSTITUTIONAL CLAIM


Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

837-I 4010A1 ST ST01 ST02

TRANSACTION SET HEADER Transaction Set Identifier Code Transaction Set Control Number

1

R

ID

3-3

R

AN

4-9

R

BHT BHT01 BHT02 BHT03 BHT04

BHT05 BHT06

REF REF01 REF02 REF03 REF04 NM1 NM101 NM102 NM103 NM104 NM105 NM106 NM107 NM108 NM109 NM110 NM111

Transaction Set Creation Time Claim or Encounter ID

___

>1

ST 837

ST01 ST02

TRANSMISSION TYPE IDENTIFICATION Reference Identification Qualifier Reference Identification Description Reference Identifier SUBMITTER NAME Entity Identifier Code Entity Type Qualifier Submitter Last or Organization Name Submitter First Name Submitter Middle Name Name Prefix Name Suffix Identification Code Qualifier Submitter Identifier Entity Relationship Code Entity Identifier Code

ID

1 4-4

R R

ID

2-2

R

AN

1-30

R

DT

8-8

R

CCYYMMDD

4-8 2-2

R R

HHMM, HHMMSS, HHMMSSD, HHMMSSDD CH, RP

1

S

ID AN AN

2-3 1-30 1-80

R R N/U N/U

ID ID

1 2-3 1-1

R R R

AN AN AN AN AN ID AN ID ID

1-35 1-25 1-25 1-10 1-10 1-2 2-80 2-2 2-3

R S S N/U N/U R R N/U N/U

TM ID

Min. Max.

Usage Reg.

Loop

Loop Repeat

___

>1

Values

837-I 5010

ST03 BEGINNING OF HIERARCHICAL TRANSACTION Hierarchical Structure Code Transaction Set Purpose Code Originator Application Transaction ID Transaction Set Creation Date

ID

___

1 0019

BHT BHT01

00, 18

BHT02 BHT03 BHT04

BHT05 BHT06

TRANSACTION SET HEADER Transaction Set Identifier Code Transaction Set Control Number Implementation Convention Reference BEGINNING OF HIERARCHICAL TRANSACTION Hierarchical Structure Code Transaction Set Purpose Code Originator Application Transaction ID Transaction Set Creation Date Transaction Set Creation Time Claim or Encounter ID

1

R

ID

3-3

R

AN

4-9

R

AN

1-35

R

ID

1 4-4

R R

ID

2-2

R

AN

1-50

R

DT

8-8

R

837

New Element

___

1 0019 00, 18 Increase from 30 - 50

TM ID

4-8 2-2

CCYYMMDD HHMM, HHMMSS, HHMMSSD, HHMMSSDD 31, CH, RP Code Added

R R

Segment Deleted

87

1000A

1 41 1, 2

46

NM1 NM101 NM102 NM103 NM104 NM105 NM106 NM107 NM108 NM109 NM110 NM111 NM112

SUBMITTER NAME Entity Identifier Code Entity Type Qualifier Submitter Last or Organization Name Submitter First Name Submitter Middle Name Name Prefix Name Suffix Identification Code Qualifier Submitter Identifier Entity Relationship Code Entity Identifier Code Name Last or Organization Name

Page 2 of 93

ID ID

1 2-3 1-1

R R R

AN AN AN AN AN ID AN ID ID

1-60 1-35 1-25 1-10 1-10 1-2 2-80 2-2 2-3

R S S N/U N/U R R N/U N/U

AN

1-60

N/U

1000A

1 41 1, 2 Increase from 35 - 60 Increase from 25 - 35

46

New Element

INSTITUTIONAL CLAIM


Description

PER PER01

SUBMITTER EDI CONTACT INFORMATION Contact Function Code

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

PER PER01

SUBMITTER EDI CONTACT INFORMATION Contact Function Code

837-I 4010A1 ID

2 2-2

R R

AN

1-60

R

ID AN

2-2 1-80

R R

PER07 PER08 PER09

Submitter Contact Name Communication Number Qualifier Communication Number Communication Number Qualifier Communication Number Communication Number Qualifier Communication Number Contact Inquiry Reference

ID AN AN

2-2 1-80 1-20

S S N/U

NM1 NM101 NM102 NM103 NM104 NM105 NM106 NM107 NM108 NM109 NM110 NM111

RECEIVER NAME Entity Identifier Code Entity Type Qualifier Receiver Name Name First Name Middle Name Prefix Name Suffix Identification Code Qualifier Receiver Primary Identifier Entity Relationship Code Entity Identifier Code

ID ID AN AN AN AN AN ID AN ID ID

1 2-3 1-1 1-35 1-25 1-25 1-10 1-10 1-2 2-80 2-2 2-3

R R R R N/U N/U N/U N/U R R N/U N/U

PER02 PER03 PER04 PER05 PER06

ID AN

2-2 1-80

HL HL01 HL02 HL03 HL04

PRV PRV01 PRV02 PRV03 PRV04

BILLING/PAY-TO PROVIDER SPECIALTY INFORMATION Provider Code Reference Identification Qualifier Provider Taxonomy Code State or Province Code

Min. Max.

Usage Reg.

Loop

Loop Repeat

Values

837-I 5010 1000A IC

PER02 ED, EM, FX. TE ED, EM, EX, FX, TE

S S

ED, EM, EX, FX, TE

1000B

1 40 2

46

PER03 PER04 PER05 PER06 PER07 PER08 PER09 NM1 NM101 NM102 NM103 NM104 NM105 NM106 NM107 NM108 NM109 NM110 NM111 NM112

BILLING/PAY-TO PROVIDER HIERARCHICAL LEVEL Hierarchical ID Number AN Hierarchical Parent ID Number AN Hierarchical Level Code ID Hierarchical Child Code ID

ID

Submitter Contact Name Communication Number Qualifier Communication Number Communication Number Qualifier Communication Number Communication Number Qualifier Communication Number Contact Inquiry Reference RECEIVER NAME Entity Identifier Code Entity Type Qualifier Receiver Name Name First Name Middle Name Prefix Name Suffix Identification Code Qualifier Receiver Primary Identifier Entity Relationship Code Entity Identifier Code Name Last or Organization Name

ID

2 2-2

R R

1000A

AN

1-60

S

ID 2-2 AN 1-256

R R

EM, FX. TE

ID 2-2 AN 1-256

S S

EM, EX, FX, TE

ID 2-2 AN 1-256 AN 1-20

S S N/U

EM, EX, FX, TE


1 2-3 1-1 1-60 1-35 1-25 1-10 1-10 1-2 2-80 2-2 2-3

R R R R N/U N/U N/U N/U R R N/U N/U

AN

1-60

N/U

IC Usage change to Situational Code deleted Increase from 80 - 256 Code deleted Increase from 80 - 256 Code deleted Increase from 80 - 256

1000B

1 40 2 Increase from 35 - 60 Increase from 25 - 35

46

New Element

Name Change 1 1-12

R R

1-12 1-2 1-1

N/U R R

2000A

>1

HL HL01

20 1

HL02 HL03 HL04

BILLING PROVIDER HIERARCHICAL LEVEL Hierarchical ID Number Hierarchical Parent ID Number Hierarchical Level Code Hierarchical Child Code

AN

1 1-12

R R

AN ID ID

1-12 1-2 1-1

N/U R R

2000A

>1

20 1 Name Change

ID

1 1-3

S R

ID AN ID

2-3 1-30 2-2

R R N/U

2000A BI, PT ZZ


BILLING PROVIDER SPECIALTY INFORMATION Provider Code ID Reference Identification Qualifier ID Provider Taxonomy Code AN State or Province Code ID

Page 3 of 93

1 1-3

S R

2-3 1-50 2-2

R R N/U

2000A BI

Code Deleted Code Change

PXC Increase from 30 - 50

INSTITUTIONAL CLAIM


Description

PRV05

PROVIDER SPECIALTY INFORMATION

PRV06

Provider Organization Code

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

837-I 4010A1

CUR CUR01 CUR02 CUR03 CUR04 CUR05 CUR06 CUR07 CUR08 CUR09 CUR10 CUR11 CUR12 CUR13 CUR14 CUR15 CUR16 CUR17 CUR18 CUR19 CUR20 CUR21

FOREIGN CURRENCY INFORMATION Entity Identifier Code Currency Code Exchange Rate Entity Identifier Code Currency Code Currency Market/Exchange Code Date/Time Qualifier Date Time Date/Time Qualifier Date Time Date/Time Qualifier Date Time Date/Time Qualifier Date Time Date/Time Qualifier Date Time

N/U

PRV05

ID

3-3

N/U

PRV06


ID ID R ID ID

1 2-3 3-3 4-10 2-3 3-3

S R R N/U N/U N/U

ID ID DT TM ID DT TM ID DT TM ID DT TM ID DT TM

3-3 3-3 8-8 4-8 3-3 8-8 4-8 3-3 8-8 4-8 3-3 8-8 4-8 3-3 8-8 4-8

N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U

ID ID

1 2-3 1-1

R R R

NM103 NM104

AN AN

1-35 1-25

R N/U

NM105 NM106

Name Middle Name Prefix

AN AN

1-25 1-10

NM107

Name Suffix

AN

1-10

NM108 NM109 NM110 NM111

Identification Code Qualifier Billing Provider Identifier Entity Relationship Code Entity Identifier Code

ID AN ID ID

1-2 2-80 2-2 2-3

Min. Max.

Usage Reg.

Loop Repeat

Values

2000A 85

CUR CUR01 CUR02 CUR03 CUR04 CUR05 CUR06 CUR07 CUR08 CUR09 CUR10 CUR11 CUR12 CUR13 CUR14 CUR15 CUR16 CUR17 CUR18 CUR19 CUR20 CUR21

FOREIGN CURRENCY INFORMATION Entity Identifier Code Currency Code Exchange Rate Entity Identifier Code Currency Code Currency Market/Exchange Code Date/Time Qualifier Date Time Date/Time Qualifier Date Time Date/Time Qualifier Date Time Date/Time Qualifier Date Time Date/Time Qualifier Date Time

N/U ID

3-3

N/U

ID ID R ID ID

1 2-3 3-3 4-10 2-3 3-3

S R R N/U N/U N/U

ID ID DT TM ID DT TM ID DT TM ID DT TM ID DT TM

3-3 3-3 8-8 4-8 3-3 8-8 4-8 3-3 8-8 4-8 3-3 8-8 4-8 3-3 8-8 4-8

N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U

ID ID

1 2-3 1-1

R R R

NM103 NM104

Billing Provider Name Entity Identifier Code Entity Type Qualifier Billing Provider Last or Organizational Name Billing Provider First Name

AN AN

1-60 1-35

R N/U

N/U N/U

NM105 NM106

Billing Provider Middle Name Name Prefix

AN AN

1-25 1-10

N/U N/U

N/U

NM107

Billing Provider Name Suffix

AN

1-10

N/U

R S N/U N/U

Loop

837-I 5010 PROVIDER SPECIALTY INFORMATION

Billing Provider Name Entity Identifier Code Entity Type Qualifier Billing Provider Last or Organizational Name Name First

NM1 NM101 NM102

ID

2010AA

1 85 2

24, 34, XX

NM1 NM101 NM102

NM108 NM109 NM110 NM111 NM112

Identification Code Qualifier Billing Provider Identifier Entity Relationship Code Entity Identifier Code Name Last or Organization Name

Page 4 of 93

2000A 85

2010AA

1 85 2 Increase from 35 - 60

ID AN ID ID

1-2 2-80 2-2 2-3

S S N/U N/U

AN

1-60

N/U

Increase from 25 - 35

XX

Code Deleted Usage change to Situational

New Element

INSTITUTIONAL CLAIM


Description

N3

BILLING PROVIDER ADDRESS

N301

Billing Provider Address Line

N302


ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

N3

BILLING PROVIDER ADDRESS

837-I 4010A1

N4 N401 N402 N403 N404 N405 N406

REF

REF01 REF02 REF03 REF04

BILLING PROVIDER CITY/STATE/ZIP CODE Billing Provider City Name Billing Provider State or Province Code Billing Provider Postal Zone or ZIP Code Country Code Location Qualifier Location Identifier

Reference Identification Qualifier Billing Provider Additional Identifier Description REFERENCE IDENTIFIER

REF02 REF03 REF04

CREDIT/DEBIT CARD BILLING INFORMATION Reference Identification Qualifier Billing Provider Additional Identifier Description REFERENCE IDENTIFIER

PER PER01

BILLING PROVIDER CONTACT INFORMATION Contact Function Code

REF REF01

PER02 PER03 PER04 PER05

R

AN

1-55

R

N301


AN

1-55

S

N302


AN

1 2-30

R R

ID

2-2

R

N402

ID ID ID AN

3-15 2-3 1-2 1-30

R S N/U N/U

N403 N404 N405 N406 N407

BILLING PROVIDER CITY/STATE/ZIP CODE Billing Provider City Name Billing Provider State or Province Code Billing Provider Postal Zone or ZIP Code Country Code Location Qualifier Location Identifier Country Subdivision Code

REF

BILLING PROVIDER TAX IDENTIFICATION

8

R

Min. Max.

Usage Reg.

Loop

Loop Repeat

Values

837-I 5010

1

BILLING PROVIDER TAX IDENTIFICATION

ID

2010AA

2010AA

N4 N401

2010AA 0B, 1A, 1B, 1C, 1D, 1G, 1H, 1J, B3, BQ, EI, FH, G2, G5, LU, SY, X5

ID

2-3

R

AN AN

1-30 1-80

R N/U N/U

8

S

ID

2-3

R

AN AN

1-30 1-80

R N/U N/U

ID

2 2-2

S R

1-60

R

2-2 1-80

R R

EM, FX, TE

2-2

S

EM, EX, FX, TE

1

R

AN

1-55

R

AN

1-55

S

AN

1 2-30

R R

ID

2-2

S

ID ID ID AN ID

3-15 2-3 1-2 1-30 1-3

S S N/U N/U S

1

R

2010AA

2010AA Usage change to Situational Usage change to Situational

New Element # Repeats change to 1 2010AA Code Deleted



ID

2-3

R

AN AN

1-50 1-80

R N/U N/U

EI Increase from 30 - 50

Segment Deleted

Billing Provider Contact Name AN Communication Number Qualifier ID Communication Number AN Communication Number Qualifier ID

2010AA 06, 8U, EM, IJ, LU, RB, ST, TT

2010AA IC

PER PER01 PER02 PER03 PER04 PER05

BILLING PROVIDER CONTACT INFORMATION Contact Function Code

ID

2 2-2

Billing Provider Contact Name AN 1-60 Communication Number Qualifier ID 2-2 Communication Number AN 1-256 Communication Number Qualifier ID 2-2

Page 5 of 93

S R

2010AA IC Usage change to Situational

S R R

EM, FX, TE

S

EM, EX, FX, TE


INSTITUTIONAL CLAIM


Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

837-I 4010A1 PER06 PER07 PER08 PER09

Communication Number Communication Number Qualifier Communication Number Contact Inquiry Reference

AN

1-80

S

ID AN AN

2-2 1-80 1-20

S S N/U

ID ID

1 2-3 1-1

S R R

NM103

PAY-TO PROVIDER NAME Entity Identifier Code Entity Type Qualifier Pay-to Provider Last or Organization Name

AN

1-35

N/U

NM104

Name First

AN

1-25

NM105 NM106

Name Middle Name Prefix

AN AN

NM107

Name Suffix

NM108 NM109 NM110 NM111

Identification Code Qualifier Pay-to Provider Identifier Entity Relationship Code Entity Identifier Code

NM1 NM101 NM102

ID

Min. Max.

Usage Reg.

Loop

Loop Repeat

Values

837-I 5010 PER06 EM, EX, FX, TE

PER07 PER08 PER09

Communication Number Communication Number Qualifier Communication Number Contact Inquiry Reference

AN 1-256

S

ID 2-2 AN 1-256 AN 1-20

S S N/U

ID ID

1 2-3 1-1

S R R

NM103

PAY-TO ADDRESS NAME Entity Identifier Code Entity Type Qualifier Pay-to Provider Last or Organization Name

AN

1-60

N/U

N/U

NM104

Pay-to Provider First Name

AN

1-35

N/U

1-25 1-10

N/U N/U

NM105 NM106

Pay-to Provider Middle Name AN Name Prefix AN

1-25 1-10

N/U N/U

AN

1-10

N/U

NM107

Pay-to Provider Name Suffix

AN

1-10

N/U

ID AN ID ID

1-2 2-80 2-2 2-3

N/U N/U N/U N/U

NM108 NM109 NM110 NM111

ID AN ID ID

1-2 2-80 2-2 2-3

N/U N/U N/U N/U

NM112

Identification Code Qualifier Pay-to Provider Identifier Entity Relationship Code Entity Identifier Code Name Last or Organization Name

AN

1-60

N/U

N3

PAY-TO PROVIDER ADDRESS

1

R

2010AB

1 87 2

NM1 NM101 NM102

Increase from 80 - 256 EM, EX, FX, TE Increase from 80 - 256

2010AB

Name Change

1 87 2

Increase from 35 - 60 Increase from 25 - 35 Name Change Name Change

Name Change

N3

PAY-TO PROVIDER ADDRESS

1

R

24, 34, XX

2010AB

Code Deleted

New Element

2010AB

N301

Pay-to Provider Address Line AN

1-55

R

N301


1-55

R

N302


1-55

S

N302


1-55

S

AN

1 2-30

R R

AN

1 2-30

R R

ID

2-2

R

N402

ID

2-2

S

Usage change to Situational Usage change to

ID

3-15

R

N403

ID

3-15

S

Situational

Pay-to Provider Country Code ID Location Qualifier ID Location Identifier AN

2-3 1-2 1-30

S N/U N/U

N404 N405 N406 N407

Pay-to Provider Country Code ID Location Qualifier ID Location Identifier AN Country Subdivision Code ID

2-3 1-2 1-30 1-3

S N/U N/U S

N4 N401 N402 N403 N404 N405 N406

REF

PAY-TO PROVIDER CITY/STATE/ZIP CODE Pay-to Provider City Name Pay-to Provider State Code Pay-to Provider Postal Zone or ZIP Code

PAY-TO PROVIDER SECONDARY IDENTIFICATION

5

S

2010AB

2010AB

N4 N401

PAY-TO PROVIDER CITY/STATE/ZIP CODE Pay-to Provider City Name Pay-to Provider State Code Pay-to Provider Postal Zone or ZIP Code

2010AB

New Element Segment Deleted

0B, 1A, 1B, 1C, 1D, 1G, 1H, 1J, B3, BQ, EI, FH, G2, G5, LU, SY, X5

Page 6 of 93

INSTITUTIONAL CLAIM


Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

837-I 4010A1 REF01 REF02 REF03 REF04


ID

2-3

R

AN AN

1-30 1-80

R N/U N/U

ID

Min. Max.

Usage Reg.

Loop

Loop Repeat

2010AC

1

Values

837-I 5010

NM1 NM101 NM102 NM103 NM104 NM105 NM106 NM107

PAY TO PLAN NAME Entity Identifier Code Entity Type Qualifier Pay to Plan Organizational Name Name First Name Middle Name Prefix Name Suffix

NM112

Identification Code Qualifier Identification Code Entity Relationship Code Entity Identifier Code Name Last or Organization Name

N3 N301 N302

PAY-TO PLAN ADDRESS Pay-to Plan Address Line Pay-to Plan Address Line

NM108 NM109 NM110 NM111

N4 N401 N402 N403 N404 N405 N406 N407

PAY-TO PLAN CITY/STATE/ZIP CODE Pay-to Plan City Name Pay-to Plan State Code Pay-to Plan Postal Zone or ZIP Code Pay-to Plan Country Code Location Qualifier Location Identifier Country Subdivision Code


SECONDARY IDENTIFICATION Reference Identification Qualifier Reference Identification Description REFERENCE IDENTIFIER

REF

PAY-TO PLAN TAX IDENTIFICATION

REF

Page 7 of 93

ID ID

1 2-3 1-1

S R R

AN AN AN AN AN

1-60 1-35 1-25 1-10 1-10

R N/U N/U N/U N/U

ID AN ID ID

1-2 2-80 2-2 2-3

R R N/U N/U

AN

1-60

N/U

1 1-55 1-55

R R S

2010AC

AN AN

R R S

2010AC

AN ID

1 2-30 2-2

ID ID ID AN ID

3-15 2-3 1-2 1-30 1-3

S S N/U N/U S

1

S

2-3 1-50 1-80

R R N/U N/U

1

R

New Segment PE 2

PI, XV

New Segment

New Segment

New Segment

ID AN AN

2010AC 2U, FY, NF

New Segment 2010AC

INSTITUTIONAL CLAIM


Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description


Reference Identification Qualifier Reference Identification Description REFERENCE IDENTIFIER

837-I 4010A1

HL HL01 HL02 HL03 HL04

SBR SBR01 SBR02 SBR03 SBR04 SBR05 SBR06 SBR07 SBR08

SUBSCRIBER HIERARCHICAL LEVEL Hierarchical ID Number Hierarchical Parent ID Number Hierarchical Level Code Hierarchical Child Code

AN

R R

AN ID ID

1-12 1-2 1-1

R R R

1

R

ID

1-1

R

P, S, T

SBR01

ID

2-2

S

18

SBR02

AN AN ID

1-30 1-60 1-3

S S N/U

SBR03 SBR04 SBR05

Coordination of Benefits Code ID Yes/No Condition or Response Code ID Employment Status Code ID

1-1

N/U

SBR06

1-1 2-2

N/U N/U

SBR07 SBR08

Individual Relationship Code Insured Group or Policy Number Insured Group Name Insurance Type Code

SBR09

Claim Filing Indicator Code

ID

1-2

S


SUBSCRIBER NAME Entity Identifier Code Entity Type Qualifier Subscriber Last Name Subscriber First Name Subscriber Middle Name Name Prefix Subscriber Name Suffix

ID ID AN AN AN AN AN

1 2-3 1-1 1-35 1-25 1-25 1-10 1-10

R R R R S S N/U S

Min. Max.

Usage Reg.

Loop

Loop Repeat

Values

837-I 5010

1 1-12

SUBSCRIBER INFORMATION Payer Responsibility Sequence Number Code

ID

2000B

>1

HL HL01

22 0, 1

2000B

SBR

09, 10, 11, 12, 13, 14, 15, 16, AM, BL, CH, CI, DS, HM, LI, LM, MA, MB, MC, OF, TV, VA, WC, ZZ 2010BA

HL02 HL03 HL04

1 IL 1, 2

ID AN AN

2-3 1-50 1-80

R R N/U N/U

AN

1 1-12

R R

AN ID ID

1-12 1-2 1-1

R R R

1

R

ID

1-1

R

ID

2-2

S

AN AN ID

1-50 1-60 1-3

S S N/U


1-1

N/U

1-1 2-2

N/U N/U

SUBSCRIBER HIERARCHICAL LEVEL Hierarchical ID Number Hierarchical Parent ID Number Hierarchical Level Code Hierarchical Child Code SUBSCRIBER INFORMATION Payer Responsibility Sequence Number Code Individual Relationship Code Insured Group or Policy Number Insured Group Name Insurance Type Code

EI

2000B

>1

22 0, 1

2000B A, B, C, D, E, F, Code Added G, H, P, S, T, U 18 Increase from 30 - 50

SBR09

Claim Filing Indicator Code

ID

1-2

S


SUBSCRIBER NAME Entity Identifier Code Entity Type Qualifier Subscriber Last Name Subscriber First Name Subscriber Middle Name Name Prefix Subscriber Name Suffix


1 2-3 1-1 1-60 1-35 1-25 1-10 1-10

R R R R S S N/U S

11, 12, 13, 14, 15, Code Change 16, 17, AM, BL, CH, CI, DS, FI, HM, LM, MA, MB, MC, OF, TV, VA, WC, ZZ 2010BA

1 IL 1, 2 Increase from 35 - 60 Increase from 25 - 35

Code Change Usage change to Required NM108

Identification Code Qualifier

ID

1-2

S

NM109 NM110

Subscriber Primary Identifier Entity Relationship Code

AN ID

2-80 2-2

S N/U

MI, ZZ

NM108


ID

1-2

R

NM109 NM110

Subscriber Primary Identifier Entity Relationship Code

AN ID

2-80 2-2

R N/U

II, MI Usage change to Required

Page 8 of 93

INSTITUTIONAL CLAIM


Description

NM111

Entity Identifier Code

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

N3 N301 N302

SUBSCRIBER ADDRESS Subscriber Address Line Subscriber Address Line

N4 N401

SUBSCRIBER CITY/STATE/ZIP CODE Subscriber City Name

N402 N403 N404 N405 N406

Subscriber State Code Subscriber Postal Zone or ZIP Code Subscriber Country Code Location Qualifier Location Identifier

DMG01 DMG02 DMG03 DMG04 DMG05 DMG06

SUBSCRIBER DEMOGRAPHIC INFORMATION Date Time Period Format Qualifier Subscriber Birth Date Subscriber Gender Code Marital Status Code Race or Ethnicity Code Citizenship Status Code

DMG07 DMG08 DMG09

Country Code Basis of Verification Code Quantity

DMG

REF REF01 REF02 REF03 REF04

REF

ID

2-3

N/U

NM112

Entity Identifier Code Name Last or Organization Name

AN

1-60

N/U

N3 N301 N302

SUBSCRIBER ADDRESS Subscriber Address Line Subscriber Address Line

1 1-55 1-55

S R S

2010BA

AN AN

N4 N401

SUBSCRIBER CITY/STATE/ZIP CODE Subscriber City Name

1 2-30

S R

2010BA

AN ID

2-2

S

ID ID ID AN ID

3-15 2-3 1-2 1-30 1-3

S S N/U N/U S

1

S

REF01

NM111

1 1-55 1-55

S R S

2010BA

S R

2010BA

AN

1 2-30

ID

2-2

R

N402

ID ID ID AN

3-15 2-3 1-2 1-30

R S N/U N/U

N403 N404 N405 N406 N407

1

S

ID AN ID ID ID ID

2-3 1-35 1-1 1-1 1-1 1-2

R R R N/U N/U N/U

ID ID R

2-3 1-2 1-15

N/U N/U N/U

ID

4

S

2-3

R

1-30 1-80

R N/U N/U

1

S

2-3

R

Loop

Loop Repeat

Values

837-I 5010

N/U

AN AN

SUBSCRIBER SECONDARY IDENTIFICATION Reference Identification Qualifier ID Subscriber Supplemental Identifier AN Description AN REFERENCE IDENTIFIER CASUALTY CLAIM NUMBER Reference Identification Qualifier

2-3

Usage Reg.

ID

837-I 4010A1 ID

Min. Max.

Description

2010BA

DMG01 DMG02 DMG03 DMG04 DMG05 DMG06

SUBSCRIBER DEMOGRAPHIC INFORMATION Date Time Period Format Qualifier Subscriber Birth Date Subscriber Gender Code Marital Status Code Race or Ethnicity Code Citizenship Status Code

ID AN ID ID ID ID

2-3 1-35 1-1 1-1 1-1 1-2

R R R N/U N/U N/U

DMG07 DMG08 DMG09 DMG10 DMG11

Country Code Basis of Verification Code Quantity Code List Qualifier Code Industry Code

ID ID R ID AN

2-3 1-2 1-15 1-3 1-30

N/U N/U N/U N/U N/U

1

S

2-3

R

1-50 1-80

R N/U N/U

1

S

2-3

R

DMG D8 CCYYMMDD F, M, U

2010BA

REF 1W, 23, IG, SY


2010BA

REF Y4

Subscriber State Code Subscriber Postal Zone or ZIP Code Subscriber Country Code Location Qualifier Location Identifier Country Subdivision Code

New Element

REF01

SUBSCRIBER SECONDARY IDENTIFICATION Reference Identification Qualifier ID Subscriber Supplemental Identifier AN Description AN REFERENCE IDENTIFIER CASUALTY CLAIM NUMBER Reference Identification Qualifier

Page 9 of 93

ID

Usage change to Situational Usage change to Situational

New Element

2010BA D8 CCYYMMDD F, M, U

New Element New Element

2010BA Code Deleted SY Increase rom 30 - 50

2010BA Y4

INSTITUTIONAL CLAIM


Description

REF02 REF03 REF04

Property Casualty Claim Number Description REFERENCE IDENTIFIER

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

REF02 REF03 REF04

Property Casualty Claim Number Description REFERENCE IDENTIFIER

837-I 4010A1

NM107

CREDIT/DEBIT CARD ACCOUNT HOLDER NAME Entity Identifier Code Entity Type Qualifier Credit or Debt Card Holder Last or Organization Name Credit or Debt Card Holder First Name Credit or Debt Card Holder Middle Name Name Prefix Credit or Debt Card Holder Name Suffix

NM108 NM109 NM110 NM111

Identification Code Qualifier Payer Identifier Entity Relationship Code Entity Identifier Code

NM1 NM101 NM102 NM103 NM104 NM105 NM106

AN AN

1-30 1-80

R N/U N/U

ID ID

1 2-3 1-1

S R R

AN

1-35

R

AN

1-25

S

AN AN

1-25 1-10

S N/U

AN

1-10

S

ID AN ID ID

1-2 2-80 2-2 2-3

R R N/U N/U

2

S

ID

2-3

R

AN AN

1-30 1-80

R N/U N/U


PAYER NAME Entity Identifier Code Entity Type Qualifier Payer Name Name First Name Middle Name Prefix Name Suffix


1 2-3 1-1 1-35 1-25 1-25 1-10 1-10

R R R R N/U N/U N/U N/U

NM108 NM109 NM110 NM111

Identification Code Qualifier Payer Identifier Entity Relationship Code Entity Identifier Code

ID AN ID ID

1-2 2-80 2-2 2-3

R R N/U N/U

N3

PAYER ADDRESS

Usage Reg.

Loop

Loop Repeat

Values

837-I 5010 Increase rom 30 - 50 AN AN

1-50 1-80

R N/U N/U

2010BB

1 AO 1, 2

MI

Segment Deleted

REF02 REF03 REF04

REF01

Min. Max.

Segment Deleted

CREDIT/DEBT CARD INFORMATION Reference Identification Qualifier Credit or Debt Card Authorization Number Description REFERENCE IDENTIFIER

REF

ID

1

S

2010BB AB, BB

2010BC

1 PR 2

PI, XV

2010BC


PAYER NAME Entity Identifier Code Entity Type Qualifier Payer Name Name First Name Middle Name Prefix Name Suffix

NM108 NM109 NM110 NM111 NM112

Identification Code Qualifier Payer Identifier Entity Relationship Code Entity Identifier Code Name Last or Organization Name

N3

PAYER ADDRESS

Page 10 of 93


1 2-3 1-1 1-60 1-35 1-25 1-10 1-10

R R R R N/U N/U N/U N/U

ID AN ID ID

1-2 2-80 2-2 2-3

R R N/U N/U

AN

1-60

N/U

1

S

2010BB

Loop Change

1 PR 2

Increase from 35 - 60 Increase from 25 - 35

PI, XV

New Element

2010BB

Loop Change

INSTITUTIONAL CLAIM


Description

N301 N302

Payer Address Line Payer Address Line

N4 N401

PAYER CITY/STATE/ZIP CODE Payer City Name

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Description

ID

N301 N302

Payer Address Line Payer Address Line

AN AN

1-55 1-55

R S

N4 N401

PAYER CITY/STATE/ZIP CODE Payer City Name

AN

1 2-30

R R

ID

2-2

S

ID ID ID AN ID

3-15 2-3 1-2 1-30 1-3

S S N/U N/U S

3

S

2-3 1-50 1-80

R R N/U N/U

837-I 4010A1

N402 N403 N404 N405 N406


Payer State Code Payer Postal Zone or ZIP Code Payer Country Code Location Qualifier Location Identifier

PAYER SECONDARY IDENTIFICATION Reference Identification Qualifier Payer Additional Identifier Description REFERENCE IDENTIFIER

1-55 1-55

R S

AN

1 2-30

R R

ID

2-2

R

N402

ID ID ID AN

3-15 2-3 1-2 1-30

R S N/U N/U

N403 N404 N405 N406 N407

ID AN AN

S

2-3 1-30 1-80

R R N/U N/U

2010BC

2010BC

REF 2U, FY, NF, TJ




RESPONSIBLE PARTY NAME Entity Identifier Code Entity Type Qualifier Payer Name Name First Name Middle Name Prefix Name Suffix

NM108 NM109 NM110 NM111

Identification Code Qualifier Identification Code Entity Relationship Code Entity Identifier Code

N3

RESPONSIBLE PARTY ADDRESS

Loop

Loop Repeat

Values

837-I 5010

AN AN

3

Min. Max.

Usage Reg.

Element Identifier

Payer State Code Payer Postal Zone or ZIP Code Payer Country Code Location Qualifier Location Identifier Country Subdivision Code PAYER SECONDARY IDENTIFICATION Reference Identification Qualifier Payer Additional Identifier Description REFERENCE IDENTIFIER BILLING PROVIDER SECONDARY IDENTIFICATION Reference Identification Qualifier Payer Additional Identifier Description REFERENCE IDENTIFIER

Loop Change 2010BB Usage change to Situational Usage change to Situational

New Element Loop Change 2010BB Code Change

ID AN AN

2U, EI, FY, NF Increase from 30 - 50

Segment Added

ID AN AN

1

S

2-3 1-50 1-80

R R N/U N/U

2010BB G2, LU

Segment Deleted ID ID AN AN AN AN AN

1 2-3 1-1 1-35 1-25 1-25 1-10 1-10

S R R R S S N/U S

ID AN ID ID

1-2 2-80 2-2 2-3

N/U N/U N/U N/U

1

S

2010BD

1 QD

Segment Deleted 2010BC

Page 11 of 93

INSTITUTIONAL CLAIM


Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

837-I 4010A1

N302

Responsible Party Address Line Responsible Party Address Line

N4

RESPONSIBLE PARTY CITY/STATE/ZIP CODE

N301

AN

1-55

R

AN

1-55

S

1

R

Responsible Party City Name AN

2-30

R

N402

Responsible Party State Code ID

2-2

R

ID

3-15

R

ID ID AN

2-3 1-2 1-30

S N/U N/U

AN

1 1-12

S R

AN ID ID

1-12 1-2 1-1

R R R

1

R

N404 N405 N406

Responsible Party ZIP Code Responsible Party Country Code Location Qualifier Location Identifier

HL02 HL03 HL04

PATIENT HIERARCHICAL LEVEL Hierarchical ID Number Hierarchical Parent ID Number Hierarchical Level Code Hierarchical Child Code

PAT

PATIENT INFORMATION

HL HL01

Min. Max.

Usage Reg.

Loop

Loop Repeat

Values

837-I 5010

Segment Deleted

N401

N403

ID

2010BC

2000C

>1

HL02 HL03 HL04

PATIENT HIERARCHICAL LEVEL Hierarchical ID Number Hierarchical Parent ID Number Hierarchical Level Code Hierarchical Child Code

PAT

PATIENT INFORMATION

HL HL01

23 0 2000C

AN

1 1-12

S R

AN ID ID

1-12 1-2 1-1

R R R

1

R

2000C

>1

23 0 2000C Code Deleted

ID ID ID ID

2-2 1-1 2-2 1-1

R N/U N/U N/U

PAT05 PAT06

Individual Relationship Code Patient Location Code Employment Status Code Student Status Code Date Time Period Format Qualifier Patient Unit orDeath Basis Date for

ID AN

2-3 1-35

N/U N/U

PAT07 PAT08 PAT09

Measurement Code Patient Weight Pregnancy Indicator

ID R ID

2-2 1-10 1-1

N/U N/U N/U

NM1 NM101 NM102 NM103

PATIENT NAME Entity Identifier Code Entity Type Qualifier Patient Last Name

ID ID AN

1 2-3 1-1 1-35

R R R R

PAT01 PAT02 PAT03 PAT04

01, 04, 05, 07, 10, 15, 17, 19, 20, 21, 22, 23, 24, 29, 32, 33, 36, 39, 40, 41, 43, 53, G8

2010CA

1 QC 1

ID ID ID ID

2-2 1-1 2-2 1-1

R N/U N/U N/U

PAT05 PAT06

Individual Relationship Code Patient Location Code Employment Status Code Student Status Code Date Time Period Format Qualifier Patient Unit orDeath Basis Date for

ID AN

2-3 1-35

N/U N/U

PAT07 PAT08 PAT09

Measurement Code Patient Weight Pregnancy Indicator

ID R ID

2-2 1-10 1-1

N/U N/U N/U

NM1 NM101 NM102 NM103

PATIENT NAME Entity Identifier Code Entity Type Qualifier Patient Last Name

ID ID AN

1 2-3 1-1 1-60

R R R R

PAT01 PAT02 PAT03 PAT04

Page 12 of 93

01, 19, 20, 21, 39, 40, 53, G8

2010CA

1 QC 1 Increase from 35 - 60

INSTITUTIONAL CLAIM


Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

837-I 4010A1 NM104 NM105 NM106 NM107

Patient First Name Patient Middle Name Name Prefix Patient Name Suffix

AN AN AN AN

1-25 1-25 1-10 1-10

ID

Min. Max.

Usage Reg.

Loop

Loop Repeat

Values

837-I 5010

R S N/U S

NM104 NM105 NM106 NM107

Patient First Name Patient Middle Name Name Prefix Patient Name Suffix

AN AN AN AN

1-35 1-25 1-10 1-10

Increase from 25 - 35 Usage change to Situational

S S N/U S

Code Deleted Usage change to Not Used NM108


ID

1-2

S

NM109 NM110 NM111

Patient Primary Identifier Entity Relationship Code Entity Identifier Code

AN ID ID

2-80 2-2 2-3

S N/U N/U

MI, ZZ

NM108


ID

1-2

N/U

NM109 NM110 NM111

AN ID ID

2-80 2-2 2-3

N/U N/U N/U

NM112

Patient Primary Identifier Entity Relationship Code Entity Identifier Code Name Last or Organization Name

AN

1-60

N/U

N3 N301 N302

PATIENT ADDRESS Patient Address Line Patient Address Line

1 1-55 1-55

R R S

2010CA

AN AN

N4 N401

PATIENT CITY/STATE/ZIP CODE Patient City Name

1 2-30

R R

2010CA

AN ID

2-2

S

ID ID ID AN ID

3-15 2-3 1-2 1-30 1-3

S S N/U N/U S

1

R

2-3 1-35 1-1 1-1 1-1 1-2 2-3 1-2 1-15 1-3 1-30

R R R N/U N/U N/U N/U N/U N/U N/U N/U

Usage change to Not Used

N3 N301 N302

PATIENT ADDRESS Patient Address Line Patient Address Line

N4 N401

PATIENT CITY/STATE/ZIP CODE Patient City Name

N402 N403 N404 N405 N406

DMG DMG01 DMG02 DMG03 DMG04 DMG05 DMG06 DMG07 DMG08 DMG09

Patient State Code Patient Postal Zone or ZIP Code Patient Country Code Location Qualifier Location Identifier

PATIENT DEMOGRAPHIC INFORMATION Date Time Period Format Qualifier Patient Birth Date Patient Gender Code Marital Status Code Race or Ethnicity Code Citizenship Status Code Country Code Basis of Verification Code Quantity

1 1-55 1-55

R R S

2010CA

AN AN

R R

2010CA

AN

1 2-30

ID

2-2

R

N402

ID ID ID AN

3-15 2-3 1-2 1-30

R S N/U N/U

N403 N404 N405 N406 N407

ID AN ID ID ID ID ID ID R

1

R

2-3 1-35 1-1 1-1 1-1 1-2 2-3 1-2 1-15

R R R N/U N/U N/U N/U N/U N/U

2010CA

DMG D8 CCYYMMDD F, M, U

DMG01 DMG02 DMG03 DMG04 DMG05 DMG06 DMG07 DMG08 DMG09 DMG10 DMG11

Patient State Code Patient Postal Zone or ZIP Code Patient Country Code Location Qualifier Location Identifier Country Subdivision Code PATIENT DEMOGRAPHIC INFORMATION Date Time Period Format Qualifier Patient Birth Date Patient Gender Code Marital Status Code Race or Ethnicity Code Citizenship Status Code Country Code Basis of Verification Code Quantity Code List Qualifier Code Industry Code

New Element

ID AN ID ID ID ID ID ID R ID AN


New Element

2010CA D8 CCYYMMDD F, M, U

New Element New Element Segment Deleted

REF

PATIENT SECONDARY IDENTIFICATION NUMBER

5

S

2010CA

Page 13 of 93

INSTITUTIONAL CLAIM


Description

REF01

Reference Identification Qualifier

REF02 REF03 REF04

Patient Secondary Identifier Description REFERENCE IDENTIFIER

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

837-I 4010A1

REF

PROPERTY AND CASUALTY CLAIM NUMBER Reference Identification Qualifier Property Casualty Claim Number Description REFERENCE IDENTIFIER

ID

2-3

R

AN AN

1-30 1-80

R N/U N/U

ID

2-3

R

AN AN

1-30 1-80

R N/U N/U

AN R ID

1 1-38 1-18 1-2

R R R N/U

ID

1-2

N/U R

CLM05

Facility Type Code Facility Code Qualifier Claim Frequency Code Provider or Supplier Signature Indicator

AN ID ID

1-2 1-2 1-1

R R R

A

CLM05-1 CLM05-2 CLM05-3

ID

1-1

N/U

N, Y

CLM06

ID

1-1

R

A, C

CLM07

CLM08

Medicare Assignment Code Benefits Assignment Certification Indicator

ID

1-1

R

N

CLM09

Release of Information Code

ID

1-1

R

A, I, M, N, O, Y

CLM CLM01 CLM02 CLM03 CLM04 CLM05 CLM05-1 CLM05-2 CLM05-3 CLM06

CLAIM INFORMATION Patient Account Number Total Claim Charge Amount Claim Filing Indicator Code Non-Institutional Claim Type Code HEALTH CARE SERVICE LOCATION INFORMATION

Usage Reg.

Loop

Loop Repeat

Values

1W, 23, IG, SY

S

REF02 REF03 REF04

Min. Max.

837-I 5010

1

REF01

ID

2010CA

REF Y4

1

S

ID

2-3

R

AN AN

1-50 1-80

R N/U N/U

AN R ID

1 1-38 1-18 1-2

R R R N/U

ID

1-2

N/U

Facility Type Code Facility Code Qualifier Claim Frequency Code Provider or Supplier Signature Indicator

AN ID ID

1-2 1-2 1-1

R R R

A

ID

1-1

N/U

N, Y

ID

1-1

R

A, B, C

CLM08

Medicare Assignment Code Benefits Assignment Certification Indicator

ID

1-1

R

N, W, Y

CLM09


ID

1-1

R

I, Y


2300

100

PROPERTY AND CASUALTY CLAIM NUMBER Reference Identification Qualifier Property Casualty Claim Number Description REFERENCE IDENTIFIER

CLM CLM01 CLM02 CLM03 CLM04

CLAIM INFORMATION Patient Account Number Total Claim Charge Amount Claim Filing Indicator Code Non-Institutional Claim Type Code HEALTH CARE SERVICE LOCATION INFORMATION

2010CA Y4 Increase from 30 - 50

2300

100

R

Code Added CLM07

Code Added Code Deleted

CLM10 CLM11

CLM12 CLM13 CLM14 CLM15

Patient Signature Source Code RELATED CAUSES INFORMATION

Special Program Indicator Yes/No Condition or Response Code Level of Service Code Yes/No Condition or Response Code

ID

1-1

N/U

CLM10

N/U

CLM11

ID

2-3

N/U

CLM12

ID ID

1-1 1-3

N/U N/U

CLM13 CLM14

ID

1-1

N/U

CLM15

Patient Signature Source Code RELATED CAUSES INFORMATION

Special Program Indicator Yes/No Condition or Response Code Level of Service Code Yes/No Condition or Response Code

Page 14 of 93

ID

1-1

S

P

Usage change to Situational Code Added

02, 03, 05, 09

Usage change to Situational Code Added

N/U

ID

2-3

S

ID ID

1-1 1-3

N/U N/U

ID

1-1

N/U

INSTITUTIONAL CLAIM


Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

CLM18 CLM19

Participation Agreement Claim Status Code Yes/No Condition or Response Code Claim Submission Reason Code

CLM20

Delay Reason Code

DTP DTP01

DATE - DISCHARGE HOUR Date Time Qualifier Date Time Period Format Qualifier Discharge Hour

ID ID

1-1 1-2

N/U N/U

ID

1-1

R

ID

2-2

N/U

ID

1-2

S

ID

1 3-3

S R

ID AN

2-3 1-35

R R

ID

1 3-3

R R

DTP02

DATE - STATEMENT DATES Date Time Qualifier Date Time Period Format Qualifier

ID

2-3

R

DTP03

Statement From or To Date

AN

1-35

R

ID

1 3-3

S R

ID

2-3

DTP02 DTP03

DTP DTP01

DTP DTP01 DTP02

DTP03

DATE - ADMISSION DATE/HOUR Date Time Qualifier Date Time Period Format Qualifier

Admission Date and Hour

AN

1-35

ID ID

1-1 1-2

N/U N/U

ID

1-1

N/U

ID

2-2

N/U

ID

1-2

S

ID

1 3-3

S R

ID AN

2-3 1-35

R R

ID

1 3-3

S R

ID

2-3

R

Statement From and To Date AN

1-35

R

ID

1 3-3

S R

ID

2-3

R

INSTITUTIONAL CLAIM CODE Admission Type Code Admission Source Code

CLM19 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11

CLM20

Delay Reason Code

96

DTP DTP01

TM HHMM

DTP02 DTP03

DATE - DISCHARGE HOUR Date Time Qualifier Date Time Period Format Qualifier Discharge Time

434

DTP DTP01

N, Y

2300

2300

CLM18

D8, RD8 CCYYMMDDCCY YMMDD

DTP03

435

DTP DTP01

R

DT

DTP02

R

CCYYMMDDHHM M

CL103 CL104

Patient Status Code Nursing Home Code

PWK

CLAIM SUPPLEMENTAL INFORMATION

ID ID

1 1-1 1-1

S S S

ID ID

1-2 1-1

S NU

10

S

Loop

Loop Repeat

Values

837-I 5010 Participation Agreement Claim Status Code Yes/No Condition or Response Code Claim Submission Reason Code

CLM16 CLM17

2300

DTP02

DTP03

2300

DATE - STATEMENT DATES Date Time Qualifier Date Time Period Format Qualifier

DATE - ADMISSION DATE/HOUR Date Time Qualifier Date Time Period Format Qualifier

Admission Date and Hour


1, 2, 3, 4, 5, 6, 7, Code Added 8, 9, 10, 11, 15

2300 96 TM HHMM

Name Change Usage change to Situational

2300 434

Code Deleted RD8 CCYYMMDDCCY Name Change YMMDD

2300 435 Code Added

AN

1-35

R

S R

D8, DT CCYYMMDD, Code Added CCYYMMDDHHM M New Segment

ID

1 3-3

DTP02 DTP03

DATE - REPRICER RECEIVED DATE Date Time Qualifier Date Time Period Format Qualifier Order Date

ID AN

2-3 1-35

R R

CL1 CL101 CL102

INSTITUTIONAL CLAIM CODE Admission Type Code Admission Source Code

ID ID

1 1-1 1-1

S S S

CL103 CL104

Patient Status Code Nursing Home Code

ID ID

1-2 1-1

R NU

PWK

CLAIM SUPPLEMENTAL INFORMATION

10

S

DTP DTP01

CL1 CL101 CL102

Usage Reg.

ID

837-I 4010A1 CLM16 CLM17

Min. Max.

Description

2300 050 D8 CCYYMMDD

2300

Usage change to Required

2300

Page 15 of 93

2300

INSTITUTIONAL CLAIM


Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

837-I 4010A1

ID

Min. Max.

Usage Reg.

Loop

Loop Repeat

Values

837-I 5010 Code Added

ID

2-2

R

PWK02 PWK03 PWK04

Attachment Report Type Code Attachment Transmission Code Report Copies Needed Entity Identifier Code

ID N0 ID

1-2 1-2 2-3

R N/U N/U

PWK05


ID

1-2

S

PWK06

Attachment Control Number

AN

2-80

PWK07 PWK08 PWK09

Description ACTIONS INDICATED Request Category Code

AN

1-80

ID

CN1

CONTRACT INFORMATION

PWK01

AS, B2, B3, B4, CT, DA, DG, DS, EB, MT, NN, OB, OZ, PN, PO, PZ, RB, RR, RT AA, BM, EL, EM, FX

ID

2-2

R

PWK02 PWK03 PWK04

Attachment Report Type Code Attachment Transmission Code Report Copies Needed Entity Identifier Code

ID N0 ID

1-2 1-2 2-3

R N/U N/U

PWK05


ID

1-2

S

S

PWK06

Attachment Control Number

AN

2-80

S

PWK07 PWK08 PWK09

Description ACTIONS INDICATED Request Category Code

AN

1-80

1-2

S N/U N/U

ID

1-2

N/U N/U N/U

1

S

CN1

CONTRACT INFORMATION

1

S

CN101 CN102 CN103 CN104 CN105 CN106

Contract Type Code Contract Amount Contract Percentage Contract Code Terms Discount Percent Contract Version Identifier

2-2 1-18 1-6 1-50 1-6 1-30

R S S S S S

AC

PWK01

03, 04, 05, 06, 07, 08, 09, 10, 11, 13, 15, 21, A3, A4, AM, AS, B2, B3, B4, BR, BS, BT, CB, CK, CT, D2, DA, DB, DG, DJ, DS, EB, HC, HR, I5, IR, LA, M1, MT, NN, OB, OC, OD, OE, OX, OZ, P4, P5, PE, PN, PO, PQ, PY, PZ, RB, RR, RT, RX, SG, V5, XP AA, BM, EL, EM, Code Added FT, FX

AC


CN101 CN102 CN103 CN104 CN105 CN106

Contract Type Code Contract Amount Contract Percentage Contract Code Terms Discount Percent Contract Version Identifier

AMT AMT01

ID R R AN R AN

2-2 1-18 1-6 1-30 1-6 1-30

R S S S S S

PAYER ESTIMATED AMOUNT DUE Amount Qualifier Code

ID

1 1-3

S R

AMT02 AMT03

Patient Responsibility Amount Credit/Debit Flag Code

R ID

1-18 1-1

R N/U

AMT AMT01

PATIENT ESTIMATED AMOUNT DUE Amount Qualifier Code

ID

1 1-3

S R

2300 01, 02, 03, 04, 05, 06, 09

ID R R AN R AN

2300 01, 02, 03, 04, 05, 06, 09


Segment Deleted 2300 C5

2300 F3

AMT AMT01

PATIENT ESTIMATED AMOUNT DUE Amount Qualifier Code

Page 16 of 93

ID

1 1-3

S R

2300 F3

INSTITUTIONAL CLAIM


Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

837-I 4010A1 Patient Responsibility Amount Credit/Debit Flag Code

R ID

1-18 1-1

R N/U

AMT AMT01 AMT02 AMT03

PATIENT PAID AMOUNT Amount Qualifier Code Patient Paid Amount Credit/Debit Flag Code

1 1-3 1-18 1-1

S R R N/U

2300

ID R ID

1 1-3

S R

2300

1-18 1-1

R N/U

1

S

2-3

R

4N

REF01

1-30 1-80

R N/U N/U

1, 2, 3, 4, 5, 6, 7

REF02 REF03 REF04

AMT02 AMT03


CREDIT/DEBIT CARD MAXIMUM AMOUNT Amount Qualifier Code ID Credit or Debit Card Maximum Amount R Credit/Debit Flag Code ID

SERVICE AUTHORIZATION EXCEPTION CODE Reference Identification Qualifier ID Service Authorization Exception Code AN Description AN REFERENCE IDENTIFIER

AMT02 AMT03

REF02 REF03 REF04

Prior Authorization Number Description REFERENCE IDENTIFIER

REF REF01 REF02 REF03

ORIGINAL REFERENCE NUMBER (ICN/DCN) Reference Identification Qualifier Claim Original Reference Number Description

Loop Repeat

Values

Patient Responsibility Amount Credit/Debit Flag Code

R ID

1-18 1-1

R N/U

Segment Deleted MA

2300

REF

REF02 REF03 REF04

REF01

Loop

Segment Deleted

REF01

PRIOR AUTHORIZATION Reference Identification Qualifier

Usage Reg.

F5

REF

REF

Min. Max.

837-I 5010

AMT02 AMT03

AMT AMT01

ID

2

S

ID

2-3

R

AN AN

1-30 1-80

R N/U N/U

1

S

ID

2-3

R

AN AN

1-30 1-80

R N/U

2300

REF 9F, G1


2300

REF F8

REF01 REF02 REF03

SERVICE AUTHORIZATION EXCEPTION CODE Reference Identification Qualifier ID Service Authorization Exception Code AN Description AN REFERENCE IDENTIFIER REFERRAL NUMBER Reference Identification Qualifier Prior Authorization or Referral Number Description REFERENCE IDENTIFIER

1

S

2-3

R

4N

1-50 1-80

R N/U N/U

1, 2, 3, 4, 5, 6, 7

1

S

ID

2-3

R

AN AN

1-50 1-80

R N/U N/U

1

S

2-3

R

1-50 1-80

R N/U N/U

1

S

ID

2-3

R

AN AN

1-50 1-80

R N/U

PRIOR AUTHORIZATION Reference Identification Qualifier ID Prior Authorization or Referral Number AN Description AN REFERENCE IDENTIFIER PAYER CLAIM CONTROL NUMBER Reference Identification Qualifier Claim Original Reference Number Description

Page 17 of 93

2300


New Segment

2300 9F

# Repeats change to 1 Code Deleted

2300 G1

Increase from 30 - 50 Name Change

Name Change 2300 F8 Increase from 30 - 50

INSTITUTIONAL CLAIM


Description

REF04

REFERENCE IDENTIFIER

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

REF04


837-I 4010A1






ADJUSTED REPRICED CLAIM NUMBER Reference Identification Qualifier Adjusted Repriced Claim Reference Number Description REFERENCE IDENTIFIER

1

S

2-3

R

1-30 1-80

R N/U N/U

1

S

ID

2-3

R

AN AN

1-30 1-80

R N/U N/U

1

S

2-3

R

1-30 1-80

R N/U N/U

INVESTIGATIONAL DEVICE EXEMPTION NUMBER Reference Identification Qualifier ID Investigational Device Exemption Number AN Description AN REFERENCE IDENTIFIER CLAIM IDENTIFIER FOR TRANSMISSION INTERMEDIARIES Reference Identification Qualifier Value Added Network Trace Number Description REFERENCE IDENTIFIER DOCUMENT IDENTIFICATION CODE Reference Identification Qualifier Document ControlIdentifier Description REFERENCE IDENTIFIER

1

S

ID

2-3

R

AN AN

1-30 1-80

R N/U N/U

2

S

2-3 1-30 1-80

R R N/U N/U

Min. Max.

Usage Reg.

Loop

Loop Repeat

Values

837-I 5010

N/U

REPRICED CLAIM NUMBER Reference Identification Qualifier ID Repriced Claim Reference Number AN Description AN REFERENCE IDENTIFIER

ID

2300

REF 9A


2300

REF 9C


2300

REF LX


2300

REF D9


N/U

REPRICED CLAIM NUMBER Reference Identification Qualifier ID Repriced Claim Reference Number AN Description AN REFERENCE IDENTIFIER

1

S

2-3

R

1-50 1-80

R N/U N/U

1

S

ID

2-3

R

AN AN

1-50 1-80

R N/U N/U

5

S

2-3

R

1-50 1-80

R N/U N/U

1

S

ID

2-3

R

Clearinghouse Trace Number AN Description AN REFERENCE IDENTIFIER

1-50 1-80

R N/U N/U

ADJUSTED REPRICED CLAIM NUMBER Reference Identification Qualifier Adjusted Repriced Claim Reference Number Description REFERENCE IDENTIFIER

9A Increase from 30 - 50

2300 9C Increase from 30 - 50

INVESTIGATIONAL DEVICE EXEMPTION NUMBER Reference Identification Qualifier ID Investigational Device Exemption Number AN Description AN REFERENCE IDENTIFIER CLAIM IDENTIFIER FOR TRANSMISSION INTERMEDIARIES Reference Identification Qualifier

2300

2300 LX Increase from 30 - 50

2300 D9 Increase from 30 - 50 Name Change

Segment Deleted

ID AN AN

2300 DD

REF

AUTO ACCIDENT STATE

Page 18 of 93

1

S

2300

New Segment

INSTITUTIONAL CLAIM


Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

837-I 4010A1

REF02 REF03 REF04




MEDICAL RECORD NUMBER Reference Identification Qualifier Medical Record Number Description REFERENCE IDENTIFIER DEMONSTRATION PROJECT IDENTIFIER Reference Identification Qualifier Demonstration Project Identifier Description REFERENCE IDENTIFIER PEER REVIEW ORGANIZARION (PRO) APPROVAL NUMBER Reference Identification Qualifier PRO Number Description REFERENCE IDENTIFIER

K303

FILE INFORMATION Fixed Format Information Record Format Code COMPOSITE UNIT OF MEASURE

NTE

CLAIM NOTE

K3 K301 K302

1

S

2-3 1-30 1-80

R R N/U N/U

1

S

ID

2-3

R

AN AN

1-30 1-80

R N/U N/U

ID AN AN

1

S

ID AN AN

2-3 1-30 1-80

R R N/U N/U

AN ID

10 1-80 1-2

S R N/U

2300

REF EA

2300

S

NTE01 NTE02

Note Reference Code Claim Note Text

ID AN

3-3 1-80

R R

NTE NTE01

BILLING NOTE Note Reference Code

ID

1 3-3

S R


REF P4


2300

REF G4

2300


2300 ALG, DCP, DGN, DME, MED, NTR, ODT, RHB, RLH, RNH, SET, SFM, SPT, UPI

2300 ADD

Reference Identification Qualifier Auto Accident State or Province Description REFERENCE IDENTIFIER MEDICAL RECORD NUMBER Reference Identification Qualifier Medical Record Number Description REFERENCE IDENTIFIER DEMONSTRATION PROJECT IDENTIFIER Reference Identification Qualifier Demonstration Project Identifier Description REFERENCE IDENTIFIER PEER REVIEW ORGANIZARION (PRO) APPROVAL NUMBER Reference Identification Qualifier PRO Number Description REFERENCE IDENTIFIER

K303

FILE INFORMATION Fixed Format Information Record Format Code COMPOSITE UNIT OF MEASURE

NTE

CLAIM NOTE

K3 K301 K302

N/U 10

Min. Max.

Usage Reg.

Loop

Loop Repeat

Values

837-I 5010 REF01

REF

ID

ID

2-3

R

AN AN

1-50 1-80

R N/U N/U

1

S

2-3 1-50 1-80

R R N/U N/U

1

S

ID

2-3

R

AN AN

1-50 1-80

R N/U N/U

1

S

ID AN AN

2-3 1-50 1-80

R R N/U N/U

AN ID

10 1-80 1-2

S R N/U

ID AN AN

2300 EA Increase from 30 - 50

2300 P4 Increase from 30 - 50

2300 G4 Increase from 30 - 50

2300

N/U 10

S

NTE01 NTE02

Note Reference Code Claim Note Text

ID AN

3-3 1-80

R R

NTE NTE01

BILLING NOTE Note Reference Code

ID

1 3-3

S R

Page 19 of 93

LU

2300 ALG, DCP, DGN, DME, MED, NTR, ODT, RHB, RLH, RNH, SET, SFM, SPT, UPI

2300 ADD

INSTITUTIONAL CLAIM


Description

NTE02

Billing Note Text

CR6

HOME HEALTH CARE INFORMATION

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

ID

NTE02

Billing Note Text

AN

837-I 4010A1

CR601 CR602 CR603 CR604 CR605 CR606

Prognosis Indicator Service From Date Date Time Period Format Qualifier Home Health Certification Period Diagnosis Date Skilled Nursing Facility Indicator

CR615 CR616

Medicare Coverage Indicator Certification Type Indicator Surgery Date Product or Service ID Qualifier Surgical Procedure Code Physician Order Date Last Visit Date Physician Contact Date Date Time Period Format Qualifier Last Admission Period

CR617 CR618 CR619 CR620 CR621

Patient Discharge Facility Type Code Diagnosis Date Diagnosis Date Diagnosis Date Diagnosis Date

CR607 CR608 CR609 CR610 CR611 CR612 CR613 CR614

AN

Min. Max.

Usage Reg.

Loop

Loop Repeat

Values

837-I 5010

1-80

R

1

S

ID DT

1-1 8-8

R R

1, 2, 3, 4, 5, 6, 7, 8 CCYYMMDD

ID

2-3

S

RD8

AN DT

1-35 8-8

S R

CCYYMMDD

ID

1-1

R

N, U, Y

ID ID DT

1-1 1-1 8-8

R R

N, Y I, R, S CCYYMMDD

ID AN DT DT DT

2-2 1-15 8-8 8-8 8-8

S S S S S

HC, ID

ID AN

2-3 1-35

S S

1-80

R Segment Deleted

ID DT DT DT DT

1-1 8-8 8-8 8-8 8-8

2300

CCYYMMDD CCYYMMDD CCYYMMDD RD8 A, B, C, D, E, F, G, H, L, M, O, R, S, T CCYYMMDD CCYYMMDD CCYYMMDD CCYYMMDD

R S S S S

Segment Deleted CRC CRC01 CRC02

HOME HEALTH FUNCTIONAL LIMITATIONS Code Category Certification Condition Indicator

ID

3 2-2

S R

ID

1-1

R

N, Y AA, AL, BL, CO, DY, EL, HL, LB, OL, PA, SL

CRC03

Functional Limitations Code

ID

2-2

R

CRC04


ID

2-2

S

CRC05


ID

2-2

S

CRC06


ID

2-2

S

CRC07


ID

2-2

S

2300 75

Page 20 of 93

INSTITUTIONAL CLAIM


Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

837-I 4010A1

ID

Min. Max.

Usage Reg.

Loop

Loop Repeat

Values

837-I 5010 Segment Deleted

CRC CRC01

HOME HEALTH FUNCTIONAL LIMITATIONS Code Category

ID

3 2-2

S R

CRC02


ID

1-1

R

N, Y BR, CA, CB, CR, EP, IH, NR, PW, TR, UT, WA, WR

CRC03

Activities Permitted Code

ID

2-2

R

CRC04


ID

2-2

S

CRC05


ID

2-2

S

CRC06


ID

2-2

S

CRC07


ID

2-2

S

2

S

2300 76

Segment Deleted

CRC01

HOME HEALTH MENTAL STATUS Certification Condition Indicator

ID

2-2

R

77

CRC02


ID

1-1

R

CRC03 CRC04 CRC05 CRC06 CRC07

Mental Status Code Mental Status Code Mental Status Code Mental Status Code Mental Status Code

ID ID ID ID ID

2-2 2-2 2-2 2-2 2-2

R S S S S

N, Y AG, CM, DI, DP, FO, LE, MC, OT

CRC

2300

CRC CRC01 CRC02 CRC03 CRC04 CRC05 CRC06 CRC07

EPSDT REFERRAL Code Category Certification Condition Indicator Condition Code Condition Code Condition Code Condition Indicator Condition Indicator

ID

1 2-2

S R

ID ID ID ID ID ID

1-1 2-3 2-3 2-3 2-3 2-3

R R S S N/U N/U

1

R

ID AN

1-3 1-30

R R R

ID AN R R AN

2-3 1-35 1-18 1-15 1-30

N/U N/U N/U N/U N/U

New Segment

2300 ZZ N, Y AV, NU, S2, ST AV, NU, S2, ST AV, NU, S2, ST

Usage change to Required HI HI01 HI01-1 HI01-2 HI01-3 HI01-4 HI01-5 HI01-6 HI01-7

PRINCIPAL DIAGNOSIS HEALTH CARE CODE INFORMATION Code List Qualifier Code Industry Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier

1

S

ID AN

1-3 1-30

R R R

ID AN R R AN

2-3 1-35 1-18 1-15 1-30

N/U N/U N/U N/U N/U

2300

HI

BK

HI01 HI01-1 HI01-2 HI01-3 HI01-4 HI01-5 HI01-6 HI01-7

PRINCIPAL DIAGNOSIS HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier

Page 21 of 93

2300

ABK, BK

Name Change Name Change

INSTITUTIONAL CLAIM


Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION

AN

1-30

N/U

ID

1-1

S

Loop

Loop Repeat

Values

837-I 5010 HI01-8 HI01-9

HI02

Usage Reg.

ID

837-I 4010A1

HEALTH CARE CODE INFORMATION

Min. Max.

Description

S

HI02

New Element New Element N, U, W, Y Usage change to Not Used

N/U Usage change to Not Used Name Change

HI02-1

Code List Qualifier Code

ID

1-3

R

BJ, ZZ

HI02-1

Diagnosis Type Code

ID

1-3


HI02-2 HI02-3 HI02-4 HI02-5 HI02-6 HI02-7

Industry Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier

AN

1-30

R

HI02-2

ID AN R R AN

2-3 1-35 1-18 1-15 1-30

N/U N/U N/U N/U N/U

HI02-3 HI02-4 HI02-5 HI02-6 HI02-7 HI02-8 HI02-9

HI03


S

HI03

Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION

AN

1-30

N/U

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30

N/U N/U N/U N/U N/U N/U

ID

1-1

N/U

New Element New Element Usage change to Not Used


HI03-1

Code List Qualifier Code

ID

1-3

R

BN

HI03-1

Diagnosis Type Code

ID

1-3


HI03-2 HI03-3 HI03-4 HI03-5 HI03-6 HI03-7

Industry Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier

AN

1-30

R

HI03-2

ID AN R R AN

2-3 1-35 1-18 1-15 1-30

N/U N/U N/U N/U N/U

HI03-3 HI03-4 HI03-5 HI03-6 HI03-7 HI03-8 HI03-9

HI04


N/U

HI04 HI04-1 HI04-2 HI04-3 HI04-4 HI04-5 HI04-6 HI04-7 HI04-8 HI04-9

Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator

Page 22 of 93

AN

1-30

N/U

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


ID

1-1

N/U

ID AN

1-3 1-30

N/U N/U N/U

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


ID

1-1

N/U


New Element New Element New Element New Element New Element New Element New Element New Element New Element

INSTITUTIONAL CLAIM


Description

HI05


ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

837-I 4010A1 N/U

HI05 HI05-1 HI05-2

HI05-9 HI06

N/U


HI07


N/U


HI08


N/U

Min. Max.

Usage Reg.

Loop

Loop Repeat

Values

837-I 5010

HI05-3 HI05-4 HI05-5 HI05-6 HI05-7 HI05-8


ID


HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier

Page 23 of 93

ID AN

1-3 1-30

N/U N/U N/U

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


ID

1-1

N/U

ID AN

1-3 1-30

N/U N/U N/U

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


ID

1-1

N/U

ID AN

1-3 1-30

N/U N/U N/U

ID AN R R

2-3 1-35 1-18 1-15

N/U N/U N/U N/U

AN AN

1-30 1-30

N/U N/U

ID

1-1

N/U

ID AN

1-3 1-30

N/U N/U N/U

ID AN R R AN

2-3 1-35 1-18 1-15 1-30

N/U N/U N/U N/U N/U




New Element New Element New Element New Element New Element New Element New Element

INSTITUTIONAL CLAIM


Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount

AN

1-30

N/U

ID

1-1

N/U

HI08-9 N/U

ID AN

1-3 1-30

N/U N/U N/U

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30



HI10


ID

1-1

N/U

N/U

ID AN

1-3 1-30

N/U N/U N/U

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30



HI11


ID

1-1

N/U

N/U

ID AN

1-3 1-30

N/U N/U N/U

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30



HI12


ID

1-1

N/U

N/U

ID AN

1-3 1-30

N/U N/U N/U

ID AN R

2-3 1-35 1-18

N/U N/U N/U

Loop

Loop Repeat

Values

837-I 5010 HI08-8

HI09

Usage Reg.

ID

837-I 4010A1


Min. Max.

Description

HI12 HI12-1 HI12-2 HI12-3 HI12-4 HI12-5

Page 24 of 93





New Element New Element New Element New Element New Element

INSTITUTIONAL CLAIM


Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

837-I 4010A1

ID

Min. Max.

Usage Reg.

Loop

Loop Repeat

Values

837-I 5010 HI12-6 HI12-7 HI12-8 HI12-9 HI HI01 HI01-1 HI01-2 HI01-3 HI01-4 HI01-5 HI01-6 HI01-7 HI01-8 HI01-9 HI02 HI02-1 HI02-2 HI02-3 HI02-4 HI02-5 HI02-6 HI02-7 HI02-8 HI02-9 HI03 HI03-1 HI03-2 HI03-3 HI03-4 HI03-5 HI03-6 HI03-7 HI03-8 HI03-9 HI04 HI04-1 HI04-2

Quantity Version Identifier Industry code Present on Admission indicator ADMITTING DISGNOSIS HEALTH CARE CODE INFORMATION Diagnosis Type Code Admitting Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code

Page 25 of 93

R AN AN

1-15 1-30 1-30

N/U N/U N/U

ID

1-1

N/U

1

R

ID AN

1-3 1-30

R R R

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


ID

1-1

N/U

ID AN

1-3 1-30

N/U N/U N/U

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


ID

1-1

N/U

ID AN

1-3 1-30

N/U N/U N/U

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


ID

1-1

N/U

ID AN

1-3 1-30

N/U N/U N/U

New Element New Element New Element New Element

New Segment

2300

ABJ, BJ

INSTITUTIONAL CLAIM


Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

837-I 4010A1

ID

Min. Max.

Usage Reg.

837-I 5010 HI04-3 HI04-4 HI04-5 HI04-6 HI04-7 HI04-8 HI04-9 HI05 HI05-1 HI05-2 HI05-3 HI05-4 HI05-5 HI05-6 HI05-7 HI05-8 HI05-9 HI06 HI06-1 HI06-2 HI06-3 HI06-4 HI06-5 HI06-6 HI06-7 HI06-8 HI06-9 HI07 HI07-1 HI07-2 HI07-3 HI07-4 HI07-5 HI07-6 HI07-7 HI07-8 HI07-9 HI08

Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION

Page 26 of 93

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


ID

1-1

N/U

ID AN

1-3 1-30

N/U N/U N/U

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


ID

1-1

N/U

ID AN

1-3 1-30

N/U N/U N/U

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


ID

1-1

N/U

ID AN

1-3 1-30

N/U N/U N/U

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


ID

1-1

N/U N/U

Loop

Loop Repeat

Values

INSTITUTIONAL CLAIM


Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Min. Max.

Usage Reg.

Description

ID

Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator

ID AN

1-3 1-30

N/U N/U

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


ID

1-1

N/U

ID AN

1-3 1-30

N/U N/U N/U

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


ID

1-1

N/U

ID AN

1-3 1-30

N/U N/U N/U

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


ID

1-1

N/U

ID AN

1-3 1-30

N/U N/U N/U

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


ID

1-1

N/U

837-I 4010A1

837-I 5010 HI08-1 HI08-2 HI08-3 HI08-4 HI08-5 HI08-6 HI08-7 HI08-8 HI08-9 HI09 HI09-1 HI09-2 HI09-3 HI09-4 HI09-5 HI09-6 HI09-7 HI09-8 HI09-9 HI10 HI10-1 HI10-2 HI10-3 HI10-4 HI10-5 HI10-6 HI10-7 HI10-8 HI10-9 HI11 HI11-1 HI11-2 HI11-3 HI11-4 HI11-5 HI11-6 HI11-7 HI11-8 HI11-9

Page 27 of 93

Loop

Loop Repeat

Values

INSTITUTIONAL CLAIM


Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

837-I 4010A1

ID

Min. Max.

Usage Reg.

Loop

Loop Repeat

Values

837-I 5010 HI12 HI12-1 HI12-2 HI12-3 HI12-4 HI12-5 HI12-6 HI12-7 HI12-8 HI12-9

HI HI01 HI01-1 HI01-2 HI01-3 HI01-4 HI01-5 HI01-6 HI01-7 HI01-8 HI01-9 HI02 HI02-1 HI02-2 HI02-3 HI02-4 HI02-5 HI02-6 HI02-7 HI02-8 HI02-9 HI03 HI03-1 HI03-2 HI03-3 HI03-4 HI03-5

HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator PATIENT REASON FOR VISIT HEALTH CARE CODE INFORMATION Diagnosis Type Code Patient Reason For Visit Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Diagnosis Type Code Patient Reason For Visit Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Diagnosis Type Code Patient Reason For Visit Date Time Period Format Qualifier Date Time Period Monetary Amount

Page 28 of 93

ID AN

1-3 1-30

N/U N/U N/U

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


ID

1-1

N/U

1

R

ID AN

1-3 1-30

R R R

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


ID

1-1

N/U

ID AN

1-3 1-30

S R R

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


ID

1-1

N/U

ID AN

1-3 1-30

S R R

ID AN R

2-3 1-35 1-18

N/U N/U N/U

New Segment 2300

APR, PR

APR, PR

APR, PR

INSTITUTIONAL CLAIM


Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

837-I 4010A1

ID

Min. Max.

Usage Reg.

837-I 5010 HI03-6 HI03-7 HI03-8 HI03-9 HI04 HI04-1 HI04-2 HI04-3 HI04-4 HI04-5 HI04-6 HI04-7 HI04-8 HI04-9 HI05 HI05-1 HI05-2 HI05-3 HI05-4 HI05-5 HI05-6 HI05-7 HI05-8 HI05-9 HI06 HI06-1 HI06-2 HI06-3 HI06-4 HI06-5 HI06-6 HI06-7 HI06-8 HI06-9 HI07 HI07-1 HI07-2 HI07-3

Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier

Page 29 of 93

R AN AN

1-15 1-30 1-30

N/U N/U N/U

ID

1-1

N/U

ID AN

1-3 1-30

N/U N/U N/U

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


ID

1-1

N/U

ID AN

1-3 1-30

N/U N/U N/U

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


ID

1-1

N/U

ID AN

1-3 1-30

N/U N/U N/U

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


ID

1-1

N/U

ID AN

1-3 1-30

N/U N/U N/U

ID

2-3

N/U

Loop

Loop Repeat

Values

INSTITUTIONAL CLAIM


Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Min. Max.

Usage Reg.

Description

ID

Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code

AN R R AN AN

1-35 1-18 1-15 1-30 1-30

N/U N/U N/U N/U N/U

ID

1-1

N/U

ID AN

1-3 1-30

N/U N/U N/U

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


ID

1-1

N/U

ID AN

1-3 1-30

N/U N/U N/U

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


ID

1-1

N/U

ID AN

1-3 1-30

N/U N/U N/U

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


ID

1-1

N/U

ID AN

1-3 1-30

N/U N/U N/U

837-I 4010A1

837-I 5010 HI07-4 HI07-5 HI07-6 HI07-7 HI07-8 HI07-9 HI08 HI08-1 HI08-2 HI08-3 HI08-4 HI08-5 HI08-6 HI08-7 HI08-8 HI08-9 HI09 HI09-1 HI09-2 HI09-3 HI09-4 HI09-5 HI09-6 HI09-7 HI09-8 HI09-9 HI10 HI10-1 HI10-2 HI10-3 HI10-4 HI10-5 HI10-6 HI10-7 HI10-8 HI10-9 HI11 HI11-1 HI11-2

Page 30 of 93

Loop

Loop Repeat

Values

INSTITUTIONAL CLAIM


Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

837-I 4010A1

ID

Min. Max.

Usage Reg.

Loop

Loop Repeat

Values

837-I 5010 HI11-3 HI11-4 HI11-5 HI11-6 HI11-7 HI11-8 HI11-9 HI12 HI12-1 HI12-2 HI12-3 HI12-4 HI12-5 HI12-6 HI12-7 HI12-8 HI12-9

HI HI01 HI01-1 HI01-2 HI01-3 HI01-4 HI01-5 HI01-6 HI01-7 HI01-8 HI01-9 HI02 HI02-1 HI02-2 HI02-3 HI02-4 HI02-5 HI02-6 HI02-7

Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator EXTERNAL CAUSE OF INJURY HEALTH CARE CODE INFORMATION Diagnosis Type Code External Cause of Injury Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code External Cause of Injury Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier

Page 31 of 93

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


ID

1-1

N/U

ID AN

1-3 1-30

N/U N/U N/U

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


ID

1-1

N/U

1

R

ID

1-3

R R

AN

1-30

R

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


ID

1-1

S

N, U, W, Y

ID

1-3

S R

ABN, BN

AN

1-30

R

ID AN R R AN

2-3 1-35 1-18 1-15 1-30

N/U N/U N/U N/U N/U

New Segment 2300

ABN, BN

INSTITUTIONAL CLAIM


Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Min. Max.

Usage Reg.

Loop Repeat

Description

ID

Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code

AN

1-30

N/U

ID

1-1

S

N, U, W, Y

ID

1-3

S R

ABN, BN

External Cause of Injury Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code

AN

1-30

R

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


ID

1-1

S

N, U, W, Y

ID

1-3

S R

ABN, BN

AN

1-30

R

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


ID

1-1

N/U

N, U, W, Y

ID AN

1-3 1-30

S R R

ABN, BN

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


ID

1-1

S

N, U, W, Y

ABN, BN

837-I 4010A1

Loop

Values

837-I 5010 HI02-8 HI02-9 HI03 HI03-1 HI03-2 HI03-3 HI03-4 HI03-5 HI03-6 HI03-7 HI03-8 HI03-9 HI04 HI04-1

HI06 HI06-1

External Cause of Injury Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code

ID

1-3

S R

HI06-2

External Cause of Injury Code AN

1-30

R

HI04-2 HI04-3 HI04-4 HI04-5 HI04-6 HI04-7 HI04-8 HI04-9 HI05 HI05-1 HI05-2 HI05-3 HI05-4 HI05-5 HI05-6 HI05-7 HI05-8 HI05-9

Page 32 of 93

INSTITUTIONAL CLAIM


Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

837-I 4010A1

ID

Min. Max.

Usage Reg.

Loop

Loop Repeat

Values

837-I 5010 HI06-3 HI06-4 HI06-5 HI06-6 HI06-7 HI06-8 HI06-9 HI07 HI07-1 HI07-2 HI07-3 HI07-4 HI07-5 HI07-6 HI07-7 HI07-8 HI07-9 HI08 HI08-1 HI08-2 HI08-3 HI08-4 HI08-5 HI08-6 HI08-7 HI08-8 HI08-9 HI09 HI09-1 HI09-2 HI09-3 HI09-4 HI09-5 HI09-6 HI09-7 HI09-8

Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code External Cause of Injury Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code External Cause of Injury Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code External Cause of Injury Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code

Page 33 of 93

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


ID

1-1

S

N, U, W, Y

ID

1-3

S R

ABN, BN

AN

1-30

R

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


ID

1-1

S

N, U, W, Y

ID

1-3

S R

ABN, BN

AN

1-30

R

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


ID

1-1

S

N, U, W, Y

ID

1-3

S R

ABN, BN

AN

1-30

R

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


INSTITUTIONAL CLAIM


Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

837-I 4010A1

HI10 HI10-1 HI10-2 HI10-3 HI10-4 HI10-5 HI10-6 HI10-7 HI10-8 HI10-9 HI11 HI11-1 HI11-2 HI11-3 HI11-4 HI11-5 HI11-6 HI11-7 HI11-8 HI11-9 HI12 HI12-1

R

2300

External Cause of Injury Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code External Cause of Injury Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code

HI12-9

HI

DIAGNOSIS RELATED GROUP (DRG) INFORMATION

HI12-3 HI12-4 HI12-5 HI12-6 HI12-7 HI12-8

1

Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code

External Cause of Injury Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator

HI12-2

HI

Min. Max.

Usage Reg.

Loop

Loop Repeat

Values

837-I 5010 HI09-9

DIAGNOSIS RELATED GROUP (DRG) INFORMATION

ID

Page 34 of 93

ID

1-1

S

N, U, W, Y

ID

1-3

S R

ABN, BN

AN

1-30

R

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


ID

1-1

S

N, U, W, Y

ID

1-3

S R

ABN, BN

AN

1-30

R

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


ID

1-1

S

N, U, W, Y

ID

1-3

S R

ABN, BN

AN

1-30

R

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


ID

1-1

S

1

R

N, U, W, Y

2300

INSTITUTIONAL CLAIM


Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

837-I 4010A1 HI01 HI01-1 HI01-2 HI01-3 HI01-4 HI01-5 HI01-6 HI01-7

HEALTH CARE CODE INFORMATION Code List Qualifier Code DRG Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier

ID AN

1-3 1-30

R R R

ID AN R R AN

2-3 1-35 1-18 1-15 1-30

N/U N/U N/U N/U N/U

HI02

S

DR

HI01 HI01-1 HI01-2 HI01-3 HI01-4 HI01-5 HI01-6 HI01-7 HI01-8


HI03


N/U


HI04


N/U

Min. Max.

Usage Reg.

Loop

Loop Repeat

Values

837-I 5010

HI01-9 HEALTH CARE CODE INFORMATION

ID


HEALTH CARE CODE INFORMATION Qualifier DRG Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code

Page 35 of 93

ID AN

1-3 1-30

R R R

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


ID

1-1

N/U

ID AN

1-3 1-30

S N/U N/U

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


ID

1-1

N/U

ID AN

1-3 1-30

N/U N/U N/U

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


ID

1-1

N/U

ID AN

1-3 1-30

N/U N/U N/U

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


DR

Name Change




New Element New Element New Element New Element New Element New Element New Element New Element

INSTITUTIONAL CLAIM


Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

837-I 4010A1 HEALTH CARE CODE INFORMATION

N/U


HI06


N/U


HI07


N/U


HI08


N/U

Min. Max.

Usage Reg.

Loop

Loop Repeat

Values

837-I 5010 HI04-9

HI05

ID

HI08 HI08-1 HI08-2 HI08-3 HI08-4 HI08-5 HI08-6

Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity

Page 36 of 93

New Element ID

1-1

N/U

ID AN

1-3 1-30

N/U N/U N/U

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


ID

1-1

N/U

ID AN

1-3 1-30

N/U N/U N/U

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


ID

1-1

N/U

ID AN

1-3 1-30

N/U N/U N/U

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


ID

1-1

N/U

ID AN

1-3 1-30

N/U N/U N/U

ID AN R R

2-3 1-35 1-18 1-15

N/U N/U N/U N/U




New Element New Element New Element New Element New Element New Element

INSTITUTIONAL CLAIM


Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period

AN AN

1-30 1-30

N/U N/U

ID

1-1

N/U

HI08-9 N/U

ID AN

1-3 1-30

N/U N/U N/U

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30



HI10


ID

1-1

N/U

N/U

ID AN

1-3 1-30

N/U N/U N/U

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30



HI11


ID

1-1

N/U

N/U

ID AN

1-3 1-30

N/U N/U N/U

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30



HI12


ID

1-1

N/U

N/U

ID AN

1-3 1-30

N/U N/U N/U

ID AN

2-3 1-35

N/U N/U

Loop

Loop Repeat

Values

837-I 5010 HI08-7 HI08-8

HI09

Usage Reg.

ID

837-I 4010A1


Min. Max.

Description

HI12 HI12-1 HI12-2 HI12-3 HI12-4

Page 37 of 93

New Element New Element New Element




New Element New Element New Element New Element

INSTITUTIONAL CLAIM


Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

837-I 4010A1

HI12-9


OTHER DIAGNOSIS INFORMATION HEALTH CARE CODE INFORMATION Code List Qualifier Code Other Diagnosis Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier

2

R

2300

HI

R ID AN

1-3 1-30

R R

ID AN R R AN

2-3 1-35 1-18 1-15 1-30

N/U N/U N/U N/U N/U

HI01 BF

HI01-1 HI01-2 HI01-3 HI01-4 HI01-5 HI01-6 HI01-7 HI01-8 HI01-9


HEALTH CARE CODE INFORMATION Code List Qualifier Code Other Diagnosis Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier

S ID AN

1-3 1-30

R R

ID AN R R AN

2-3 1-35 1-18 1-15 1-30

N/U N/U N/U N/U N/U

HI02 BF




S ID AN

1-3 1-30

R R

ID AN R R AN

2-3 1-35 1-18 1-15 1-30

N/U N/U N/U N/U N/U

Min. Max.

Usage Reg.

Loop

Loop Repeat

Values

837-I 5010 HI12-5 HI12-6 HI12-7 HI12-8

HI

ID

HI03 BF

HI03-1 HI03-2 HI03-3 HI03-4 HI03-5 HI03-6 HI03-7 HI03-8

Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator

R R AN AN

1-18 1-15 1-30 1-30

N/U N/U N/U N/U

ID

1-1

N/U

2

R

OTHER DIAGNOSIS INFORMATION HEALTH CARE CODE INFORMATION

2300

R

Diagnosis Type Code Other Diagnosis Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION

ID AN

1-3 1-30

R R

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


ID

1-1

S


ID AN

1-3 1-30

R R

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


ID

1-1

N/U

Diagnosis Type Code Other Diagnosis Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code

ID AN

1-3 1-30

R R

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


Page 38 of 93

New Element New Element New Element New Element New Element

ABF, BF

Name Change Code Added

New Element New Element N, U, W, Y

S ABF, BF



S ABF, BF


New Element

INSTITUTIONAL CLAIM


Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

837-I 4010A1

HI04-1 HI04-2 HI04-3 HI04-4 HI04-5 HI04-6 HI04-7


S ID AN

1-3 1-30

R R

ID AN R R AN

2-3 1-35 1-18 1-15 1-30

N/U N/U N/U N/U N/U

HI04 BF


Code List Qualifier Code Other Diagnosis Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier

1-3 1-30

R R

ID AN R R AN

2-3 1-35 1-18 1-15 1-30

N/U N/U N/U N/U N/U



ID AN

1-3 1-30

R R

ID AN R R AN

2-3 1-35 1-18 1-15 1-30

N/U N/U N/U N/U N/U


ID

1-1

N/U


ID AN

1-3 1-30

R R

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


ID

1-1

N/U

ID AN

1-3 1-30

R R

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


ID

1-1

N/U

HI07


HI07-1 HI07-2

Diagnosis Type Code Other Diagnosis

ID AN

HI05-1 HI05-2


HI07


HI07-1 HI07-2

Code List Qualifier Code Other Diagnosis

S ID AN

1-3 1-30

R R

Loop Repeat

Values

BF

Page 39 of 93

N, U, W, Y

S

2-3 1-35 1-18 1-15 1-30 1-30

HI06 BF

N/U

ID AN R R AN AN

HI05-3 HI05-4 HI05-5 HI05-6 HI05-7 HI05-8

S

1-1

R R


Loop

New Element ID

1-3 1-30

HI05 BF

Present on Admission indicator HEALTH CARE CODE INFORMATION

ID AN

HI04-3 HI04-4 HI04-5 HI04-6 HI04-7 HI04-8

S ID AN

Usage Reg.


HI04-1 HI04-2


Min. Max.

837-I 5010 HI03-9

HI04

ID

ABF, BF



S ABF, BF



S ABF, BF



S 1-3 1-30

R R

ABF, BF


INSTITUTIONAL CLAIM


Description

HI07-3 HI07-4 HI07-5 HI07-6 HI07-7

Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

837-I 4010A1 ID AN R R AN

2-3 1-35 1-18 1-15 1-30



N/U N/U N/U N/U N/U

HI07-3 HI07-4 HI07-5 HI07-6 HI07-7 HI07-8

S ID AN

1-3 1-30

R R

ID AN R R AN

2-3 1-35 1-18 1-15 1-30

N/U N/U N/U N/U N/U

HI08 BF




S ID AN

1-3 1-30

R R

ID AN R R AN

2-3 1-35 1-18 1-15 1-30

N/U N/U N/U N/U N/U

HI09 BF




S ID AN

1-3 1-30

R R

ID AN R R AN

2-3 1-35 1-18 1-15 1-30

N/U N/U N/U N/U N/U

Min. Max.

Usage Reg.

Loop

Loop Repeat

Values

837-I 5010


ID

HI10 BF


Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


ID

1-1

N/U

N, U, W, Y

S


ID AN

1-3 1-30

R R

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


ID

1-1

N/U


ID AN

1-3 1-30

R R

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


ID

1-1

N/U

Diagnosis Type Code Other Diagnosis Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code

ID AN

1-3 1-30

R R

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


Page 40 of 93


ABF, BF



S ABF, BF



S ABF, BF


New Element

INSTITUTIONAL CLAIM


Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

837-I 4010A1

HI11-1 HI11-2 HI11-3 HI11-4 HI11-5 HI11-6 HI11-7


S ID AN

1-3 1-30

R R

ID AN R R AN

2-3 1-35 1-18 1-15 1-30

N/U N/U N/U N/U N/U

HI11 BF




S ID AN

1-3 1-30

R R

ID AN R R AN

2-3 1-35 1-18 1-15 1-30

N/U N/U N/U N/U N/U

HI12 BF


HI HI01

PRINCIPAL PROCEDURE INFORMATION HEALTH CARE CODE INFORMATION

1

R

2300

HI

R

HI01

ID AN

1-3 1-30

R R

BP

HI01-1 HI01-2

HI01-3

Code List Qualifier Code Principal Procedure Code Date Time Period Format Qualifier

ID

2-3

S

D8

HI01-3

HI01-4 HI01-5 HI01-6 HI01-7

Date Time Period Monetary Amount Quantity Version Identifier

AN R R AN

1-35 1-18 1-15 1-30

S N/U N/U N/U

HI01-1 HI01-2

Min. Max.

Usage Reg.

Loop

Loop Repeat

Values

837-I 5010 HI10-9

HI11

ID

Present on Admission indicator HEALTH CARE CODE INFORMATION

New Element ID

1-1

N, U, W, Y

N/U S


ID AN

1-3 1-30

R R

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


ID

1-1

N/U

Diagnosis Type Code Other Diagnosis Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator

ID AN

1-3 1-30

R R

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


ID

1-1

N/U

1

R

ABF, BF



S

PRINCIPAL PROCEDURE INFORMATION HEALTH CARE CODE INFORMATION

ABF, BF



2300

R

Qualifier Principal Procedure Code Date Time Period Format Qualifier

ID AN

1-3 1-30

R R

ID

2-3

N/U

Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION

AN R R AN AN

1-35 1-18 1-15 1-30 1-30

N/U N/U N/U N/U N/U

ID

1-1

N/U

BBR, BR

Name Change Code Change Usage change to Not Used Usage change to Not Used

HI01-4 HI01-5 HI01-6 HI01-7 HI01-8 HI01-9

HI02


N/U

HI02

Page 41 of 93

N/U


INSTITUTIONAL CLAIM


Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator

ID AN

1-3 1-30

N/U N/U

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


ID

1-1

N/U

HI02-3 HI02-4 HI02-5 HI02-6 HI02-7 HI02-8 HI02-9 N/U

ID AN

1-3 1-30

N/U N/U N/U

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30



HI04


ID

1-1

N/U

N/U

ID AN

1-3 1-30

N/U N/U N/U

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30



HI05


ID

1-1

N/U

N/U

ID AN

1-3 1-30

N/U N/U N/U

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


ID

1-1

N/U

Loop

Loop Repeat

Values

837-I 5010 HI02-1 HI02-2

HI03

Usage Reg.

ID

837-I 4010A1


Min. Max.

Description


Page 42 of 93





INSTITUTIONAL CLAIM


Description

HI06


ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

837-I 4010A1 N/U

HI06 HI06-1 HI06-2

HI06-9 HI07

N/U


HI08


N/U


HI09


N/U

Min. Max.

Usage Reg.

Loop

Loop Repeat

Values

837-I 5010

HI06-3 HI06-4 HI06-5 HI06-6 HI06-7 HI06-8


ID


HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code

Page 43 of 93

ID AN

1-3 1-30

N/U N/U N/U

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


ID

1-1

N/U

ID AN

1-3 1-30

N/U N/U N/U

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


ID

1-1

N/U

ID AN

1-3 1-30

N/U N/U N/U

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


ID

1-1

N/U

ID AN

1-3 1-30

N/U N/U N/U

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30





New Element New Element New Element New Element New Element New Element New Element New Element

INSTITUTIONAL CLAIM


Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

837-I 4010A1 HEALTH CARE CODE INFORMATION

N/U


HI11


N/U


HI12


N/U


HI01

OTHER PROCEDURE INFORMATION HEALTH CARE CODE INFORMATION

HI01-1 HI01-2

Code List Qualifier Code Procedure Code

HI

2

R

2300

1-3 1-30

R R

BO, BQ

Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator

HI01

OTHER PROCEDURE INFORMATION HEALTH CARE CODE INFORMATION

HI01-1 HI01-2

Qualifier Code Procedure Code

HI

R ID AN

Min. Max.

Usage Reg.

Loop

Loop Repeat

Values

837-I 5010 HI09-9

HI10

ID

Page 44 of 93

New Element ID

1-1

N/U

ID AN

1-3 1-30

N/U N/U N/U

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


ID

1-1

N/U

ID AN

1-3 1-30

N/U N/U N/U

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


ID

1-1

N/U

ID AN

1-3 1-30

N/U N/U N/U

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


ID

1-1

N/U

2

R




2300

R ID AN

1-3 1-30

R R

BBQ, BQ

Name Change Code Change

INSTITUTIONAL CLAIM

4010A1 Description

HI01-3

Date Time Period Format Qualifier

ID

2-3

S

HI01-4 HI01-5 HI01-6 HI01-7


AN R R AN

1-35 1-18 1-15 1-30

S N/U N/U N/U

ID

Min. Max.

Usage Reg.

Element Identifier

5010 Loop

Loop Repeat

Element Identifier

Description

D8

HI01-3


CCYYMMDD

HI01-4 HI01-5 HI01-6 HI01-7 HI01-8

Values

837-I 4010A1

ID

Min. Max.

Usage Reg.

Loop

Loop Repeat

Values

837-I 5010 Usage change to Required ID

2-3

R

D8

Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION

AN R R AN AN

1-35 1-18 1-15 1-30 1-30

R N/U N/U N/U N/U

CCYYMMDD

ID

1-1

N/U

Qualifier Code Procedure Code Date Time Period Format Qualifier

ID AN

1-3 1-30

R R

BBQ, BQ

ID

2-3

R

D8


AN R R AN AN

1-35 1-18 1-15 1-30 1-30

R N/U N/U N/U N/U

CCYYMMDD

ID

1-1

N/U


ID AN

1-3 1-30

R R

BBQ, BQ

ID

2-3

R

D8


AN R R AN AN

1-35 1-18 1-15 1-30 1-30

R N/U N/U N/U N/U

CCYYMMDD

ID

1-1

N/U

ID AN

1-3 1-30

R R

BBQ, BQ

ID

2-3

R

D8

AN R

1-35 1-18

R N/U

CCYYMMDD


HI01-9 HI02


S

HI02

ID AN

1-3 1-30

R R

BO, BQ

HI02-1 HI02-2

HI02-3

Code List Qualifier Code Procedure Code Date Time Period Format Qualifier

ID

2-3

S

D8

HI02-3

HI02-4 HI02-5 HI02-6 HI02-7


AN R R AN

1-35 1-18 1-15 1-30

S N/U N/U N/U

CCYYMMDD

HI02-4 HI02-5 HI02-6 HI02-7 HI02-8

HI02-1 HI02-2


S Name Change Code Change Usage change to Required Usage change to Required

HI02-9 HI03


S

HI03

ID AN

1-3 1-30

R R

BO, BQ

HI03-1 HI03-2

HI03-3


ID

2-3

S

D8

HI03-3

HI03-4 HI03-5 HI03-6 HI03-7


AN R R AN

1-35 1-18 1-15 1-30

S N/U N/U N/U

CCYYMMDD

HI03-4 HI03-5 HI03-6 HI03-7 HI03-8

HI03-1 HI03-2



HI03-9 HI04


S

HI04

ID AN

1-3 1-30

R R

BO, BQ

HI04-1 HI04-2

HI04-3


ID

2-3

S

D8

HI04-3


HI04-4 HI04-5

Date Time Period Monetary Amount

AN R

1-35 1-18

S N/U

CCYYMMDD

HI04-4 HI04-5

Date Time Period Monetary Amount

HI04-1 HI04-2



Page 45 of 93

INSTITUTIONAL CLAIM


Description

HI04-6 HI04-7

Quantity Version Identifier

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

837-I 4010A1 R AN

1-15 1-30

HI05

HI04-6 HI04-7 HI04-8

S

HI05

ID AN

1-3 1-30

R R

BO, BQ

HI05-1 HI05-2

HI05-3


ID

2-3

S

D8

HI05-3

HI05-4 HI05-5 HI05-6 HI05-7


AN R R AN

1-35 1-18 1-15 1-30

S N/U N/U N/U

CCYYMMDD

HI05-4 HI05-5 HI05-6 HI05-7 HI05-8

HI05-1 HI05-2

Min. Max.

Usage Reg.

Loop

Loop Repeat

Values

837-I 5010

N/U N/U


ID

Quantity R Version Identifier AN Industry code AN Yes/No Condition or response Code ID HEALTH CARE CODE INFORMATION

1-15 1-30 1-30

N/U N/U N/U

1-1

N/U


S


ID AN

1-3 1-30

R R

BBQ, BQ

ID

2-3

R

D8


AN R R AN AN

1-35 1-18 1-15 1-30 1-30

R N/U N/U N/U N/U

CCYYMMDD

ID

1-1

N/U


ID AN

1-3 1-30

R R

BBQ, BQ

ID

2-3

R

D8


AN R R AN AN

1-35 1-18 1-15 1-30 1-30

R N/U N/U N/U N/U

CCYYMMDD

ID

1-1

N/U


ID AN

1-3 1-30

R R

BBQ, BQ

ID

2-3

R

D8

Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code

AN R R AN AN

1-35 1-18 1-15 1-30 1-30

R N/U N/U N/U N/U

CCYYMMDD

ID

1-1

N/U

Name Change Code Change Usage change to Required Usage change to Required

HI05-9 HI06


S

HI06

ID AN

1-3 1-30

R R

BO, BQ

HI06-1 HI06-2

HI06-3


ID

2-3

S

D8

HI06-3

HI06-4 HI06-5 HI06-6 HI06-7


AN R R AN

1-35 1-18 1-15 1-30

S N/U N/U N/U

CCYYMMDD

HI06-4 HI06-5 HI06-6 HI06-7 HI06-8

HI06-1 HI06-2



HI06-9 HI07


S

HI07

ID AN

1-3 1-30

R R

BO, BQ

HI07-1 HI07-2

HI07-3


ID

2-3

S

D8

HI07-3

HI07-4 HI07-5 HI07-6 HI07-7


AN R R AN

1-35 1-18 1-15 1-30

S N/U N/U N/U

CCYYMMDD

HI07-4 HI07-5 HI07-6 HI07-7 HI07-8

HI07-1 HI07-2



HI07-9

Page 46 of 93


INSTITUTIONAL CLAIM


Description

HI08


ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

HI08


837-I 4010A1

Min. Max.

Usage Reg.

Loop

Loop Repeat

Values

837-I 5010

S ID AN

1-3 1-30

R R

BO, BQ

HI08-1 HI08-2

HI08-3


ID

2-3

S

D8

HI08-3

HI08-4 HI08-5 HI08-6 HI08-7


AN R R AN

1-35 1-18 1-15 1-30

S N/U N/U N/U

CCYYMMDD

HI08-4 HI08-5 HI08-6 HI08-7 HI08-8

HI08-1 HI08-2

ID

S


ID AN

1-3 1-30

R R

BBQ, BQ

ID

2-3

R

D8


AN R R AN AN

1-35 1-18 1-15 1-30 1-30

R N/U N/U N/U N/U

CCYYMMDD

ID

1-1

N/U


ID AN

1-3 1-30

R R

BBQ, BQ

ID

2-3

R

D8


AN R R AN AN

1-35 1-18 1-15 1-30 1-30

R N/U N/U N/U N/U

CCYYMMDD

ID

1-1

N/U


ID AN

1-3 1-30

R R

BBQ, BQ

ID

2-3

R

D8

AN R R AN AN

1-35 1-18 1-15 1-30 1-30

R N/U N/U N/U N/U

CCYYMMDD

ID

1-1

N/U

HI11


HI11-1 HI11-2

Qualifier Code Procedure Code

ID AN

Name Change Code Change Usage change to Required Usage change to Required

HI08-9 HI09


S

HI09

ID AN

1-3 1-30

R R

BO, BQ

HI09-1 HI09-2

HI09-3


ID

2-3

S

D8

HI09-3

HI09-4 HI09-5 HI09-6 HI09-7


AN R R AN

1-35 1-18 1-15 1-30

S N/U N/U N/U

CCYYMMDD

HI09-4 HI09-5 HI09-6 HI09-7 HI09-8

HI09-1 HI09-2



HI09-9 HI10


S

HI10

ID AN

1-3 1-30

R R

BO, BQ

HI10-1 HI10-2

HI10-3


ID

2-3

S

D8

HI10-3

HI10-4 HI10-5 HI10-6 HI10-7


AN R R AN

1-35 1-18 1-15 1-30

S N/U N/U N/U

CCYYMMDD

HI10-4 HI10-5 HI10-6 HI10-7 HI10-8

HI10-1 HI10-2



HI10-9 HI11


HI11-1 HI11-2

Code List Qualifier Code Procedure Code

S ID AN

1-3 1-30

R R

BO, BQ

Page 47 of 93


S 1-3 1-30

R R

BBQ, BQ

Name Change Code Change

INSTITUTIONAL CLAIM

4010A1 Description

HI11-3


ID

2-3

S

HI11-4 HI11-5 HI11-6 HI11-7


AN R R AN

1-35 1-18 1-15 1-30

S N/U N/U N/U

ID

Min. Max.

Usage Reg.

Element Identifier

5010 Loop

Loop Repeat

Element Identifier

Description

D8

HI11-3


CCYYMMDD

HI11-4 HI11-5 HI11-6 HI11-7 HI11-8

Values

837-I 4010A1

ID

Min. Max.

Usage Reg.

Loop

Loop Repeat

Values

837-I 5010 Usage change to Required ID

2-3

R

D8


AN R R AN AN

1-35 1-18 1-15 1-30 1-30

R N/U N/U N/U N/U

CCYYMMDD

ID

1-1

N/U


ID AN

1-3 1-30

R R

BBQ, BQ

ID

2-3

R

D8


AN R R AN AN

1-35 1-18 1-15 1-30 1-30

R N/U N/U N/U N/U

CCYYMMDD

ID

1-1

N/U

2

R

ID AN

1-3 1-30

R R R

ID

2-3

R

AN R R AN AN

1-35 1-18 1-15 1-30 1-30

R N/U N/U N/U N/U

ID

1-1

N/U

ID AN

1-3 1-30

S R R

HI02-3

Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Occurrence Span Code Date Time Period Format Qualifier

ID

2-3

R

HI02-4

Date Time Period

AN

1-35

R


HI11-9 HI12


S

HI12

ID AN

1-3 1-30

R R

BO, BQ

HI12-1 HI12-2

HI12-3


ID

2-3

S

D8

HI12-3

HI12-4 HI12-5 HI12-6 HI12-7


AN R R AN

1-35 1-18 1-15 1-30

S N/U N/U N/U

CCYYMMDD

HI12-4 HI12-5 HI12-6 HI12-7 HI12-8

HI12-1 HI12-2



HI12-9

HI01-3

OCCURRENCE SPAN INFORMATION HEALTH CARE CODE INFORMATION Code List Qualifier Code Occurrence Span Code Date Time Period Format Qualifier

HI01-4 HI01-5 HI01-6 HI01-7


HI HI01 HI01-1 HI01-2

2

S

ID AN

1-3 1-30

R R R

ID

2-3

R

AN R R AN

1-35 1-18 1-15 1-30

R N/U N/U N/U

2300

HI

BI

RD8 CCYYMMDDCCYYMMDD


ID AN

1-3 1-30

S R R

HI02-3

HEALTH CARE CODE INFORMATION Code List Qualifier Code Occurrence Span Code Date Time Period Format Qualifier

ID

2-3

R

HI02-4

Date Time Period

AN

1-35

R

HI02 HI02-1 HI02-2

BI


HI02 HI02-1 HI02-2

OCCURRENCE SPAN INFORMATION HEALTH CARE CODE INFORMATION Qualifier Occurrence Span Code Date Time Period Format Qualifier

Page 48 of 93


Usage change to Required 2300

BI

Name Change



BI


Name Change

INSTITUTIONAL CLAIM


Description

HI02-5 HI02-6 HI02-7

Monetary Amount Quantity Version Identifier

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

837-I 4010A1 R R AN

1-18 1-15 1-30

HI03 HI03-1 HI03-2

ID AN

1-3 1-30

S R R

ID

2-3

R

AN R R AN AN

1-35 1-18 1-15 1-30 1-30

R N/U N/U N/U N/U

ID

1-1

N/U

ID AN

1-3 1-30

S R R

HI04-3

Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Code List Qualifier Code Occurrence Span Code Date Time Period Format Qualifier

ID

2-3

R

HI04-4 HI04-5 HI04-6 HI04-7


AN R R AN

1-35 1-18 1-15 1-30

R N/U N/U N/U

HI03-3 HI03-4 HI03-5 HI03-6 HI03-7 HI03-8 HI03-9 HI04 HI04-1 HI04-2

HI02-5 HI02-6 HI02-7 HI02-8

BI



BI



ID AN

1-3 1-30

S R R

HI05-3


ID

2-3

R

HI05-4 HI05-5 HI05-6 HI05-7


AN R R AN

1-35 1-18 1-15 1-30

R N/U N/U N/U

HI05 HI05-1 HI05-2

BI



HI06


S

Min. Max.

Usage Reg.

Loop

Loop Repeat

Values

837-I 5010

N/U N/U N/U

HI02-9 HEALTH CARE CODE INFORMATION Code List Qualifier Code Occurrence Span Code Date Time Period Format Qualifier

ID

HI06

Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Occurrence Span Code Date Time Period Format Qualifier

R R AN AN

1-18 1-15 1-30 1-30

N/U N/U N/U N/U

ID

1-1

N/U

ID AN

1-3 1-30

S R R

ID

2-3

R


AN R R AN AN

1-35 1-18 1-15 1-30 1-30

R N/U N/U N/U N/U

ID

1-1

N/U

ID AN

1-3 1-30

S R R

ID

2-3

R


AN R R AN AN

1-35 1-18 1-15 1-30 1-30

R N/U N/U N/U N/U

ID

1-1

N/U

ID AN

1-3 1-30

S R R

ID

2-3

R


AN R R AN AN

1-35 1-18 1-15 1-30 1-30

R N/U N/U N/U N/U

ID

1-1

N/U

Page 49 of 93

S


BI

Name Change



BI

Name Change

RD8 CCYYMMDDCCY YMMDD


BI

Name Change



INSTITUTIONAL CLAIM


Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

ID AN

1-3 1-30

R R

BI

ID

2-3

R


AN R R AN AN

1-35 1-18 1-15 1-30 1-30

R N/U N/U N/U N/U


ID

1-1

N/U

ID AN

1-3 1-30

S R R

ID

2-3

R


AN R R AN AN

1-35 1-18 1-15 1-30 1-30

R N/U N/U N/U N/U

ID

1-1

N/U

ID AN

1-3 1-30

S R R

ID

2-3

R

AN R R AN AN

1-35 1-18 1-15 1-30 1-30

R N/U N/U N/U N/U

ID

1-1

N/U

ID AN

1-3 1-30

S R R

HI09-3


ID

2-3

R

HI09-4 HI09-5 HI09-6

Date Time Period Monetary Amount Quantity

AN R R

1-35 1-18 1-15

R N/U N/U

1-3 1-30

R R

BI

HI06-1 HI06-2

HI06-3

ID

2-3

R

HI06-3

HI06-4 HI06-5 HI06-6 HI06-7


AN R R AN

1-35 1-18 1-15 1-30

R N/U N/U N/U


HI06-4 HI06-5 HI06-6 HI06-7 HI06-8 HI06-9

ID AN

1-3 1-30

S R R

HI07-3

ID

2-3

R

HI07-4 HI07-5 HI07-6 HI07-7


AN R R AN

1-35 1-18 1-15 1-30

R N/U N/U N/U

BI



ID AN

1-3 1-30

S R R

HI08-3


ID

2-3

R

HI08-4 HI08-5 HI08-6 HI08-7


AN R R AN

1-35 1-18 1-15 1-30

R N/U N/U N/U

HI08 HI08-1 HI08-2

BI



ID AN

1-3 1-30

S R R

HI09-3


ID

2-3

R

HI09-4 HI09-5 HI09-6

Date Time Period Monetary Amount Quantity

AN R R

1-35 1-18 1-15

R N/U N/U

HI09 HI09-1 HI09-2

Loop

Values

837-I 5010

ID AN

HI07 HI07-1 HI07-2

Loop Repeat

Qualifier Occurrence Span Code Date Time Period Format Qualifier

837-I 4010A1


Usage Reg.

ID

Code List Qualifier Code Occurrence Span Code Date Time Period Format Qualifier

HI06-1 HI06-2

Min. Max.

Description

BI


HI09 HI09-1 HI09-2

Page 50 of 93

Name Change


BI

Name Change



BI

Name Change



BI


Name Change

INSTITUTIONAL CLAIM


Description

HI09-7

Version Identifier

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

1-30

Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Occurrence Span Code Date Time Period Format Qualifier

AN AN

1-30 1-30

N/U N/U

ID

1-1

N/U

ID AN

1-3 1-30

S R R

ID

2-3

R


AN R R AN AN

1-35 1-18 1-15 1-30 1-30

R N/U N/U N/U N/U

ID

1-1

N/U

ID AN

1-3 1-30

S R R

ID

2-3

R


AN R R AN AN

1-35 1-18 1-15 1-30 1-30

R N/U N/U N/U N/U

ID

1-1

N/U

ID AN

1-3 1-30

S R R

ID

2-3

R

AN R R AN AN

1-35 1-18 1-15 1-30 1-30

R N/U N/U N/U N/U

HI12-9


ID

1-1

N/U

HI

OCCURRENCE INFORMATION

2

R

HI09-7 HI09-8 HI09-9

ID AN

1-3 1-30

S R R

HI10-3

ID

2-3

R

HI10-4 HI10-5 HI10-6 HI10-7


AN R R AN

1-35 1-18 1-15 1-30

R N/U N/U N/U

HI10 HI10-1 HI10-2

BI



ID AN

1-3 1-30

S R R

HI11-3


ID

2-3

R

HI11-4 HI11-5 HI11-6 HI11-7


AN R R AN

1-35 1-18 1-15 1-30

R N/U N/U N/U

HI11 HI11-1 HI11-2

BI



ID AN

1-3 1-30

S R R

HI12-3


ID

2-3

R

HI12-4 HI12-5 HI12-6 HI12-7


AN R R AN

1-35 1-18 1-15 1-30

R N/U N/U N/U

HI12 HI12-1 HI12-2

HI

OCCURRENCE INFORMATION

2

R

Loop

Loop Repeat

Values

837-I 5010

N/U


Usage Reg.

ID

837-I 4010A1 AN

Min. Max.

Description

BI


2300


Page 51 of 93


BI

Name Change



BI

Name Change



BI

Name Change



2300

INSTITUTIONAL CLAIM


Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description


HEALTH CARE CODE INFORMATION Code List Qualifier Code Occurrence Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier

ID AN

1-3 1-30

R R R

ID AN R R AN

2-3 1-35 1-18 1-15 1-30

R R N/U N/U N/U


ID AN

1-3 1-30

S R R

ID AN R R AN

2-3 1-35 1-18 1-15 1-30

R R N/U N/U N/U

BH

D8 CCYYMMDD


BH

D8 CCYYMMDD




ID AN

1-3 1-30

S R R

ID AN R R AN

2-3 1-35 1-18 1-15 1-30

R R N/U N/U N/U

BH

D8 CCYYMMDD




ID AN

1-3 1-30

S R R

ID AN R R AN

2-3 1-35 1-18 1-15 1-30

R R N/U N/U N/U

Min. Max.

Usage Reg.

Loop

Loop Repeat

Values

837-I 5010

HI01-9 HEALTH CARE CODE INFORMATION Code List Qualifier Code Occurrence Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier

ID

BH

D8 CCYYMMDD


HEALTH CARE CODE INFORMATION Qualifier Occurrence Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Occurrence Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Occurrence Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Occurrence Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code

Page 52 of 93

ID AN

1-3 1-30

R R R

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30

R R N/U N/U N/U N/U

ID

1-1

N/U

ID AN

1-3 1-30

S R R

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30

R R N/U N/U N/U N/U

ID

1-1

N/U

ID AN

1-3 1-30

S R R

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30

R R N/U N/U N/U N/U

ID

1-1

N/U

ID AN

1-3 1-30

S R R

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30

R R N/U N/U N/U N/U

BH

Name Change

D8 CCYYMMDD


BH

Name Change

D8 CCYYMMDD


BH

Name Change

D8 CCYYMMDD


BH

Name Change

D8 CCYYMMDD

New Element

INSTITUTIONAL CLAIM


Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

837-I 4010A1

HI05-3 HI05-4 HI05-5 HI05-6 HI05-7


ID AN

1-3 1-30

S R R

ID AN R R AN

2-3 1-35 1-18 1-15 1-30

R R N/U N/U N/U

BH

D8 CCYYMMDD




ID AN

1-3 1-30

S R R

ID AN R R AN

2-3 1-35 1-18 1-15 1-30

R R N/U N/U N/U

BH

D8 CCYYMMDD




ID AN

1-3 1-30

S R R

ID AN R R AN

2-3 1-35 1-18 1-15 1-30

R R N/U N/U N/U

BH

D8 CCYYMMDD


HI08 HI08-1 HI08-2 HI08-3 HI08-4 HI08-5 HI08-6

HEALTH CARE CODE INFORMATION Code List Qualifier Code Occurrence Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity

ID AN

1-3 1-30

S R R

ID AN R R

2-3 1-35 1-18 1-15

R R N/U N/U

Min. Max.

Usage Reg.

Loop

Loop Repeat

Values

837-I 5010 HI04-9

HI05 HI05-1 HI05-2

ID

BH

D8 CCYYMMDD

HI08 HI08-1 HI08-2 HI08-3 HI08-4 HI08-5 HI08-6

Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Occurrence Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Occurrence Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Occurrence Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Occurrence Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity

Page 53 of 93

New Element ID

1-1

N/U

ID AN

1-3 1-30

S R R

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30

R R N/U N/U N/U N/U

ID

1-1

N/U

ID AN

1-3 1-30

S R R

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30

R R N/U N/U N/U N/U

ID

1-1

N/U

ID AN

1-3 1-30

S R R

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30

R R N/U N/U N/U N/U

ID

1-1

N/U

ID AN

1-3 1-30

S R R

ID AN R R

2-3 1-35 1-18 1-15

R R N/U N/U

BH

Name Change

D8 CCYYMMDD


BH

Name Change

D8 CCYYMMDD


BH

Name Change

D8 CCYYMMDD


BH

D8 CCYYMMDD

Name Change

INSTITUTIONAL CLAIM


Description

HI08-7

Version Identifier

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

1-30


ID AN

1-3 1-30

S R R

ID AN R R AN

2-3 1-35 1-18 1-15 1-30

R R N/U N/U N/U

HI08-7 HI08-8

BH

D8 CCYYMMDD




ID AN

1-3 1-30

S R R

ID AN R R AN

2-3 1-35 1-18 1-15 1-30

R R N/U N/U N/U

BH

D8 CCYYMMDD




ID AN

1-3 1-30

S R R

ID AN R R AN

2-3 1-35 1-18 1-15 1-30

R R N/U N/U N/U

BH

D8 CCYYMMDD


HI12 HI12-1 HI12-2 HI12-3 HI12-4

HEALTH CARE CODE INFORMATION Code List Qualifier Code Occurrence Code Date Time Period Format Qualifier Date Time Period

Loop Repeat

Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Occurrence Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Occurrence Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Occurrence Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Occurrence Code Date Time Period Format Qualifier Date Time Period

AN AN

1-30 1-30

N/U N/U

ID

1-1

N/U

ID AN

1-3 1-30

S R R

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30

R R N/U N/U N/U N/U

ID

1-1

N/U

ID AN

1-3 1-30

S R R

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30

R R N/U N/U N/U N/U

ID

1-1

N/U

ID AN

1-3 1-30

S R R

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30

R R N/U N/U N/U N/U

ID

1-1

N/U

ID AN

1-3 1-30

S R R

BH

ID AN

2-3 1-35

R R

D8 CCYYMMDD

Loop

Values

837-I 5010

N/U

HI08-9 HEALTH CARE CODE INFORMATION Code List Qualifier Code Occurrence Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier

Usage Reg.

ID

837-I 4010A1 AN

Min. Max.

Description

ID AN

1-3 1-30

S R R

BH

HI12 HI12-1 HI12-2

ID AN

2-3 1-35

R R

D8 CCYYMMDD

HI12-3 HI12-4

Page 54 of 93


BH

Name Change

D8 CCYYMMDD


BH

Name Change

D8 CCYYMMDD


BH

Name Change

D8 CCYYMMDD


Name Change

INSTITUTIONAL CLAIM


Description

HI12-5 HI12-6 HI12-7

Monetary Amount Quantity Version Identifier

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

837-I 4010A1 R R AN

1-18 1-15 1-30


VALUE INFORMATION HEALTH CARE CODE INFORMATION Code List Qualifier Code Value Code Date Time Period Format Qualifier Date Time Period Value Code Associated Amount Quantity Version Identifier

HI12-5 HI12-6 HI12-7 HI12-8

2

R

2300

HI

ID AN

1-3 1-30

R R R

ID AN

2-3 1-35

N/U N/U

HI01-3 HI01-4

R R AN

1-18 1-15 1-30

R N/U N/U

HI01-5 HI01-6 HI01-7 HI01-8

BE

HI01 HI01-1 HI01-2


ID AN

1-3 1-30

S R R

ID AN

2-3 1-35

N/U N/U

HI02-3 HI02-4

R R AN

1-18 1-15 1-30

R N/U N/U

HI02-5 HI02-6 HI02-7 HI02-8

BE

HI02 HI02-1 HI02-2


Loop

Loop Repeat

Values

Monetary Amount R Quantity R Version Identifier AN Industry code AN Yes/No Condition or response Code ID

1-18 1-15 1-30 1-30

N/U N/U N/U N/U

1-1

N/U

2

R

ID AN

1-3 1-30

R R R

ID AN

2-3 1-35

N/U N/U

R R AN AN

1-18 1-15 1-30 1-30

R N/U N/U N/U

ID

1-1

N/U

ID AN

1-3 1-30

S R R

ID AN

2-3 1-35

N/U N/U

R R AN AN

1-18 1-15 1-30 1-30

R N/U N/U N/U

ID

1-1

N/U

ID AN

1-3 1-30

S R R

ID AN

2-3 1-35

N/U N/U

Value Code Amount R Quantity R Version Identifier AN Industry code AN Yes/No Condition or response Code ID

1-18 1-15 1-30 1-30

R N/U N/U N/U

1-1

N/U

VALUE INFORMATION HEALTH CARE CODE INFORMATION Qualifier Value Code Date Time Period Format Qualifier Date Time Period


2300

BE

Name Change

Value Code Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Value Code Date Time Period Format Qualifier Date Time Period


BE

Name Change

Name Change

HI02-9 HEALTH CARE CODE INFORMATION Code List Qualifier Code Value Code Date Time Period Format Qualifier Date Time Period Value Code Associated Amount Quantity Version Identifier

Usage Reg.

Name Change


Min. Max.

837-I 5010

N/U N/U N/U

HI12-9 HI

ID

ID AN

1-3 1-30

S R R

ID AN

2-3 1-35

N/U N/U

HI03-3 HI03-4

R R AN

1-18 1-15 1-30

R N/U N/U

HI03-5 HI03-6 HI03-7 HI03-8

BE

HI03 HI03-1 HI03-2



BE

Name Change

Name Change

HI03-9

Page 55 of 93


INSTITUTIONAL CLAIM


Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description


HEALTH CARE CODE INFORMATION Code List Qualifier Code Value Code Date Time Period Format Qualifier Date Time Period Value Code Associated Amount Quantity Version Identifier


ID AN

1-3 1-30

S R R

ID AN

2-3 1-35

N/U N/U

HI04-3 HI04-4

R R AN

1-18 1-15 1-30

R N/U N/U

HI04-5 HI04-6 HI04-7 HI04-8

BE

HI04 HI04-1 HI04-2


ID AN

1-3 1-30

S R R

ID AN

2-3 1-35

N/U N/U

HI05-3 HI05-4

R R AN

1-18 1-15 1-30

R N/U N/U

HI05-5 HI05-6 HI05-7 HI05-8

BE

HI05 HI05-1 HI05-2

HI07 HI07-1 HI07-2 HI07-3 HI07-4

Loop

Loop Repeat

Values

HEALTH CARE CODE INFORMATION Qualifier Value Code Date Time Period Format Qualifier Date Time Period

ID AN

1-3 1-30

S R R

ID AN

2-3 1-35

N/U N/U

R R AN AN

1-18 1-15 1-30 1-30

R N/U N/U N/U

ID

1-1

N/U

ID AN

1-3 1-30

S R R

ID AN

2-3 1-35

N/U N/U

R R AN AN

1-18 1-15 1-30 1-30

R N/U N/U N/U

ID

1-1

N/U

ID AN

1-3 1-30

S R R

ID AN

2-3 1-35

N/U N/U

R R AN AN

1-18 1-15 1-30 1-30

R N/U N/U N/U

ID

1-1

N/U

ID AN

1-3 1-30

S R R

ID AN

2-3 1-35

N/U N/U

BE

Name Change



BE

Name Change

Name Change

ID AN

1-3 1-30

S R R

ID AN

2-3 1-35

N/U N/U

HI06-3 HI06-4

R R AN

1-18 1-15 1-30

R N/U N/U

HI06-5 HI06-6 HI06-7 HI06-8

BE

HI06 HI06-1 HI06-2



BE

Name Change

Name Change

HI06-9 HEALTH CARE CODE INFORMATION Code List Qualifier Code Value Code Date Time Period Format Qualifier Date Time Period

Usage Reg.

Name Change


Min. Max.

837-I 5010


ID

ID AN

1-3 1-30

S R R

ID AN

2-3 1-35

N/U N/U

BE

HI07 HI07-1 HI07-2 HI07-3 HI07-4


Page 56 of 93


BE

Name Change

INSTITUTIONAL CLAIM


Description

HI07-5 HI07-6 HI07-7

Value Code Associated Amount Quantity Version Identifier

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

837-I 4010A1



1-18 1-15 1-30

R N/U N/U

HI07-5 HI07-6 HI07-7 HI07-8

ID AN

1-3 1-30

S R R

ID AN

2-3 1-35

N/U N/U

HI08-3 HI08-4

R R AN

1-18 1-15 1-30

R N/U N/U

HI08-5 HI08-6 HI08-7 HI08-8

BE

HI08 HI08-1 HI08-2


Loop

Loop Repeat

Values


R R AN AN

1-18 1-15 1-30 1-30

R N/U N/U N/U

ID

1-1

N/U

ID AN

1-3 1-30

S R R

ID AN

2-3 1-35

N/U N/U


R R AN AN

1-18 1-15 1-30 1-30

R N/U N/U N/U

ID

1-1

N/U

ID AN

1-3 1-30

S R R

ID AN

2-3 1-35

N/U N/U

R R AN AN

1-18 1-15 1-30 1-30

R N/U N/U N/U

ID

1-1

N/U

ID AN

1-3 1-30

S R R

ID AN

2-3 1-35

N/U N/U


1-18 1-15 1-30 1-30

R N/U N/U N/U

1-1

N/U


BE

Name Change

Name Change

ID AN

1-3 1-30

S R R

ID AN

2-3 1-35

N/U N/U

HI09-3 HI09-4

R R AN

1-18 1-15 1-30

R N/U N/U

HI09-5 HI09-6 HI09-7 HI09-8

BE

HI09 HI09-1 HI09-2


BE

Name Change

Name Change


Usage Reg.

Name Change R R AN


Min. Max.

837-I 5010


ID

ID AN

1-3 1-30

S R R

ID AN

2-3 1-35

N/U N/U

HI10-3 HI10-4

R R AN

1-18 1-15 1-30

R N/U N/U

HI10-5 HI10-6 HI10-7 HI10-8

BE

HI10 HI10-1 HI10-2



BE

Name Change

Name Change

HI10-9

Page 57 of 93


INSTITUTIONAL CLAIM


Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description


HEALTH CARE CODE INFORMATION Code List Qualifier Code Value Code Date Time Period Format Qualifier Date Time Period Value Code Associated Amount Quantity Version Identifier


ID AN

1-3 1-30

S R R

ID AN

2-3 1-35

N/U N/U

HI11-3 HI11-4

R R AN

1-18 1-15 1-30

R N/U N/U

HI11-5 HI11-6 HI11-7 HI11-8

BE

HI11 HI11-1 HI11-2


CONDITION INFORMATION HEALTH CARE CODE INFORMATION Code List Qualifier Code Condition Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier

ID AN

1-3 1-30

S R R

ID AN

2-3 1-35

N/U N/U

HI12-3 HI12-4

R R AN

1-18 1-15 1-30

R N/U N/U

HI12-5 HI12-6 HI12-7 HI12-8

BE

HI12 HI12-1 HI12-2

HI02 HI02-1 HI02-2 HI02-3

Loop

Loop Repeat

Values

HEALTH CARE CODE INFORMATION Qualifier Value Code Date Time Period Format Qualifier Date Time Period

ID AN

1-3 1-30

S R R

ID AN

2-3 1-35

N/U N/U

R R AN AN

1-18 1-15 1-30 1-30

R N/U N/U N/U

ID

1-1

N/U

ID AN

1-3 1-30

S R R

ID AN

2-3 1-35

N/U N/U


1-18 1-15 1-30 1-30

R N/U N/U N/U

1-1

N/U

2

R

ID AN

1-3 1-30

R R R

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


ID

1-1

N/U

ID AN

1-3 1-30

S R R

ID

2-3

N/U

BE

Name Change



BE

Name Change

Name Change

2

R

ID AN

1-3 1-30

R R R

ID AN R R AN

2-3 1-35 1-18 1-15 1-30

N/U N/U N/U N/U N/U

2300

HI

BG


HEALTH CARE CODE INFORMATION Code List Qualifier Code Condition Code Date Time Period Format Qualifier

Usage Reg.

Name Change

HI12-9

HI

Min. Max.

837-I 5010


ID

ID AN

1-3 1-30

S R R

ID

2-3

N/U

BG

HI02 HI02-1 HI02-2 HI02-3

CONDITION INFORMATION HEALTH CARE CODE INFORMATION Qualifier Condition Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Condition Code Date Time Period Format Qualifier

Page 58 of 93


2300

BG

Name Change


BG

Name Change

INSTITUTIONAL CLAIM


Description

HI02-4 HI02-5 HI02-6 HI02-7


ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

1-35 1-18 1-15 1-30

Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Condition Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Condition Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Condition Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Condition Code

AN R R AN AN

1-35 1-18 1-15 1-30 1-30

N/U N/U N/U N/U N/U

ID

1-1

N/U


ID AN

1-3 1-30

S R R

ID AN

1-3 1-30

S R R

ID AN R R AN

2-3 1-35 1-18 1-15 1-30

N/U N/U N/U N/U N/U

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


HI02-4 HI02-5 HI02-6 HI02-7 HI02-8

BG



HEALTH CARE CODE INFORMATION Code List Qualifier Code Condition Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier

ID

1-1

N/U

ID AN

1-3 1-30

S R R

ID AN

1-3 1-30

S R R

ID AN R R AN

2-3 1-35 1-18 1-15 1-30

N/U N/U N/U N/U N/U

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


BG




ID

1-1

N/U

ID AN

1-3 1-30

S R R

ID AN

1-3 1-30

S R R

ID AN R R AN

2-3 1-35 1-18 1-15 1-30

N/U N/U N/U N/U N/U

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


BG


HI06 HI06-1 HI06-2

HEALTH CARE CODE INFORMATION Code List Qualifier Code Condition Code

ID

1-1

N/U

ID AN

1-3 1-30

S R R

ID AN

1-3 1-30

S R R

Loop

Loop Repeat

Values

837-I 5010

N/U N/U N/U N/U

HI02-9 HEALTH CARE CODE INFORMATION Code List Qualifier Code Condition Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier

Usage Reg.

ID

837-I 4010A1 AN R R AN

Min. Max.

Description

BG

HI06 HI06-1 HI06-2

Page 59 of 93


BG

Name Change


BG

Name Change


BG

Name Change


BG

Name Change

INSTITUTIONAL CLAIM


Description

HI06-3 HI06-4 HI06-5 HI06-6 HI06-7

Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

837-I 4010A1 ID AN R R AN

2-3 1-35 1-18 1-15 1-30

HI07 HI07-1 HI07-2

N/U N/U N/U N/U N/U

HI07-3 HI07-4 HI07-5 HI07-6 HI07-7

ID AN

1-3 1-30

S R R

ID AN R R AN

2-3 1-35 1-18 1-15 1-30

N/U N/U N/U N/U N/U

HI06-3 HI06-4 HI06-5 HI06-6 HI06-7 HI06-8

BG




ID AN

1-3 1-30

S R R

ID AN R R AN

2-3 1-35 1-18 1-15 1-30

N/U N/U N/U N/U N/U

BG




ID AN

1-3 1-30

S R R

ID AN R R AN

2-3 1-35 1-18 1-15 1-30

N/U N/U N/U N/U N/U

BG


HI10


S

Min. Max.

Usage Reg.

Loop

Loop Repeat

Values

837-I 5010


ID

HI10

Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Condition Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Condition Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Condition Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION

Page 60 of 93

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


ID

1-1

N/U

ID AN

1-3 1-30

S R R

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


ID

1-1

N/U

ID AN

1-3 1-30

S R R

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


ID

1-1

N/U

ID AN

1-3 1-30

S R R

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


ID

1-1

N/U S


BG

Name Change


BG

Name Change


BG

Name Change


INSTITUTIONAL CLAIM


Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

HI10-3 HI10-4 HI10-5 HI10-6 HI10-7

Code List Qualifier Code Condition Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier

ID AN

1-3 1-30

R R

ID AN R R AN

2-3 1-35 1-18 1-15 1-30

N/U N/U N/U N/U N/U

Qualifier Condition Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Condition Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Condition Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code

ID AN

1-3 1-30

R R

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


ID

1-1

N/U


ID AN

1-3 1-30

S R R

ID AN

1-3 1-30

S R R

ID AN R R AN

2-3 1-35 1-18 1-15 1-30

N/U N/U N/U N/U N/U

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30



BG




ID

1-1

N/U

ID AN

1-3 1-30

S R R

ID AN

1-3 1-30

S R R

ID AN R R AN

2-3 1-35 1-18 1-15 1-30

N/U N/U N/U N/U N/U

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


ID

1-1

N/U

BG


HI HI01 HI01-1 HI01-2 HI01-3 HI01-4 HI01-5 HI01-6 HI01-7

TREATMENT CODE INFORMATION HEALTH CARE CODE INFORMATION Code List Qualifier Code Treatment Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier

2

R

2

R

ID AN

1-3 1-30

R R R

ID AN

1-3 1-30

R R R

ID AN R R AN

2-3 1-35 1-18 1-15 1-30

N/U N/U N/U N/U N/U

ID AN R R AN

2-3 1-35 1-18 1-15 1-30

N/U N/U N/U N/U N/U

Loop

Loop Repeat

Values

837-I 5010 BG


Usage Reg.

ID

837-I 4010A1 HI10-1 HI10-2

Min. Max.

Description

2300

HI

TC


TREATMENT CODE INFORMATION HEALTH CARE CODE INFORMATION Qualifier Treatment Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier

Page 61 of 93

BG

Name Change


BG

Name Change


BG

Name Change


2300

TC

Name Change

INSTITUTIONAL CLAIM


Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Treatment Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Treatment Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Treatment Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Treatment Code Date Time Period Format Qualifier Date Time Period Monetary Amount

AN

1-30

N/U

ID

1-1

N/U

HI01-9

HI02-3 HI02-4 HI02-5 HI02-6 HI02-7

ID AN

1-3 1-30

S R R

ID AN

1-3 1-30

S R R

ID AN R R AN

2-3 1-35 1-18 1-15 1-30

N/U N/U N/U N/U N/U

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


TC



HEALTH CARE CODE INFORMATION Code List Qualifier Code Treatment Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier

ID

1-1

N/U

ID AN

1-3 1-30

S R R

ID AN

1-3 1-30

S R R

ID AN R R AN

2-3 1-35 1-18 1-15 1-30

N/U N/U N/U N/U N/U

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


TC




ID

1-1

N/U

ID AN

1-3 1-30

S R R

ID AN

1-3 1-30

S R R

ID AN R R AN

2-3 1-35 1-18 1-15 1-30

N/U N/U N/U N/U N/U

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


TC


HI05 HI05-1 HI05-2 HI05-3 HI05-4 HI05-5

HEALTH CARE CODE INFORMATION Code List Qualifier Code Treatment Code Date Time Period Format Qualifier Date Time Period Monetary Amount

ID

1-1

N/U

ID AN

1-3 1-30

S R R

ID AN

1-3 1-30

S R R

ID AN R

2-3 1-35 1-18

N/U N/U N/U

ID AN R

2-3 1-35 1-18

N/U N/U N/U

Loop

Loop Repeat

Values

837-I 5010 HI01-8

HI02 HI02-1 HI02-2

Usage Reg.

ID

837-I 4010A1


Min. Max.

Description

TC

HI05 HI05-1 HI05-2 HI05-3 HI05-4 HI05-5

Page 62 of 93


TC

Name Change


TC

Name Change


TC

Name Change


TC

Name Change

INSTITUTIONAL CLAIM


Description

HI05-6 HI05-7

Quantity Version Identifier

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

837-I 4010A1 R AN

1-15 1-30


ID AN

1-3 1-30

S R R

ID AN R R AN

2-3 1-35 1-18 1-15 1-30

N/U N/U N/U N/U N/U

HI05-6 HI05-7 HI05-8

TC




ID AN

1-3 1-30

S R R

ID AN R R AN

2-3 1-35 1-18 1-15 1-30

N/U N/U N/U N/U N/U

TC




ID AN

1-3 1-30

S R R

ID AN R R AN

2-3 1-35 1-18 1-15 1-30

N/U N/U N/U N/U N/U

TC


HI09 HI09-1 HI09-2 HI09-3

HEALTH CARE CODE INFORMATION Code List Qualifier Code Treatment Code Date Time Period Format Qualifier

ID AN

1-3 1-30

S R R

ID

2-3

N/U

Min. Max.

Usage Reg.

Loop

Loop Repeat

Values

837-I 5010

N/U N/U

HI05-9 HEALTH CARE CODE INFORMATION Code List Qualifier Code Treatment Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier

ID

TC

HI09 HI09-1 HI09-2 HI09-3

Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Treatment Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Treatment Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Treatment Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Treatment Code Date Time Period Format Qualifier

Page 63 of 93

R AN AN

1-15 1-30 1-30

N/U N/U N/U

ID

1-1

N/U

ID AN

1-3 1-30

S R R

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


ID

1-1

N/U

ID AN

1-3 1-30

S R R

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


ID

1-1

N/U

ID AN

1-3 1-30

S R R

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


ID

1-1

N/U

ID AN

1-3 1-30

S R R

ID

2-3

N/U


TC

Name Change


TC

Name Change


TC

Name Change


TC

Name Change

INSTITUTIONAL CLAIM


Description

HI09-4 HI09-5 HI09-6 HI09-7


ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

1-35 1-18 1-15 1-30

Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Treatment Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Treatment Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Treatment Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code

AN R R AN AN

1-35 1-18 1-15 1-30 1-30

N/U N/U N/U N/U N/U

ID

1-1

N/U


ID AN

1-3 1-30

S R R

ID AN

1-3 1-30

S R R

ID AN R R AN

2-3 1-35 1-18 1-15 1-30

N/U N/U N/U N/U N/U

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


HI09-4 HI09-5 HI09-6 HI09-7 HI09-8

TC




ID

1-1

N/U

ID AN

1-3 1-30

S R R

ID AN

1-3 1-30

S R R

ID AN R R AN

2-3 1-35 1-18 1-15 1-30

N/U N/U N/U N/U N/U

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


TC




ID

1-1

N/U

ID AN

1-3 1-30

S R R

ID AN

1-3 1-30

S R R

ID AN R R AN

2-3 1-35 1-18 1-15 1-30

N/U N/U N/U N/U N/U

ID AN R R AN AN

2-3 1-35 1-18 1-15 1-30 1-30


ID

1-1

N/U

TC


QTY QTY01 QTY02

CLAIM QUANTITY Quantity Qualifier Claim Days Count

ID R

4 2-2 1-15

S R R

Loop

Loop Repeat

Values

837-I 5010

N/U N/U N/U N/U

HI09-9 HEALTH CARE CODE INFORMATION Code List Qualifier Code Treatment Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier

Usage Reg.

ID

837-I 4010A1 AN R R AN

Min. Max.

Description


TC

Name Change


TC

Name Change


TC

Name Change


Segment Deleted

2300 CA, CD, LA, NA

Page 64 of 93

INSTITUTIONAL CLAIM


Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

837-I 4010A1

QTY03-13 QTY03-14 QTY03-15 QTY04

COMPOSITE UNIT OF MEASURE Unit or Basis for Measurement Code Exponent Multiplier Unit or Basis for Measurement Code Exponent Multiplier Unit or Basis for Measurement Code Exponent Multiplier Unit or Basis for Measurement Code Exponent Multiplier Unit or Basis for Measurement Code Exponent Multiplier Free-Form Message

HCP

CLAIM PRICING/REPRICING INFORMATION

QTY03 QTY03-1 QTY03-2 QTY03-3 QTY03-4 QTY03-5 QTY03-6 QTY03-7 QTY03-8 QTY03-9 QTY03-10 QTY03-11 QTY03-12

HCP06

Pricing Methodology Repriced Allowed Amount Repriced Saving Amount Repricing Organization Identifier Repricing Per Diem or Flat Rate Amount Repriced Approved DRG Code

HCP07 HCP08

HCP01 HCP02 HCP03

Usage Reg.

Loop

Loop Repeat

Values

R ID R R

2-2 1-15 1-10

R N/U N/U

ID R R

2-2 1-15 1-10

N/U N/U N/U

ID R R

2-2 1-15 1-10

N/U N/U N/U

ID R R

2-2 1-15 1-10

N/U N/U N/U

ID R R AN

2-2 1-15 1-10 1-30

N/U N/U N/U N/U

1

S

DA

2300

HCP 00, 01, 02, 03, 04, 05, 06, 07, 08, 09, 10 ,11, 12, 13, 14

CLAIM PRICING/REPRICING INFORMATION

HCP07 HCP08

Pricing Methodology Repriced Allowed Amount Repriced Saving Amount Repricing Organization Identifier Repricing Per Diem or Flat Rate Amount Ambulatory Patient Group Code Ambulatory Patient Group Amount Product/Service ID

HCP09 HCP10

2-2 1-18 1-18

R R S

AN

1-30

S

HCP04

R

1-9

S

HCP05

AN

1-30

S

HCP06

Repriced Approved Amount Product/Service ID

R AN

1-18 1-48

S S

HCP09

Product/Service ID Qualifier

ID

2-2

S

HCP10

Product/Service ID Unit or Basis for Measurement Code Quantity

AN

1-48

S

ID R

2-2 1-15

S S

HCP05

Min. Max.

837-I 5010

ID R R

HCP04

ID

HCP01 HCP02 HCP03

1

S

ID R R

2-2 1-18 1-18

R R S

AN

1-50

S

R

1-9

S

AN

1-50

S

R AN

1-18 1-48

S S

Product/Service ID Qualifier

ID

2-2

N/U

Product/Service ID Unit or Basis for Measurement Code Quantity

AN

1-48

N/U

ID R

2-2 1-15

S S

2300 00, 01, 02, 03, 04, 05, 06, 07, 08, 09, 10 ,11, 12, 13, 14


Increase from 30 - 50 Name Change Name Change

Usage change to Not Used HC


HCP11 HCP12

DA, UN

HCP11 HCP12

Page 65 of 93

DA, UN

INSTITUTIONAL CLAIM


Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

837-I 4010A1 HCP13 HCP14 HCP15

Reject Reason Code Policy Compliance Code Exception Code

CR7

HOME HEALTH CARE PLAN INFORMATION

CR701 CR702 CR703

HSD HSD01 HSD02 HSD03 HSD04 HSD05 HSD06

Disipline Type Code Vsits Prior to Recertification Date Count Total Visits Projected This Certification Count HOME CARE SERVICES DELIVERY Visits Number of Visits Frequency Period Frequency Count Duration of Visits Units Duration of Visits, Number of Units

HSD07 HSD08

Ship, Delivery or Caledar Pattern Code Delivery Pattern Time Code

NM1 NM101 NM102

ID ID ID

2-2 1-2 1-2

S S S

1

S

ID

2-2

R

NO

1-9

R

NO

1-9

R

ID R ID R ID

12 2-2 1-15 2-2 1-6 1-2

S S S S S S

NO

1-3

S

ID

Min. Max.

Usage Reg.

Loop

Loop Repeat

Values

837-I 5010 T1, T2, T3, T4, T5, T6 1, 2, 3, 4, 5 1, 2, 3, 4, 5, 6

HCP13 HCP14 HCP15


ID ID ID

2-2 1-2 1-2

T1, T2, T3, T4, T5, T6 1, 2, 3, 4, 5 1, 2, 3, 4, 5, 6

S S S

Segment Deleted 2305

6 AI, MS, OT, PT, SN, ST

Segment Deleted

ID ID

1-2 1-1

S S

ATTENDING PHYSICIAN NAME Entity Identifier Code Entity Type Qualifier

ID ID

1 2-3 1-1

S R R

NM103

Name Last

AN

1-35

NM104 NM105 NM106 NM107

NameFirst Name Middle Name Prefix Name Suffix

AN AN AN AN

1-25 1-25 1-10 1-10

2305

DA, MO, Q1, WK 7, 35

1, 2, 3, 4, 5, 6, 7, 8, 9, A, B, C, D, E, F, G, J, K, L, N, O, S, SA, SB, SC, SD, SG, SL, SP, SX, SY, SZ, W, D, E, F

NM1 NM101 NM102

ATTENDING PROVIDER NAME Entity Identifier Code Entity Type Qualifier

R

NM103

S S N/U S

NM104 NM105 NM106 NM107

NM108


ID

1-2

R

NM109 NM110 NM111

Provider Identifier Entity Relationship Code Entity Identifier Code

AN ID ID

2-80 2-2 2-3

R N/U N/U

2310A

1 71 1, 2

24, 34, XX

Name Change ID ID

1 2-3 1-1

S R R

Last Name

AN

1-60

R

First Name Middle Name Name Prefix Name Suffix

AN AN AN AN

1-35 1-25 1-10 1-10

S S N/U S

NM108


ID

1-2

S

NM109 NM110 NM111

Provider Identifier Entity Relationship Code Entity Identifier Code

AN ID ID

2-80 2-2 2-3

S N/U N/U

Page 66 of 93

2310A

1 71 1

XX

Code Deleted Name Change Increase from 35 - 60 Name Change Increase 25 - 35 Name Change

Code Deleted Usage change to Situational Usage change to Situational

INSTITUTIONAL CLAIM


Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

NM112

Name Last or Organization Name

837-I 4010A1

ID

Min. Max.

Usage Reg.

Loop

Loop Repeat

Values

837-I 5010 New Element AN

1-60

N/U Name Change

PRV PRV01 PRV02 PRV03 PRV04 PRV05

ATTENDING PHYSICIAN SPECIALTY INFORMATION Provider Code ID Reference Identification Qualifier ID Provider Taxonomy Code AN State or Province Code ID PROVIDER SPECIALTY INFORMATION

PRV06


REF

ATTENDING PHYSICIAN SECONDARY IDENTIFICATION

ID

1 1-3

S R

2-3 1-30 2-2

R R N/U

3-3

5

REF02 REF03 REF04

Reference Identification Qualifier Attending Physician Secondary Identifier Description REFERENCE IDENTIFIER

NM1 NM101 NM102 NM103

OPERATING PHYSICIAN NAME Entity Identifier Code Entity Type Qualifier Last or Organization Name

ID ID AN

1 2-3 1-1 1-35

NM104 NM105 NM106 NM107

Name First Middle Name Name Prefix Name Suffix

AN AN AN AN

1-25 1-25 1-10 1-10

REF01

2310A AT, SU ZZ


ATTENDING PROVIDER SPECIALTY INFORMATION Provider Code ID Reference Identification Qualifier ID Provider Taxonomy Code AN State or Province Code ID PROVIDER SPECIALTY INFORMATION

N/U

PRV05

N/U

PRV06


REF

ATTENDING PROVIDER SECONDARY IDENTIFICATION

S

ID

2-3

R

AN AN

1-30 1-80

R N/U N/U

S R R R

R S N/U S

NM108


ID

1-2

R

NM109 NM110 NM111

Identifier Entity Relationship Code Entity Identifier Code

AN ID ID

2-80 2-2 2-3

R N/U N/U

2310A 0B, 1A, 1B, 1C, 1D, 1G, 1H, EI, G2, LU, N5, SY, X5

2310B

1 72 1

24, 34, XX

ID

1 1-3

S R

2-3 1-50 2-2

R R N/U

2310A AT

Code Deleted Code Change

PXC Increase from 30 - 50

N/U 3-3

N/U Name Change # Repeats change to 4

4

S

2310A Code Deleted

REF01

Reference Identification Qualifier

REF02 REF03 REF04

Secondary Identifier Description REFERENCE IDENTIFIER

NM1 NM101 NM102 NM103

NM104 NM105 NM106 NM107

ID

2-3

R

AN AN

1-50 1-80

R N/U N/U

OPERATING PHYSICIAN NAME Entity Identifier Code Entity Type Qualifier Last or Organization Name

ID ID AN

1 2-3 1-1 1-60

S R R R


AN AN AN AN

1-35 1-25 1-10 1-10

S S N/U S

NM108


ID

1-2

S

NM109 NM110 NM111

Identifier Entity Relationship Code Entity Identifier Code Name Last or Organization Name

AN ID ID

2-80 2-2 2-3

S N/U N/U

AN

1-60

N/U

NM112

Page 67 of 93

0B, 1G, G2, LU Increase from 30 - 50 Name Change

2310B

1 72 1 Increase from 35 - 60 Increase from 25 - 35 Usage change to Situational

XX

Code Deleted Usage change to Situational Usage change to Situational

New Element

INSTITUTIONAL CLAIM


Description

REF

OPERATING PHYSICIAN SECONDARY IDENTIFICATION

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

REF


837-I 4010A1


Reference Identification Qualifier Secondary Identifier Description REFERENCE IDENTIFIER

NM1 NM101 NM102 NM103

NM104 NM105 NM106 NM107

NM108 NM109 NM110 NM111

REF


5

S

ID AN AN

2-3 1-30 1-80

R R N/U N/U

OTHER PROVIDER NAME Entity Identifier Code Entity Type Qualifier Last or Organization Name

ID ID AN

1 2-3 1-1 1-35

S R R R


AN AN AN AN

1-25 1-25 1-10 1-10

R S N/U S

Identification Code Qualifier Identifier Entity Relationship Code Entity Identifier Code

ID AN ID ID

OTHER PROVIDER SECONDARY IDENTIFICATION

Reference Identification Qualifier Rendering Provider Secondary Identifier Description REFERENCE IDENTIFIER

1-2 2-80 2-2 2-3

5

ID

2-3

R

AN AN

1-30 1-80

R N/U N/U

Min. Max.

Usage Reg.

Loop

Loop Repeat

Values

837-I 5010 2310B 0B, 1A, 1B, 1C, 1D, 1G, 1H, EI, G2, LU, N5, SY, X5

2310C

1 73 1, 2

24, 34, XX

R S N/U N/U

S

ID

2310C 0B, 1A, 1B, 1C, 1D, 1G, 1H, EI, G2, LU, N5, SY, X5

# Repeats change to 4 4

S

2310B Code Deleted


Qualifier Secondary Identifier Description REFERENCE IDENTIFIER

NM1 NM101 NM102 NM103

NM104 NM105 NM106 NM107

ID AN AN

2-3 1-50 1-80

R R N/U N/U

OTHER OPERATING PHYSICIAN NAME Entity Identifier Code Entity Type Qualifier Last or Organization Name

ID ID AN

1 2-3 1-1 1-60

S R R R


AN AN AN AN

1-35 1-25 1-10 1-10

S S N/U S

NM112

Identification Code Qualifier Identifier Entity Relationship Code Entity Identifier Code Name Last or Organization Name

REF


NM108 NM109 NM110 NM111

0B, 1G, G2, LU Increase from 30 - 50

Name Change

ID AN ID ID

1-2 2-80 2-2 2-3

S S N/U N/U

AN

1-60

N/U

2310C

1 ZZ 1

XX

Code Change Code Deleted Increase from 35 - 60 Increase from 25 - 35 Usage change to Situational

Code Deleted Usage change to Situational

New Element

Name Chnge # of Repeats change to 4 4

S

2310C Code Deleted


NM1 NM101 NM102 NM103

Reference Identification Qualifier Rendering Provider Secondary Identifier Description REFERENCE IDENTIFIER RENDERING PHYSICIAN NAME Entity Identifier Code Entity Type Qualifier Rendering Provider Last or Organization Name

Page 68 of 93

ID

2-3

R

AN AN

1-50 1-80

R N/U N/U

ID ID

1 2-3 1-1

S R R

AN

1-60

R


New Segment 2310D

1 82 1

INSTITUTIONAL CLAIM


Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

837-I 4010A1

NM107 NM108


ID

1-2

S

NM109 NM110 NM111

Rendering Provider Identifier Entity Relationship Code Entity Identifier Code Name Last or Organization Name

AN ID ID

2-80 2-2 2-3

S N/U N/U

AN

1-60

N/U

NM112

NM103 NM104 NM105 NM106 NM107

Laboratory or Facility Name Name First Name Middle Name Prefix Name Suffix


1-35 1-25 1-25 1-10 1-10

R N/U N/U N/U N/U

Identification Code Qualifier ID Laboratory or Facility Primary Identifier AN Entity Relationship Code ID Entity Identifier Code ID

1-2

S

2-80 2-2 2-3

S N/U N/U

2310E

1 FA 2

1-35

S

AN AN

1-25 1-10

S N/U

AN

1-10

S

Loop

Loop Repeat

Values

XX

New Segment

REF02 REF03 REF04

NM1 NM101 NM102

SERVICE FACILITY LOCATION Entity Identifier Code Entity Type Qualifier

ID ID

1 2-3 1-1

NM103 NM104 NM105 NM106 NM107

Laboratory or Facility Name Name First Name Middle Name Prefix Name Suffix

AN AN AN AN AN

1-60 1-35 1-25 1-10 1-10

R N/U N/U N/U N/U

Identification Code Qualifier ID Laboratory or Facility Primary Identifier AN Entity Relationship Code ID Entity Identifier Code ID Name Last or Organization Name AN

1-2

S

2-80 2-2 2-3

S N/U N/U

1-60

N/U

1

R

1-55

R

REF01

S R R

AN

RENDERING PHYSICIAN SECONDARY IDENTIFICATION Reference Identification Qualifier Rendering Provider Secondary Identifier Description REFERENCE IDENTIFIER

REF

1 2-3 1-1

Usage Reg.

837-I 5010

NM105 NM106

SERVICE FACILITY NAME Entity Identifier Code Entity Type Qualifier

Min. Max.

Rendering Provider First Name Rendering Provider Middle Name Name Prefix Rendering Provider Name Suffix

NM104

NM1 NM101 NM102

ID

4

S

ID

2-3

R

AN AN

1-50 1-80

R N/U N/U

S R R

2310D 0B, 1G, G2, LU

Name Change 2310E

1 77 2

Code Change Increase from 35 - 60 Increase from 25 - 35

Code Deleted NM108 NM109 NM110 NM111

24, 34, XX

NM108 NM109 NM110 NM111 NM112

N3 N301

SERVICE FACILITY ADDRESS Laboratory or Facility Address Line AN

1

R

1-55

R

2310E

N3 N301

SERVICE FACILITY LOCATION ADDRESS Laboratory or Facility Address Line AN

Page 69 of 93

XX

New Element

Name Change 2310E

INSTITUTIONAL CLAIM


Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

837-I 4010A1 N302

N4 N401 N402 N403 N404 N405 N406

REF


Laboratory or Facility Address Line AN SERVICE FACILITY CITY/STATE/ZIP CODE Laboratory or Facility City Name AN Laboratory or Facility State or Province Code ID Laboratory or Facility Postal Zone or ZIP Code ID Laboratory/Facility Country Code ID Location Qualifier ID Location Identifier AN

SERVICE FACILITY SECONDARY IDENTIFICATION

Reference Identification Qualifier Laboratory or Facility Secondary Identifier Description REFERENCE IDENTIFIER

S

1

R

2-30

R

N401

2-2

R

N402

3-15

R

N403

2-3 1-2 1-30

S N/U N/U

N404 N405 N406 N407

S

ID

2-3

R

AN AN

1-30 1-80

R N/U N/U

Min. Max.

Usage Reg.

Loop

Loop Repeat

Values

837-I 5010

1-55

5

ID

N302

2310E

N4

2310E

REF 0B, 1A, 1B, 1C, 1D, 1G, 1H, EI, G2, LU, N5, SY, X5

Laboratory or Facility Address Line AN SERVICE FACILITY LOCATION CITY/STATE/ZIP Laboratory or Facility City Name AN Laboratory or Facility State or Province Code ID Laboratory or Facility Postal Zone ZIP Code ID Laboratory/Facility Country Code ID Location Qualifier ID Location Identifier AN Country Subdivision Code ID

1-55

S

1

R

2-30

R

2-2

S

3-15

S

2-3 1-2 1-30 1-3

S N/U N/U S

3

S

Name Change 2310E


New Element Name Change # of Repeats change to 3

SERVICE FACILITY LOCATION SECONDARY IDENTIFICATION

2310E Code Deleted

REF02 REF03 REF04

Reference Identification Qualifier Laboratory or Facility Secondary Identifier Description REFERENCE IDENTIFIER

NM1 NM101 NM102

REFERRING PROVIDER NAME Entity Identifier Code Entity Type Qualifier

REF01

ID

2-3

R

AN AN

1-50 1-80

R N/U N/U

ID ID

1 2-3 1-1

S R R

NM103

Referring Provider Last Name AN

1-60

R

NM104

AN

1-35

S

AN AN

1-25 1-10

S N/U

NM107

Referring Provider First Name Referring Provider Middle Name Name Prefix Referring Provider Name Suffix

AN

1-10

S

NM108


ID

1-2

S

NM109 NM110 NM111

Referring Provider Identifier Entity Relationship Code Entity Identifier Code Name Last or Organization Name

AN ID ID

2-80 2-2 2-3

S N/U N/U

AN

1-60

N/U

NM105 NM106

NM112

Page 70 of 93

0B, G2, LU Increase from 30 - 50

New Segment 2310F

1 DN 1

XX

INSTITUTIONAL CLAIM


Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

837-I 4010A1


SBR01

SBR02 SBR03 SBR04 SBR05 SBR06 SBR07 SBR08

SBR09

CAS CAS01 CAS02 CAS03 CAS04 CAS05 CAS06 CAS07 CAS08 CAS09

OTHER SUBSCRIBER INFORMATION Payer Responsibility Sequence Number Code

Individual Relationship Code Insured Group or Policy Number Other Insured Group Name Insurance Type Code

ID

1

S

2320

10

SBR

1-1

R

P, S, T

SBR01

01, 04, 05, 07, 10, 15, 17, 18, 19, 20, 21, 22, 23, 24, 29, 32, 33, 36, 39, 40, 41, 43, 53, G8

SBR02

ID

2-2

R

AN AN ID

1-30 1-60 1-3

S S N/U

SBR03 SBR04 SBR05


1-1

N/U

SBR06

1-1 2-2

N/U N/U

SBR07 SBR08

Claim Filing Indicator Code CLAIM LEVEL ADJUSTMENTS Claim Adjustment Group Code Adjustment Reason Code Adjustment Amount Adjustment Quantity Adjustment Reason Code Adjustment Amount Adjustment Quantity Adjustment Reason Code Adjustment Amount

ID

ID ID R R ID R R ID R

1-2

S

5

S

1-2 1-5 1-18 1-15 1-5 1-18 1-15 1-5 1-18

R R R S S S S S S

Min. Max.

Usage Reg.

Loop

Loop Repeat

Values

837-I 5010

REF

SBR

ID

09, 10, 11, 12, 13, 14, 15, 16, AM, BL, CH, CI, DS, HM, LI, LM, MA, MB, MC, OF, TV, VA, WC, ZZ

2320

SBR09

CAS CO, CR, OA, PI, PR

CAS01 CAS02 CAS03 CAS04 CAS05 CAS06 CAS07 CAS08 CAS09

REFERRING PROVIDER SECONDARY IDENTIFICATION Reference Identification Qualifier ID Referring Provider Secondary Identifier AN Description AN REFERENCE IDENTIFIER

New Segment 3

S

2-3

R

1-50 1-80

R N/U N/U

1

S

ID

1-1

R

ID

2-2

R

AN AN ID

1-50 1-60 1-3

S S N/U


1-1

N/U

1-1 2-2

N/U N/U

OTHER SUBSCRIBER INFORMATION Payer Responsibility Sequence Number Code

Individual Relationship Code Insured Group or Policy Number Other Insured Group Name Insurance Type Code

Claim Filing Indicator Code CLAIM LEVEL ADJUSTMENTS Claim Adjustment Group Code Adjustment Reason Code Adjustment Amount Adjustment Quantity Adjustment Reason Code Adjustment Amount Adjustment Quantity Adjustment Reason Code Adjustment Amount

Page 71 of 93

2310F 0B, 1G, G2

2320

10 A, B, C, D, E, F, Code Added G, H, P, S, T, U Code Deleted

01, 18, 19, 20, 21, 39, 40, 53, G8 Increase from 30 - 50

ID

ID ID R R ID R R ID R

1-2

S

5

S

1-2 1-5 1-18 1-15 1-5 1-18 1-15 1-5 1-18

R R R S S S S S S

11, 12, 13, 14, 15, 16, 17, AM, BL, CH, CI, DS, FI, HM, LM, MA, MB, MC, OF, TV, VA, WC, ZZ

2320 CO, CR, OA, PI, PR

Code Change

INSTITUTIONAL CLAIM

4010A1 Description

CAS10 CAS11 CAS12 CAS13 CAS14 CAS15 CAS16 CAS17 CAS18 CAS19

Adjustment Quantity Adjustment Reason Code Adjustment Amount Adjustment Quantity Adjustment Reason Code Adjustment Amount Adjustment Quantity Adjustment Reason Code Adjustment Amount Adjustment Quantity


PAYER PRIOR PAYMENT Amount Qualifier Code Other Payer Patient Paid Amount Credit/Debit Flag Code


COORDINATION OF BENEFITS (COB) TOTAL ALLOWED AMOUNT Amount Qualifier Code Allowed Amount Credit/Debit Flag Code

AMT AMT01

COORDINATION OF BENEFITS (COB) TOTAL SUBMITED CHARGES Amount Qualifier Code

ID

1 1-3

S R

AMT02 AMT03

Coordination of Benefits Total Submitted Charge Amount Credit/Debit Flag Code

R ID

1-18 1-1

R N/U


DIAGNOSTIC RELATED GROUP (DRG) OUTLIER AMOUNT Amount Qualifier Code Claim DRG Outlier Amount Credit/Debit Flag Code


COORDINATION OF BENEFITS (COB) TOTAL MEDICARE PAID AMOUNT Amount Qualifier Code Total Medicare Paid Amout Credit/Debit Flag Code

AMT

MEDICARE PAID AMOUNT 100%

ID

Min. Max.

Usage Reg.

Element Identifier

5010 Loop

Loop Repeat

Values

Element Identifier

Description

CAS10 CAS11 CAS12 CAS13 CAS14 CAS15 CAS16 CAS17 CAS18 CAS19

Adjustment Quantity Adjustment Reason Code Adjustment Amount Adjustment Quantity Adjustment Reason Code Adjustment Amount Adjustment Quantity Adjustment Reason Code Adjustment Amount Adjustment Quantity


837-I 4010A1 R ID R R ID R R ID R R

1-15 1-5 1-18 1-15 1-5 1-18 1-15 1-5 1-18 1-15

S S S S S S S S S S

ID

1 1-3

S R

R ID

1-18 1-1

R N/U

ID

Min. Max.

Usage Reg.

Loop

Loop Repeat

Values

837-I 5010 R ID R R ID R R ID R R

1-15 1-5 1-18 1-15 1-5 1-18 1-15 1-5 1-18 1-15

S S S S S S S S S S

COB PAYER PAID AMOUNT Amount Qualifier Code

ID

1 1-3

S R

Payer Paid Amount Credit/Debit Flag Code

R ID

1-18 1-1

R N/U

Name Change 2320 C4

2320 D

Code Change Name Change

Segment Deleted

ID R ID

1 1-3 1-18 1-1

S R R N/U

2320 B6

Segment Deleted 2320 T3

Segment Deleted

ID R ID

1 1-3 1-18 1-1

S R R N/U

2320 ZZ

Segment Deleted

ID R ID

1 1-3 1-18 1-1

S R R N/U

2320

1

S

2320

N1

Segment Deleted

Page 72 of 93

INSTITUTIONAL CLAIM


Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

837-I 4010A1 AMT01 AMT02 AMT03



Amount Qualifier Code Medicare Paid at 100% Amount Credit/Debit Flag Code MEDICARE PAID AMOUNT 80% Amount Qualifier Code Medicare Paid at 80% Amount Credit/Debit Flag Code COORDINATION OF BENEFITS (COB) MEDICARE A TRUST FUND PAID AMOUNT Amount Qualifier Code Paid From Part A Medicare Trust Fund Amount Credit/Debit Flag Code

ID

1-3

R

R ID

1-18 1-1

R N/U

ID

1 1-3

S R

R ID

1-18 1-1

R N/U

ID

1 1-3

S R

R ID

1-18 1-1

R N/U

AMT AMT01

ID

1 1-3

S R

AMT02 AMT03

Non-Covered Charge Amount Credit/Debit Flag Code

R ID

1-18 1-1

R N/U

AMT02 AMT03

Loop

Loop Repeat

Values

837-I 5010 KF

2320 PG

2320 AA

Segment Deleted

COORDINATION OF BENEFITS (COB) TOTAL NON-COVERED AMOUNT Amount Qualifier Code

AMT AMT01

Usage Reg.

Segment Deleted

AMT02 AMT03

COORDINATION OF BENEFITS (COB) TOTAL DENIED AMOUNT Amount Qualifier Code Claim Total Denied Charge Amount Credit/Debit Flag Code

Min. Max.

Segment Deleted

COORDINATION OF BENEFITS (COB) MEDICARE B TRUST FUND PAID AMOUNT Amount Qualifier Code Paid From Part B Medicare Trust Fund Amount Credit/Debit Flag Code

AMT AMT01

ID

ID

1 1-3

S R

R ID

1-18 1-1

R N/U

2320 B1

Segment Deleted 2320 A8

Segment Deleted

ID

1 1-3

S R

R ID

1-18 1-1

R N/U

2320 YT

AMT AMT01

REMAINING PATIENT LIABILITY Amount Qualifier Code

Page 73 of 93

New Segment ID

1 1-3

S R

2320 EAF

INSTITUTIONAL CLAIM


Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

AMT02 AMT03

Remaining Patient Liability Amount Credit/Debit Flag Code


COB TOTAL NONCOVERED AMOUNT Amount Qualifier Code Non-Covered Amount Credit/Debit Flag Code

837-I 4010A1

DMG DMG01 DMG02 DMG03 DMG04 DMG05 DMG06 DMG07 DMG08 DMG09

OTHER SUBSCRIBER DEMOGRAPHIC INFORMATION Date Time Period Format Qualifier Other Insured Birth Date Gender Code Marital Status Code Race or Ethnicity Code Citizenship Status Code Country Code Basis of Veification Code Quantity

1

S

ID AN ID ID ID ID ID ID R

2-3 1-35 1-1 1-1 1-1 1-2 2-3 1-2 1-15

R R R N/U N/U N/U N/U N/U N/U

ID

1 1-2

R N/U

ID

2-2

N/U

ID

1-1

R

OI04 OI05

ID ID

1-1 1-1

N/U N/U

OI06


ID

1-1

R

MIA

MEDICARE INPATIENT ADJUDICATION INFORMATION

1

S

MIA01

Covered Days or Visits Count

R

1-15

MIA02 MIA03

Lifetime Reserve Days Count Lifetime Psychiatric Days

R R

MIA04

Claim DRG Amount

R

OI02 OI03

Min. Max.

Usage Reg.

Loop

Loop Repeat

Values

837-I 5010 R ID

1-18 1-1

R N/U

ID R ID

1 1-3 1-18 1-1

S R R N/U

New Segment 2320 A8

Segment Deleted

OTHER INSURANCE COVERAGE INFORMATION Claim Filing Indicator Code Claim Submission Reason Code Benefits Assignment Certification Indicator Patient Signature Source Code Provider Agreement Code

OI OI01

ID

2320 D8 F, M, U

OI04 OI05

OTHER INSURANCE COVERAGE INFORMATION Claim Filing Indicator Code Claim Submission Reason Code Benefits Assignment Certification Indicator Patient Signature Source Code Provider Agreement Code

OI06


MIA

INPATIENT ADJUDICATION INFORMATION

R

MIA01

Covered Days or Visits Count

1-15 1-15

S S

MIA02 MIA03

1-18

S

MIA04

Amount Lifetime Psychiatric Days Remaining Patient Liability Amount

2320

OI OI01 OI02 N, Y

OI03

ID

1 1-2

R N/U

ID

2-2

N/U

ID

1-1

R

ID ID

1-1 1-1

N/U N/U

ID

1-1

R

1

S

R

1-15

S

R R

1-18 1-15

N/U S

R

1-18

S

2320

Code Added N, W, Y

Code Deleted A, I, M, N, O, Y

2320

Page 74 of 93

I, Y

2320 Usage change to Situational Usage change to Not Used Increase from 15 - 18 Name Change

Name Change

INSTITUTIONAL CLAIM


Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

837-I 4010A1 MIA05 MIA06 MIA07 MIA08 MIA09 MIA10 MIA11 MIA12 MIA13 MIA14 MIA15 MIA16 MIA17 MIA18 MIA19

Remark Code AN Claim Disproportionate Share Amount R Claim MSP Pass-through Amount R Claim PPS Capital Amount R PPS-Capital FSP DRG Amount R PPS-Capital HSP DRG Amount R PPS-Capital DSH DRG Amount R Old Capital Amount R PPS-Capital IME Amount R PPS-Operating Hospital Specific DRG Amount R Cost Report Day Count R PPS-Operating Federal Specific DRG Amount R Claim PPS Capital Outlier Amount R Claim Indirect Teaching Amount R Non-Payable Professional Component Amount R

ID

Min. Max.

Usage Reg.

MIA19

Claim Payment Remark Code AN Claim Disproportionate Share Amount R Claim MSP Pass-through Amount R Claim PPS Capital Amount R PPS-Capital FSP DRG Amount R PPS-Capital HSP DRG Amount R PPS-Capital DSH DRG Amount R Old Capital Amount R PPS-Capital IME Amount R PPS-Operating Hospital Specific DRG Amount R Cost Report Day Count R PPS-Operating Federal Specific DRG Amount R Claim PPS Capital Outlier Amount R Claim Indirect Teaching Amount R Non-Payable Professional Component Billed Amount R

1-30

S

MIA05

1-18

S

MIA06

1-18 1-18

S S

MIA07 MIA08

1-18

S

MIA09

1-18

S

MIA10

1-18 1-18 1-18

S S S

MIA11 MIA12 MIA13

1-18 1-15

S S

MIA14 MIA15

1-18

S

MIA16

1-18

S

MIA17

1-18

S

MIA18

1-18

S

1-50

S

1-18

S

1-18 1-18

S S

1-18

S

1-18

S

1-18 1-18 1-18

S S S

1-18 1-15

S S

1-18

S

1-18

S

1-18

S

1-18

S

AN

1-30

S

MIA20

Claim Payment Remark Code AN

1-50

S

MIA21

Remark Code

AN

1-30

S

MIA21


1-50

S

MIA22

Remark Code

AN

1-30

S

MIA22


1-50

S

MIA23

Remark Code PPS-Capital Exception Amount

AN

1-30

S

MIA23

1-50

S

R

1-18

S

MIA24

Claim Payment Remark Code AN PPS-Capital Exception Amount R

1-18

S

MOA MOA01 MOA02 MOA03 MOA04 MOA05 MOA06 MOA07

R

1 1-10

S S

R AN AN AN AN AN

1-18 1-30 1-30 1-30 1-30 1-30

S S S S S S

Values

2320

Increase from 30 - 50 Name Change

Name Change

Remark Code

MEDICARE OUTPATIENT ADJUDICATION INFORMATION Reimbursement Rate Claim HCPCS Payable Amount Remark Code Remark Code Remark Code Remark Code Remark Code

Loop Repeat

837-I 5010

MIA20

MIA24

Loop

MOA MOA01

MEDICARE OUTPATIENT ADJUDICATION INFORMATION Reimbursement Rate

R

1 1-10

S S

MOA02 MOA03 MOA04 MOA05 MOA06 MOA07

HCPCS Payable Amount Remark Code Remark Code Remark Code Remark Code Remark Code

R AN AN AN AN AN

1-18 1-50 1-50 1-50 1-50 1-50

S S S S S S

Increase from 30 - 50 Name Change Increase from 30 - 50 Name Change Increase from 30 - 50 Name Change Increase from 30 - 50 Name Change

2320 Name Change

Page 75 of 93

Increase from 30 - 50 Increase from 30 - 50 Increase from 30 - 50 Increase from 30 - 50 Increase from 30 - 50

INSTITUTIONAL CLAIM


Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

837-I 4010A1

MOA09

Claim ESRD Payment Amount Non-Payable Professional Component Amount


OTHER SUBSCRIBER NAME Entity Identifier Code Entity Type Qualifier Other Insured Last Name Other Insured First Name Other Insured Middle Name Name Prefix Other Insured Name Suffix Identification Code Qualifier Other Insured Identifier Entity Relationship Code Entity Identifier Code

MOA08

N3

OTHER SUBSCRIBER ADDRESS

N301

Other Insured Address Line

N302


N4 N401

OTHER SUBSCRIBER CITY/STATE/ZIP CODE Other Insured City Name

N402 N403 N404 N405 N406


Min. Max.

Usage Reg.

1-18

S

MOA08

R

1-18

S

MOA09


1 2-3 1-1 1-35 1-25 1-25 1-10 1-10 1-2 2-80 2-2 2-3

R R R R S S N/U S R R N/U N/U

2330A

1 IL 1, 2

MI, ZZ

NM112

OTHER SUBSCRIBER NAME Entity Identifier Code Entity Type Qualifier Other Insured Last Name Other Insured First Name Other Insured Middle Name Name Prefix Other Insured Name Suffix Identification Code Qualifier Other Insured Identifier Entity Relationship Code Entity Identifier Code Name Last or Organization Name

N3

OTHER SUBSCRIBER ADDRESS


1-18

S

R

1-18

S


1 2-3 1-1 1-60 1-35 1-25 1-10 1-10 1-2 2-80 2-2 2-3

R R R R S S N/U S R R N/U N/U

AN

1-60

N/U

1

S

R

N301


AN

1-55

R

AN

1-55

S

N302


AN

1-55

S

AN

1 2-30

S R

N4 N401

OTHER SUBSCRIBER CITY/STATE/ZIP CODE Other Insured City Name

AN

1 2-30

R R

2-2

R

N402

2-2

S

3-15 2-3 1-2 1-30

R S N/U N/U

N403 N404 N405 N406 N407

3-15 2-3 1-2 1-30 1-3

S S N/U N/U S

R

AN AN

1-30 1-80

R N/U N/U

2330A

2330A

REF 1W, 23, !G, SY


Other Insured State Code ID Other Insured Postal Zone or ZIP Code ID Subscriber Country Code ID Location Qualifier ID Location Identifier AN Country Subdivision Code ID OTHER SUBSCRIBER SECONDARY IDENTIFICATION Reference Identification Qualifier Other Insured Additional Identifier Description REFERENCE IDENTIFIER

Page 76 of 93

2330A

1 IL 1, 2 Increase from 35 - 60 Increase from 25 - 35

II, MI

Code Change

New Element

1-55

2-3

Values

Name Change

AN

ID

Loop Repeat

Name Change R

S

S

2330A

End Stage Renal Disease Payment Amount Non-Payable Professional Component Billed Amount

1

3

Loop

837-I 5010

R

Other Insured State Code ID Other Insured Postal Zone or ZIP Code ID Subscriber Country Code ID Location Qualifier ID Location Identifier AN

OTHER SUBSCRIBER SECONDARY IDENTIFICATION Reference Identification Qualifier Other Insured Additional Identifier Description REFERENCE IDENTIFIER

ID

2330A

2330A Usage change to Situational Usage change to Situational

New Element # of Repeat change to 2

2

S

ID

2-3

R

AN AN

1-50 1-80

R N/U N/U

2330A Code Deleted SY Increase from 30 - 50

INSTITUTIONAL CLAIM


Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

2330B

1

Values

Element Identifier

PR 2

NM1 NM101 NM102

PI, XV

NM103 NM104 NM105 NM106 NM107 NM108

Description

837-I 4010A1 NM1 NM101 NM102 NM103 NM104 NM105 NM106 NM107 NM108 NM109 NM110 NM111

OTHER PAYER NAME Entity Identifier Code Entity Type Qualifier Other Payer Last or Organization Name Name First Name Middle Name Prefix Name Suffix Identification Code Qualifier

ID ID

1 2-3 1-1

R R R

AN AN AN AN AN ID

1-35 1-25 1-25 1-10 1-10 1-2

R N/U N/U N/U N/U R

Other Payer Primary Identifier AN Entity Relationship Code ID Entity Identifier Code ID

2-80 2-2 2-3

R N/U N/U

OTHER PAYER ADDRESS Other Payer Address Line Other Payer Address Line

N4 N401

OTHER PAYER CITY/STATE/ZIP CODE Other Payer City Name

N402 N403 N404 N405 N406

DTP DTP01 DTP02 DTP03

REF REF01 REF02 REF03

Other Payer State Code Other Payer Postal Zone or ZIP Code Payer Country Code Location Qualifier Location Identifier

CLAIM ADJUDICATION DATE Date Time Qualifier Date Time Period Format Qualifier

NM109 NM110 NM111

2330B

AN ID

2-2

R

N402

ID ID ID AN

3-15 2-3 1-2 1-30

R S N/U N/U

N403 N404 N405 N406 N407

2-3

Adjudication or Payment Date AN

1-35

OTHER PAYER SECONDARY IDENTIFICATION AND REFERENCE NUMBER Reference Identification Qualifier Other Payer Secondary Identifier Description

Loop Repeat

2330B

1

Values

2330B

R R R

AN AN AN AN AN ID

1-60 1-35 1-25 1-10 1-10 1-2

R N/U N/U N/U N/U R

Other Payer Primary Identifier AN Entity Relationship Code ID Entity Identifier Code ID Name Last or Organization Name AN

2-80 2-2 2-3

R N/U N/U

1-60

N/U

1 1-55 1-55

S R S

2330B

AN AN

R R

2330B

AN

1 2-30

ID

2-2

S

ID ID ID AN ID

3-15 2-3 1-2 1-30 1-3

S S N/U N/U S

ID

1 3-3

S R

ID

2-3

R

D8


1-35

R

CCYYMMDD

OTHER PAYER CITY/STATE/ZIP CODE Other Payer City Name

S R

ID

Loop

1 2-3 1-1

N4 N401

1 2-30

ID

Usage Reg.

ID ID

OTHER PAYER ADDRESS Other Payer Address Line Other Payer Address Line

S R S

S R

OTHER PAYER NAME Entity Identifier Code Entity Type Qualifier Other Payer Last or Organization Name Name First Name Middle Name Prefix Name Suffix Identification Code Qualifier

N3 N301 N302

1 1-55 1-55

2330B

AN AN

1 3-3

Min. Max.

837-I 5010

NM112 N3 N301 N302

ID

573

DTP DTP01

R

D8

DTP02

R

CCYYMMDD

DTP03

Other Payer State Code Other Payer Postal Zone or ZIP Code Other Payer Country Code Location Qualifier Location Identifier Country Subdivision Code DATE - CLAIM CHECK OR REMITTANCE DATE Date Time Qualifier Date Time Period Format Qualifier

PR 2 Increase from 35 - 60 Increase from 25 - 35

PI, XV

New Element


Usage change to Situational Usage change to Situational Name Change

New Element Name Change 2330B 573

Name Change

2

S

ID

2-3

R

AN AN

1-30 1-80

R N/U

2330B

REF 2U, F8, FY, NF, TJ

REF01 REF02 REF03

OTHER PAYER SECONDARY IDENTIFICATION Reference Identification Qualifier Other Payer Secondary Identifier Description

Page 77 of 93

2

S

ID

2-3

R

AN AN

1-50 1-80

R N/U

2330B Code Change 2U, EI, FY, NF Increase from 30 - 50

INSTITUTIONAL CLAIM


Description

REF04


ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

REF04


837-I 4010A1


OTHER PAYER PRIOR AUTHORIZATION OR REFERRAL NUMBER Reference Identification Qualifier Authorization or Referral Number Description REFERENCE IDENTIFIER

S

ID

2-3

R

AN AN

1-30 1-80

R N/U N/U

2330B

REF 9F, G1


OTHER PAYER PRIOR AUTHORIZATION NUMBER Reference Identification Qualifier Other Payer Prior Authorization Number Description REFERENCE IDENTIFIER

1

S

ID

2-3

R

Loop Repeat

Values

AN AN

1-50 1-80

R N/U N/U

1

S

New Segment

R

REF02 REF03 REF04

Other Payer Referral Number AN Description AN REFERENCE IDENTIFIER

1-50 1-80

R N/U N/U

1

S

ID

2-3

R

AN AN

1-50 1-80

R N/U N/U

1

S

ID

2-3

R

AN AN

1-50 1-80

R N/U N/U

REF02 REF03 REF04


OTHER PAYER CLAIM CONTROL NUMBER Reference Identification Qualifier Other Payer Claim Control Number Description REFERENCE IDENTIFIER

G1 Increase from 30 - 50

2-3

OTHER PAYER CLAIM ADJUSTMENT INDICATOR Reference Identification Qualifier Other Payer Claim Adjustment Indicator Description REFERENCE IDENTIFIER

2330B Code Change

ID

REF01

NM103 NM104 NM105 NM106 NM107

Loop

N/U

REF01

REF

OTHER PAYER PATIENT INFORMATION Entity Identifier Code Entity Type Qualifier Name Last or Organization Name Name First Name Middle Name Prefix Name Suffix

Usage Reg.

OTHER PAYER REFERRAL NUMBER Reference Identification Qualifier

REF

NM1 NM101 NM102

Min. Max.

837-I 5010

N/U

1

ID

2330B 9F

New Segment 2330B T4

New Segment 2330B F8

Segment Deleted ID ID

1 2-3 1-1

S R R

AN AN AN AN AN

1-35 1-25 1-25 1-10 1-10

N/U N/U N/U N/U N/U

2330C

1 QC 1

Page 78 of 93

INSTITUTIONAL CLAIM


Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

837-I 4010A1 NM108 NM109 NM110 NM111


Identification Code Qualifier Other Payer Patient Primary Identifier Entity Relationship Code Entity Identifier Code OTHER PAYER PATIENT IDENTIFICATION NUMBER Reference Identification Qualifier Other Payer Patient Secondary Identifier Description REFERENCE IDENTIFIER

ID

1-2

R

AN ID ID

2-80 2-2 2-3

R N/U N/U

3

S

ID

2-3

R

AN AN

1-30 1-80

R N/U N/U

S R R

Min. Max.

Usage Reg.

Loop

Loop Repeat

Values

837-I 5010 EI, MI

Segment Deleted 2330C 1W, IG, SY

ID ID

1 2-3 1-1

NM103 NM104 NM105 NM106 NM107 NM108

OTHER PAYER ATTENDING PROVIDER Entity Identifier Code Entity Type Qualifier Name Last or Organization Name Name First Name Middle Name Prefix Name Suffix Identification Code Qualifier

AN AN AN AN AN ID

1-35 1-25 1-25 1-10 1-10 1-2


NM103 NM104 NM105 NM106 NM107 NM108

NM109 NM110 NM111

Identification Code Entity Relationship Code Entity Identifier Code

AN ID ID

2-80 2-2 2-3

N/U N/U N/U

NM109 NM110 NM111

NM1 NM101 NM102

ID

2330D

1 71 1, 2

NM1 NM101 NM102

OTHER PAYER ATTENDING PROVIDER Entity Identifier Code Entity Type Qualifier Name Last or Organization Name Name First Name Middle Name Prefix Name Suffix Identification Code Qualifier

Loop Change ID ID

1 2-3 1-1

S R R

AN AN AN AN AN ID

1-60 1-35 1-25 1-10 1-10 1-2



2-80 2-2 2-3

N/U N/U N/U

1-60

N/U

2330C

1 71 1

Code Deleted Increase from 35 - 60 Increase from 25 - 35

Name Change

NM112

REF


NM1 NM101 NM102 NM103

OTHER PAYER ATTENDING PROVIDER SECONDARY IDENTIFICATION Reference Identification Qualifier Secondary Identifier Description REFERENCE IDENTIFIER OTHER PAYER OPERATING PROVIDER Entity Identifier Code Entity Type Qualifier Name Last or Organization Name

3

R

ID AN AN

2-3 1-30 1-80

R R N/U N/U

ID ID

1 2-3 1-1

S R R

AN

1-35

N/U

2330D 1A, 1B, 1C, 1D, 1G, 1H, EI, G2, LU, N5

2330E

1 72 1

REF

OTHER PAYER ATTENDING PROVIDER SECONDARY IDENTIFICATION



New Element

Loop Change # Repeats change to 4 4

R

2330C Code Change

NM1 NM101 NM102 NM103

OTHER PAYER OPERATING PROVIDER Entity Identifier Code Entity Type Qualifier Name Last or Organization Name

Page 79 of 93

ID AN AN

2-3 1-50 1-80

R R N/U N/U

ID ID

1 2-3 1-1

S R R

AN

1-60

N/U


Loop Change 2330D

1 72 1 Increase from 35 - 60

INSTITUTIONAL CLAIM


Description

NM104 NM105 NM106 NM107 NM108

Name First Name Middle Name Prefix Name Suffix Identification Code Qualifier

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Description

ID

Name First Name Middle Name Prefix Name Suffix Identification Code Qualifier

AN AN AN AN ID

1-35 1-25 1-10 1-10 1-2

N/U N/U N/U N/U N/U


2-80 2-2 2-3

N/U N/U N/U

1-60

N/U

837-I 4010A1

NM109 NM110 NM111

1-25 1-25 1-10 1-10 1-2

N/U N/U N/U N/U N/U

NM104 NM105 NM106 NM107 NM108


2-80 2-2 2-3

N/U N/U N/U

NM109 NM110 NM111 NM112

REF




3

R

2330E 1A, 1B, 1C, 1D, 1G, 1H, EI, G2, LU, N5

REF

OTHER PAYER OPERATING PROVIDER SECONDARY IDENTIFICATION



2-3 1-30 1-80

R R N/U N/U

ID ID

1 2-3 1-1

S R R

AN AN AN AN AN ID

1-35 1-25 1-25 1-10 1-10 1-2


NM103 NM104 NM105 NM106 NM107 NM108


2-80 2-2 2-3

N/U N/U N/U

NM109 NM110 NM111

2330F

1 73 1, 2

NM1 NM101 NM102

NM112

REF

REF01 REF02

OTHER PAYER OTHER PROVIDER IDENTIFICATION Reference Identification Qualifier Secondary Identifier

3

ID AN

2-3 1-30

R

R R

Loop Repeat

Values

2330F 1A, 1B, 1C, 1D, 1G, 1H, EI, G2, LU, N5, SY


Loop Change Name Change # Repeats change to 4 4

R

2330D Code Change

ID AN AN

OTHER PAYER OTHER PROVIDER Entity Identifier Code Entity Type Qualifier Name Last or Organization Name Name First Name Middle Name Prefix Name Suffix Identification Code Qualifier

Loop

837-I 5010

AN AN AN AN ID

OTHER PAYER OPERATING PROVIDER IDENTIFICATION

Min. Max.

Usage Reg.

Element Identifier

ID AN AN

2-3 1-50 1-80

R R N/U N/U

ID ID

1 2-3 1-1

S R R

AN AN AN AN AN ID

1-60 1-35 1-25 1-10 1-10 1-2



2-80 2-2 2-3

N/U N/U N/U

1-60

N/U

OTHER PAYER OTHER OPERATING PROVIDER Entity Identifier Code Entity Type Qualifier Name Last or Organization Name Name First Name Middle Name Prefix Name Suffix Identification Code Qualifier

REF

OTHER PAYER OTHER OPERATING PROVIDER SECONDARY IDENTIFICATION

REF01 REF02

Reference Identification Qualifier Secondary Identifier


2330E

1 ZZ 1

Loop Change Name Change Code Change Code Deleted Increase from 35 - 60 Increase from 25 - 35

New Element

Loop Change Name Change # Repeats change to 4 4

R

2330E Code Change

Page 80 of 93

ID AN

2-3 1-50

R R


INSTITUTIONAL CLAIM


Description

REF03 REF04

Description REFERENCE IDENTIFIER

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Description

ID

REF03 REF04


AN

1-80

N/U N/U

ID ID

1 2-3 1-1

S R R

AN AN AN AN AN ID

1-60 1-35 1-25 1-10 1-10 1-2



2-80 2-2 2-3

N/U N/U N/U

1-60

N/U

837-I 4010A1



1-80

N/U N/U

ID ID

1 2-3 1-1

S R R

AN AN AN AN AN ID

1-35 1-25 1-25 1-10 1-10 1-2


NM103 NM104 NM105 NM106 NM107 NM108


2-80 2-2 2-3

N/U N/U N/U

NM109 NM110 NM111

1-60

N/U

NM112

OTHER PAYER SERVICE FACILITY PROVIDER IDENTIFICATION Reference Identification Qualifier Other Payer Service Facility Location Secondary Identifier Description REFERENCE IDENTIFIER

3

R

ID

2-3

R

AN AN

1-30 1-80

R N/U N/U

Loop

Loop Repeat

2330F

1

Values

837-I 5010

AN

OTHER PAYER SERVICE FACILITY PROVIDER Entity Identifier Code Entity Type Qualifier Name Last or Organization Name Name First Name Middle Name Prefix Name Suffix Identification Code Qualifier

Min. Max.

Usage Reg.

Element Identifier

2330H

1 FA 2

2330H

NM1 NM101 NM102

REF 1B, 1C, 1D, EI, G2, LU, N5



OTHER PAYER SERVICE FACILITY LOCATION Entity Identifier Code Entity Type Qualifier Name Last or Organization Name Name First Name Middle Name Prefix Name Suffix Identification Code Qualifier

OTHER PAYER SERVICE FACILITY LOCATION SECONDARY IDENTIFIER Reference Identification Qualifier Other Payer Service Facility Location Secondary Identifier Description REFERENCE IDENTIFIER


R

ID

2-3

R

AN AN

1-50 1-80

R N/U N/U

ID ID

1 2-3 1-1

S R R

AN AN AN AN AN ID

1-60 1-35 1-25 1-10 1-10 1-2



2-80 2-2 2-3

N/U N/U N/U

1-60

N/U

Page 81 of 93


Loop Change Name Change 3

OTHER PAYER RENDERING PROVIDER Entity Identifier Code Entity Type Qualifier Name Last or Organization Name Name First Name Middle Name Prefix Name Suffix Identification Code Qualifier

77 2

Loop Change Name Change Code Change

2330F Code Change 0B, G2, LU Increase from 30 - 50

New Segment 2330G

1 82 1

INSTITUTIONAL CLAIM


Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

837-I 4010A1

ID

Min. Max.

Usage Reg.

Loop

Loop Repeat

Values

837-I 5010 REF REF01 REF02 REF03 REF04


OTHER PAYER RENDERING PROVIDER SECONDARY IDENTIFIER Reference Identification Qualifier Other Payer Rendering Provider Secondary Identifier Description REFERENCE IDENTIFIER

New Segment 4

R

ID

2-3

R

AN AN

1-50 1-80

R N/U N/U

ID ID

1 2-3 1-1

S R R

AN AN AN AN AN ID

1-60 1-35 1-25 1-10 1-10 1-2



2-80 2-2 2-3

N/U N/U N/U

1-60

N/U

OTHER PAYER REFERRING PROVIDER Entity Identifier Code Entity Type Qualifier Name Last or Organization Name Name First Name Middle Name Prefix Name Suffix Identification Code Qualifier

REF01

REF02 REF03 REF04

Other Payer Referring Provider Secondary Identifier Description REFERENCE IDENTIFIER


OTHER PAYER BILLING PROVIDER Entity Identifier Code Entity Type Qualifier Name Last or Organization Name Name First Name Middle Name Prefix Name Suffix

Page 82 of 93

0B, 1G, G2, LU

New Segment

OTHER PAYER REFERRING PROVIDER SECONDARY IDENTIFIER Reference Identification Qualifier ID

REF

2330G

2330H

1 DN 1

New Segment 3

R

2-3

R

AN AN

1-50 1-80

R N/U N/U

ID ID

1 2-3 1-1

S R R

AN AN AN AN AN

1-60 1-35 1-25 1-10 1-10

N/U N/U N/U N/U N/U

2330H 0B, 1G, G2

New Segment 2330I

1 85 2

INSTITUTIONAL CLAIM


Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Description

ID

NM108


ID

1-2

N/U


2-80 2-2 2-3

N/U N/U N/U

1-60

N/U

837-I 4010A1

NM112

REF02 REF03 REF04 LX LX01

SERVICE LINE Assigned Number

1 1-6

R R

2400

N0

SV2 SV201

INSTITUTIONAL SERVICE LINE Revenue Code

1 1-48

R R

2400

AN

REF01

SV2 SV201

INSTITUTIONAL SERVICE LINE Revenue Code

Loop Repeat

Values

1 1-6

R R

2400

N0

R R

2400

AN

1 1-48

999

New Segment

OTHER PAYER BILLING PROVIDER SECONDARY IDENTIFICATION Reference Identification Qualifier Other Payer Billing Provider Secondary Identification Description REFERENCE IDENTIFIER

REF

SERVICE LINE NUMBER Assigned Number

Loop

837-I 5010 NM109 NM110 NM111

LX LX01

Min. Max.

Usage Reg.

Element Identifier

2

R

ID

2-3

R

AN AN

1-50 1-80

R N/U N/U

2330I G2, LU

Name Change

999


SV202-1 SV202-2 SV202-3 SV202-4 SV202-5 SV202-6

COMPOSITE Product or Service ID Qualifier Procedure Code Procedure Modifier Procedure Modifier Procedure Modifier Procedure Modifier

ID AN AN AN AN AN

2-2 1-48 2-2 2-2 2-2 2-2

R R S S S S

SV202-7

Description

AN

1-80

N/U

SV203

R

1-18

R

SV204 SV205

Line Item Charge Amount Unit or Basis for Measurement Code Service Unit Count

ID R

2-2 1-15

R R

SV206 SV207 SV208 SV209 SV210

Unit Rate Monetary Amount Y/N NHRSC Level of Care Code

ID R ID ID ID

1-10 1-18 1-1 1-1 1-1

S S N/U N/U N/U

PWK

LINE SUPPLEMENTAL INFORMATION

5

S

SV202

S

SV202 HC, IV, ZZ

SV202-1 SV202-2 SV202-3 SV202-4 SV202-5 SV202-6

2400

R ID AN AN AN AN AN

2-2 1-48 2-2 2-2 2-2 2-2

R R S S S S

AN AN R

1-80 1-48 1-18

S N/U R

SV204 SV205

Description Product/Service ID Line Item Charge Amount Unit or Basis for Measurement Code Service Units/Days

ID R

2-2 1-15

R R

SV206 SV207 SV208 SV209 SV210

Unit Rate Monetary Amount Y/N NHRSC Level of Care Code

ID R ID ID ID

1-10 1-18 1-1 1-1 1-1

N/U S N/U N/U N/U

PWK

LINE SUPPLEMENTAL INFORMATION

10

S

SV202-7 SV202-8 SV203 DA, F2, UN

COMPOSITE Product or Service ID Qualifier Procedure Code Procedure Modifier Procedure Modifier Procedure Modifier Procedure Modifier

Page 83 of 93

ER, HC, HP, IV, Code Change WK

Usage change to Situational New Element Code Deleted DA, UN Name Change Usage change to Not Used

# Repeats change to 10 2400

INSTITUTIONAL CLAIM


Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

837-I 4010A1

ID

Min. Max.

Usage Reg.

Loop

Loop Repeat

Values

837-I 5010 Code Added

PWK01

Attachment Report Type Code

PWK02 PWK03 PWK04

Attachment Transmission Code Report Copies Needed Entity Identifier Code

PWK05 PWK06 PWK07 PWK08 PWK09

Identification Code Qualifier Identification Code Description ACTIONS INDICATED Request Category Code

ID

2-2

AS, B2, B3, B4, CT, D2, DA, DG, DS, EB, MT, NN, OB, OZ, PN, PO, PZ, RB, RR, RT

R

ID N0 ID

1-2 1-2 2-3

R N/U N/U

ID AN AN

1-2 2-80 1-80

ID

1-2

S S N/U N/U N/U

AA, AB, AD, AF, AG, BM, EL, EM, FX

AC

PWK01

Attachment Report Type Code

PWK02 PWK03 PWK04

Attachment Transmission Code Report Copies Needed Entity Identifier Code

PWK05 PWK06 PWK07 PWK08 PWK09

Identification Code Qualifier Identification Code Description ACTIONS INDICATED Request Category Code

ID

2-2

03, 04, 05, 06, 07, 08, 09, 10, 11, 13, 15, 21, A3, A4, AM, AS, B2, B3, B4, BR, BS, BT, CB, CK, CT, D2, DA, DB, DG, DJ, DS, EB, HC, HR, I5, IR, LA, M1, MT, NN, OB, OC, OD, OE, OX, OZ, P4, P5, PE, PN, PO, PQ, PY, PZ, RB, RR, RT, RX, SG, V5, XP

R

Code Change ID N0 ID

1-2 1-2 2-3

R N/U N/U

ID AN AN

1-2 2-80 1-80

ID

1-2

S S N/U N/U N/U

AA, BM, EL, EM, FT, FX

AC

Name Change Usage change to Required DTP DTP01 DTP02

SERVICE LINE DATE Date Time Qualifier Date Time Period Format Qualifier

DTP03

Service Date

DTP

ASSESSMENT DATE

DTP01

ID

1 3-3

R R

ID

2-3

2400 472

DTP DTP01

R

D8, RD8

DTP02

R

CYYMMDD, CCYYMMDDCCYYMMDD

AN

1-35 1

S

ID

3-3

R

DTP02

Date Time Qualifier Date Time Period Format Qualifier

ID

2-3

R

D8

DTP03

Assessment Date

AN

1-35

R

CCYYMMDD

DATE - SERVICE DATE Date Time Qualifier Date Time Period Format Qualifier

Service Date

DTP03

ID

1 3-3

R R

ID

2-3

R

D8, RD8

R

CYYMMDD, CCYYMMDDCCYYMMDD

AN

1-35

2400 472

Segment Deleted

2400 866

REF REF01 REF02

LINE ITEM CONTROL NUMBER Reference Identification Qualifier Line Item Control Number

Page 84 of 93

New Segment

ID AN

1

S

2-3 1-50

R R

2400 6R

INSTITUTIONAL CLAIM


Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

ID

REF03 REF04


AN

837-I 4010A1



SERVICE TAX AMOUNT Amount Qualifier Code Service Tax Amount Credit/Debit Flag Code

1 1-3 1-18 1-1

S R R N/U

2400

ID R ID


FACILITY TAX AMOUNT Amount Qualifier Code Facility Tax Amount Credit/Debit Flag Code

1 1-3 1-18 1-1

S R R N/U

2400

ID R ID

HCP01 HCP02 HCP03 HCP04 HCP05

Pricing Methodology Repriced Allowed Amount Repriced Saving Amount Repricing Organization Identifier Repricing Per Diem or Flat Rate Amount

S

GT

N8

2400 00, 01, 02, 03, 04, 05, 06, 07, 08, 09, 10, 11, 12, 13, 14

1-80

N/U N/U

1

S

2-3

R

1-50 1-80

R N/U N/U

1

S

ID

2-3

R

AN AN

1-50 1-80

R N/U N/U

REPRICED LINE ITEM REFERENCE NUMBER Reference Identification Qualifier ID Repriced Line Item Reference Number AN Description AN REFERENCE IDENTIFIER

Loop Repeat

Values

New Segment 2400 9B

New Segment

REF02 REF03 REF04 AMT AMT01 AMT02 AMT03

SERVICE TAX AMOUNT Amount Qualifier Code Tax Amount Credit/Debit Flag Code

1 1-3 1-18 1-1

S R R N/U

2400

ID R ID


FACILITY TAX AMOUNT Amount Qualifier Code Facility Tax Amount Credit/Debit Flag Code

1 1-3 1-18 1-1

S R R N/U

2400

ID R ID

NTE NTE01 NTE02

THIRD PARTY ORGANIZATION NOTES Note Reference Code Claim Note Text

S R R

2400

ID AN

1 3-3 1-80

HCP

LINE PRICING/REPRICING INFORMATION

1

S

2400

REF01

1

Loop

ITEM REFERENCE NUMBER Reference Identification Qualifier Adjusted Repriced Line Item Reference Number Description REFERENCE IDENTIFIER

REF

LINE PRICING/REPRICING INFORMATION

Usage Reg.

837-I 5010

REF

HCP

Min. Max.

ID R R

2-2 1-18 1-18

R R S

HCP01 HCP02 HCP03

AN

1-30

S

HCP04

R

1-9

S

HCP05

Pricing Methodology Repriced Allowed Amount Repriced Saving Amount Repricing Organization Identifier Repricing Per Diem or Flat Rate Amount

Page 85 of 93

2400 9D

GT Name Change

N8

Segment Added

ID R R

2-2 1-18 1-18

R R S

AN

1-50

S

R

1-9

S

TPO

00, 01, 02, 03, 04, 05, 06, 07, 08, 09, 10, 11, 12, 13, 14


INSTITUTIONAL CLAIM


Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

837-I 4010A1 HCP06 HCP07

Ambulatory Patient Group Code Ambulatory Patient Group Amount

ID

Min. Max.

Usage Reg.

Loop

Loop Repeat

Values

837-I 5010

AN

1-30

S

HCP06

R

1-18

S

HCP07

AN

1-48

S

HCP08

ID AN ID

2-2 1-48 2-2

S S S

R

1-15

S

Ambulatory Patient Group Code Ambulatory Patient Group Amount

Increase from 30 - 50 AN

1-50

S

R

1-18

S Usage change to Not Used

HCP08 HCP09 HCP10 HCP11 HCP12

Product/Service ID Product or Service ID Qualifier Procedure Code Measurement Code Repriced Approved Service Unit Count "DA" "UN"

HCP13 HCP14 HCP15


LIN LIN01

DRUG IDENTIFICATION Assigned Identification Product or Service ID Qualifier National Drug Code Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier

LIN02 LIN03 LIN04 LIN05 LIN06 LIN07 LIN08 LIN09 LIN10 LIN11 LIN12 LIN13 LIN14 LIN15 LIN16 LIN17 LIN18 LIN19 LIN20 LIN21 LIN22 LIN23 LIN24 LIN25 LIN26 LIN27 LIN28 LIN29 LIN30

ID ID ID

2-2 1-2 1-2

S S S

AN

1 1-20

S N/U

ID AN ID AN ID AN ID AN ID AN ID AN ID AN ID AN ID AN ID AN ID AN ID AN ID AN ID AN ID

2-2 1-48 2-2 1-48 2-2 1-48 2-2 1-48 2-2 1-48 2-2 1-48 2-2 1-48 2-2 1-48 2-2 1-48 2-2 1-48 2-2 1-48 2-2 1-48 2-2 1-48 2-2 1-48 2-2

R R N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U

HC DA, UN

T1, T2, T3, T4, T5, T6 1, 2, 3, 4, 5 1, 2, 3, 4, 5, 6

2410

25

N4

AN

1-48

N/U

ID AN ID

2-2 1-48 2-2

S S S

HCP12

Product/Service ID Product or Service ID Qualifier Procedure Code Measurement Code Repriced Approved Service Unit Count "DA" "UN"

R

1-15

S

HCP13 HCP14 HCP15


ID ID ID

2-2 1-2 1-2

S S S

LIN LIN01

DRUG IDENTIFICATION Assigned Identification Product or Service ID Qualifier National Drug Code Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier

AN

1 1-20

S N/U

ID AN ID AN ID AN ID AN ID AN ID AN ID AN ID AN ID AN ID AN ID AN ID AN ID AN ID AN ID

2-2 1-48 2-2 1-48 2-2 1-48 2-2 1-48 2-2 1-48 2-2 1-48 2-2 1-48 2-2 1-48 2-2 1-48 2-2 1-48 2-2 1-48 2-2 1-48 2-2 1-48 2-2 1-48 2-2

R R N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U

HCP09 HCP10 HCP11

LIN02 LIN03 LIN04 LIN05 LIN06 LIN07 LIN08 LIN09 LIN10 LIN11 LIN12 LIN13 LIN14 LIN15 LIN16 LIN17 LIN18 LIN19 LIN20 LIN21 LIN22 LIN23 LIN24 LIN25 LIN26 LIN27 LIN28 LIN29 LIN30

Page 86 of 93

ER, HC, HP, IV, Code Added WK DA, UN

T1, T2, T3, T4, T5, T6 1, 2, 3, 4, 5 1, 2, 3, 4, 5, 6

2410

# Loop Repeats change to 1

1

N4

INSTITUTIONAL CLAIM


Description

LIN31

Product/Service ID

CTP CTP01 CTP02

DRUG QUANTITY Class of Trade Code Price Identifier Code

CTP03 CTP04

Unit Price National Drug Unit Count COMPOSITE UNIT OF MEASURE Unit or Basis For Measurement Code Exponent Multiplier Unit or Basis For Measurement Code Exponent Multiplier Unit or Basis For Measurement Code Exponent Multiplier Unit or Basis For Measurement Code Exponent Multiplier Unit or Basis For Measurement Code Exponent Multiplier Price Multiplier Qualifier Multiplier Monetary Amount Basis of Unit Price Code Condition Value Multiple Price Quantity

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Description

ID

LIN31

Product/Service ID

AN

1-48

N/U

CTP CTP01 CTP02

DRUG QUANTITY Class of Trade Code Price Identifier Code

ID ID

1 2-2 3-3

R N/U N/U

Unit Price National Drug Unit Count COMPOSITE UNIT OF MEASURE Unit or Basis For Measurement Code Exponent Multiplier Unit or Basis For Measurement Code Exponent Multiplier Unit or Basis For Measurement Code Exponent Multiplier Unit or Basis For Measurement Code Exponent Multiplier Unit or Basis For Measurement Code Exponent Multiplier Price Multiplier Qualifier Multiplier Monetary Amount Basis of Unit Price Code Condition Value Multiple Price Quantity

R R

1-17 1-15

N/U R

837-I 4010A1

Min. Max.

Usage Reg.

Element Identifier

Loop

Loop Repeat

Values

837-I 5010

AN

1-48

N/U

ID ID

1 2-2 3-3

S N/U N/U

R R

1-17 1-15

R R

CTP03 CTP04

R

CTP05

Usage Change to Required 2410

2410


CTP05 CTP05-1 CTP05-2 CTP05-3 CTP05-4 CTP05-5 CTP05-6 CTP05-7 CTP05-8 CTP05-9 CTP05-10 CTP05-11 CTP05-12 CTP05-13 CTP05-14 CTP05-15 CTP06 CTP07 CTP08 CTP09 CTP10 CTP11


PRESCRIPTION NUMBER Reference Identification Qualifier Prescription Number Desciption REFERENCE IDENTIFIER

NM1

ATTENDING PHYSICIAN NAME

REF

F2, GR, ML, UN

ID R R

2-2 1-15 1-10

R N/U N/U

ID R R

2-2 1-15 1-10

N/U N/U N/U

CTP05-4 CTP05-5 CTP05-6

ID R R

2-2 1-15 1-10

N/U N/U N/U

CTP05-7 CTP05-8 CTP05-9

ID R R

2-2 1-15 1-10

N/U N/U N/U

CTP05-10 CTP05-11 CTP05-12

ID R R ID R R ID AN N0

2-2 1-15 1-10 3-3 1-10 1-18 2-2 1-10 1-2

N/U N/U N/U N/U N/U N/U N/U N/U N/U

CTP05-13 CTP05-14 CTP05-15 CTP06 CTP07 CTP08 CTP09 CTP10 CTP11

ID AN AN

1

S

2-3 1-30 1-80

R R N/U N/U

1

S

2410

CTP05-1 CTP05-2 CTP05-3

REF XZ


PRESCRIPTION OR COMPOUND DRUG ASSOCIATION NUMBER Reference Identification Qualifier Prescription Number Desciption REFERENCE IDENTIFIER

R ID R R

2-2 1-15 1-10

R N/U N/U

ID R R

2-2 1-15 1-10

N/U N/U N/U

ID R R

2-2 1-15 1-10

N/U N/U N/U

ID R R

2-2 1-15 1-10

N/U N/U N/U

ID R R ID R R ID AN N0

2-2 1-15 1-10 3-3 1-10 1-18 2-2 1-10 1-2

N/U N/U N/U N/U N/U N/U N/U N/U N/U

F2, GR, ME, ML, Code Added UN

Name Change 1

S

2-3 1-50 1-80

R R N/U N/U

2410 Code Added

ID AN AN

VY, XZ Increase from 30 - 50

Segment Deleted 2420A

1

Page 87 of 93

INSTITUTIONAL CLAIM


Description

NM101 NM102 NM103 NM104 NM105 NM106 NM107 NM108 NM109 NM110 NM111

Entity Identifier Code Entity Type Qualifier Last Name First Name Middle Name Name Prefix Name Suffix Identification Code Qualifier Identifier Entity Relationship Code Entity Identifier Code

REF

ATTENDING PHYSICIAN SECONDARY IDENTIFICATION

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

837-I 4010A1




OPERATING PHYSICIAN NAME Entity Identifier Code Entity Type Qualifier Last Name First Name Middle Name Name Prefix Name Suffix Identification Code Qualifier Identifier Entity Relationship Code Entity Identifier Code

REF


Reference Identification Qualifier Secondary Identifier Description

REF04


Min. Max.

Usage Reg.

Loop

Loop Repeat

Values

837-I 5010 71 1, 2

R R R S S N/U S S S N/U N/U

24, 34, XX

Segment Deleted 1

S

ID AN AN

2-3 1-30 1-80

R R N/U S


1 2-3 1-1 1-35 1-25 1-25 1-10 1-10 1-2 2-80 2-2 2-3

S R R R S S N/U S S S N/U N/U


REF01 REF02 REF03

2-3 1-1 1-35 1-25 1-25 1-10 1-10 1-2 2-80 2-2 2-3

ID

1

ID AN AN

2-3 1-30 1-80

S

R R N/U

2420A OB, 1A, 1B, 1C, 1D, 1G, 1H, EI, G2, LU, N5, SY, X5

2420B

1 72 1

24, 34, XX

2420B OB, 1A, 1B, 1C, 1D, 1G, 1H, EI, G2, LU, N5, SY, X5

NM112

OPERATING PHYSICIAN NAME Entity Identifier Code Entity Type Qualifier Last Name First Name Middle Name Name Prefix Name Suffix Identification Code Qualifier Identifier Entity Relationship Code Entity Identifier Code Name Last or Organization Name

REF




1 2-3 1-1 1-60 1-35 1-25 1-10 1-10 1-2 2-80 2-2 2-3


AN

1-60

N/U

2420A

1 72 1 Increase from 35 - 60 Increase from 25 - 35

XX

Code Deleted

New Element

# Reeats change to 20 20

S

2420A Code Change

REF01 REF02 REF03

Reference Identification Qualifier Secondary Identifier Description

REF04


ID AN AN

2-3 1-50 1-80

R R N/U

OB, 1G, G2, LU Increase from 30 - 50 Usage change to Siuational

N/U

Page 88 of 93

S

INSTITUTIONAL CLAIM


Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

837-I 4010A1

ID

Min. Max.

Usage Reg.

Loop

Loop Repeat

Values

837-I 5010 New Element REF04-1 REF04-2 REF04-3 REF04-4 REF04-5 REF04-6


REF REF01 REF02 REF03 REF04 REF04-1 REF04-2 REF04-3 REF04-4 REF04-5 REF04-6 NM1 NM101 NM102

OTHER PROVIDER NAME Entity Identifier Code Entity Type Qualifier

ID ID

1 2-3 1-1

S R R

NM103

Other Physician Last Name

AN

1-35

R

NM104

Other Physician First Name

AN

1-25

S

2420C

Reference Identifier Qualifier Idenitifer Reference Identification Qualifier Reference Identification Reference Identification Qualifier Reference Identification OTHER OPERATING PHYSICIAN NAME Entity Identifier Code Entity Type Qualifier Last Name First Name Middle Name Name Prefix Name Suffix Identification Code Qualifier Identifier Entity Relationship Code Entity Identifier Code Name Last or Organization Name OTHER OPERATING PHYSICIAN SECONDARY IDENTIFICATION Reference Identification Qualifier Secondary Identifier Description REFERENCE IDENTIFIER Reference Identifier Qualifier Idenitifer Reference Identification Qualifier Reference Identification Reference Identification Qualifier Reference Identification

ID AN

2-3 1-50

R R

ID AN

2-3 1-50

N/U N/U

ID AN

2-3 1-50

N/U N/U


1 2-3 1-1 1-60 1-35 1-25 1-10 1-10 1-2 2-80 2-2 2-3


AN

1-60

N/U

2U New Element New Element New Element New Element New Element New Segment 2420B

1 ZZ 1

XX

New Segment 20

S

2420B

ID AN AN

2-3 1-50 1-80

R R N/U S

OB, 1G, G2, LU

ID AN

2-3 1-50

R R

2U

ID AN

2-3 1-50

N/U N/U

ID AN

2-3 1-50

N/U N/U Segment Deleted

1 73 1, 2

Page 89 of 93

INSTITUTIONAL CLAIM


Description

NM105 NM106 NM107 NM108 NM109 NM110 NM111

Middle Name Name Prefix Name Suffix Identification Code Qualifier Identifier Entity Relationship Code Entity Identifier Code

REF

OTHER PROVIDER SECONDARY IDENTIFICATION



ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

837-I 4010A1 AN AN AN ID AN ID ID

1-25 1-10 1-10 1-2 2-80 2-2 2-3

ID

Min. Max.

Usage Reg.

Loop

Loop Repeat

Values

837-I 5010

S N/U S R R N/U N/U

24, 34, XX

Segment Deleted 1

ID AN AN

2-3 1-30 1-80

S

R R N/U S

2420B OB, 1A, 1B, 1C, 1D, 1G, 1H, EI, G2, LU, N5, SY, X5



RENDERING PROVIDER NAME Entity Identifier Code Entity Type Qualifier Rendering Provider Last or Organization Name Rendering Provider First Name Rendering Provider Middle Name Name Prefix Rendering Provider Name Suffix Identification Code Qualifier Rendering Provider Identifier Entity Relationship Code Entity Identifier Code Name Last or Organization Name RENDERING PROVIDER SECONDARY IDENTIFICATION Reference Identification Qualifier Rendering Provider Secondary Identifier Description REFERENCE IDENTIFIER

Page 90 of 93

New Segment ID ID

1 2-3 1-1

S R R

AN

1-60

R

AN

1-35

S

AN AN

1-25 1-10

S N/U

AN ID

1-10 1-2

S S

AN ID ID

2-80 2-2 2-3

S N/U N/U

AN

1-60

N/U

2420C

1 82 1

XX

New Segment 20

S

ID

2-3

R

AN AN

1-50 1-80

R N/U S

2420C OB, 1G, G2, LU

INSTITUTIONAL CLAIM


Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

837-I 4010A1

ID

Min. Max.

Usage Reg.

Loop

Loop Repeat

Values

837-I 5010 REF04-1

Reference Identifier Qualifier

ID

2-3

R

REF04-2

Other Payer Primary Idenitifer AN Reference Identification Qualifier ID Reference Identification AN Reference Identification Qualifier ID Reference Identification AN

1-50

R

2-3 1-50

N/U N/U

2-3 1-50

N/U N/U

ID ID

1 2-3 1-1

S R R

NM103

Referring Provider Last Name AN

1-60

R

NM104

Referring Provider First Name Referring Provider Middle Name or Initial Name Prefix Referring Provider Name Suffix Identification Code Qualifier

AN

1-35

S

AN AN

1-25 1-10

S N/U

AN ID

1-10 1-2

S S


2-80 2-2 2-3

S N/U N/U

1-60

N/U

REF04-3 REF04-4 REF04-5 REF04-6

NM1 NM101 NM102



REFERRING PROVIDER NAME Entity Identifier Code Entity Type Qualifier

New Segment

REFERRING PROVIDER SECONDARY IDENTIFICATION Reference Identification Qualifier ID Referring Provider Secondary Identifier AN Description AN REFERENCE IDENTIFIER

20

S

2-3

R

1-50 1-80

R N/U S

Reference Identifier Qualifier

ID

2-3

R

REF04-2

Other Payer Primary Idenitifer AN Reference Identification Qualifier ID Reference Identification AN Reference Identification Qualifier ID

1-50

R

2-3 1-50

N/U N/U

2-3

N/U

REF04-5

Page 91 of 93

2420D

1 DN 1

XX

New Segment

REF04-1

REF04-3 REF04-4

2U

2420D OB, 1G, G2

2U

INSTITUTIONAL CLAIM


Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

ID

REF04-6

Reference Identification

AN

SVD

LINE ADJUDICATION INFORMATION

837-I 4010A1

SVD

LINE ADJUDICATION INFORMATION

Min. Max.

Usage Reg.

Loop

Loop Repeat

2430

15

Values

837-I 5010

1

S

2430

25

2-80 1-18

R R

SVD01 SVD02

R

SVD03

1-50

N/U

1

S

2-80 1-18

R R

Name Change

SVD03-1 SVD03-2 SVD03-3 SVD03-4 SVD03-5 SVD03-6

Payer Identifier Service Line Paid Amount COMPOSITE MEDICAL PROCEDURE IDENTIFIER Product or Service ID Qualifier Procedure Code Procedure Modifier Procedure Modifier Procedure Modifier Procedure Modifier

ID AN AN AN AN AN

2-2 1-48 2-2 2-2 2-2 2-2

R R S S S S

SVD03-7

Procedure Code Description

AN

1-80

S

SVD01 SVD02 SVD03

SVD04 SVD05 SVD06

Product or Service ID Paid Service Unit Count Bundled or Unbundled Line Number

CAS01 CAS02 CAS03 CAS04 CAS05 CAS06 CAS07 CAS08 CAS09 CAS10 CAS11 CAS12 CAS13 CAS14 CAS15 CAS16 CAS17 CAS18 CAS19

LINE ADJUSTMENT Claim Adjustment Group Code Adjustment Reason Code Adjustment Amount Adjustment Quantity Adjustment Reason Code Adjustment Amount Adjustment Quantity Adjustment Reason Code Adjustment Amount Adjustment Quantity Adjustment Reason Code Adjustment Amount Adjustment Quantity Adjustment Reason Code Adjustment Amount Adjustment Quantity Adjustment Reason Code Adjustment Amount Adjustment Quantity

DTP

SERVICE ADJUDICATION DATE

CAS

AN R

HC, IV, ZZ

SVD03-1 SVD03-2 SVD03-3 SVD03-4 SVD03-5 SVD03-6

Other Payer Primary Identifier Service Line Paid Amount COMPOSITE MEDICAL PROCEDURE IDENTIFIER Product or Service ID Qualifier Procedure Code Procedure Modifier Procedure Modifier Procedure Modifier Procedure Modifier

ID AN AN AN AN AN

2-2 1-48 2-2 2-2 2-2 2-2

R R S S S S

SVD03-7 SVD03-8

Procedure Code Description Product/Service ID

AN AN

1-80 1-48

S N/U

Product or Service ID Paid Service Unit Count Bundled or Unbundled Line Number

AN R

1-48 1-15

N/U R

N0

1-6

S

5

S

1-2 1-5 1-18 1-15 1-5 1-18 1-15 1-5 1-18 1-15 1-5 1-18 1-15 1-5 1-18 1-15 1-5 1-18 1-15

R R R S S S S S S S S S S S S S S S S

AN R

1-48 1-15

R R

SVD04 SVD05

N0

1-6

S

SVD06

99

S

ID ID R R ID R R ID R R ID R R ID R R ID R R

1-2 1-5 1-18 1-15 1-5 1-18 1-15 1-5 1-18 1-15 1-5 1-18 1-15 1-5 1-18 1-15 1-5 1-18 1-15

1

2430

R R R S S S S S S S S S S S S S S S S

S

2430

CAS01 CAS02 CAS03 CAS04 CAS05 CAS06 CAS07 CAS08 CAS09 CAS10 CAS11 CAS12 CAS13 CAS14 CAS15 CAS16 CAS17 CAS18 CAS19

LINE ADJUSTMENT Claim Adjustment Group Code Adjustment Reason Code Adjustment Amount Adjustment Quantity Adjustment Reason Code Adjustment Amount Adjustment Quantity Adjustment Reason Code Adjustment Amount Adjustment Quantity Adjustment Reason Code Adjustment Amount Adjustment Quantity Adjustment Reason Code Adjustment Amount Adjustment Quantity Adjustment Reason Code Adjustment Amount Adjustment Quantity

DTP

LINE CHECK OR REMITTANCE DATE

CAS CO, CR, OA, PI, PR

Page 92 of 93

AN R

R

ID ID R R ID R R ID R R ID R R ID R R ID R R

ER, HC, HP, IV, Code Change WK

New Element Usage change to Not Used

2430 CO, CR, OA, PI, PR

Name Change Usage change to Required 1

R

2430

INSTITUTIONAL CLAIM


Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

DTP02 DTP03


3-3

R

573

DTP01

ID

2-3

R

D8

DTP02


1-35

R

CCYYMMDD

DTP03

AMT02 AMT03

SE02

GE GE01 GE02

TRANSACTION SET TRAILER Transaction Segment Count Transaction Set Control Number FUNCTION GROUP TRAILER Number of Transaction Sets Included Group Control Number

N0

1 1-10

R R

AN

4-9

R

1

R

1-6 1-9

R R

1

R

N0 N0

IEA01

INTERCHANGE CONTROL TRAILER Number of Included Functional Groups

N0

1-5

R

IEA02


N0

9-9

R

IEA

Loop Repeat


ID

3-3

R

573

ID

2-3

R

D8


1-35

R

CCYYMMDD

ID

1 1-3

S R

R ID

1-18 1-1

R N/U

N0

1 1-10

R R

AN

4-9

R

1

R

1-6 1-9

R R

1

R

Loop

Values

837-I 5010

ID

AMT AMT01

SE SE01

Usage Reg.

ID

837-I 4010A1 DTP01

Min. Max.

Description

___

>1

SE SE01 SE02

___

1

GE GE01 GE02

___

1

REMAINING PATIENT LIABILITY Amount Qualifier Code Remaining Patient Liability Amount Credit/Debit Flag Code TRANSACTION SET TRAILER Transaction Segment Count Transaction Set Control Number FUNCTION GROUP TRAILER Number of Transaction Sets Included Group Control Number

New Segment

N0 N0

IEA01

INTERCHANGE CONTROL TRAILER Number of Included Functional Groups

N0

1-5

R

IEA02


N0

9-9

R

IEA

Page 93 of 93

2430 EAF

___

>1

___

1

___

1