4010A Min. Max.

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1 IA INTERCHANGE CONTROL HEADER 1 R 1 IA Authorization Information Qualifier ID 2-2 R 00, 03 IA01 INTERCHANGE CONTROL HEADER 1 R 1 Authorization Information Qualifier ID 2-2 R 00, 03 IA01 IA02 Authorization Information AN R IA02 Authorization Information AN R IA03 ecurity Information Qualifier ID 2-2 R 00, 01 IA03 ecurity Information Qualifier ID 2-2 R 00, 01 IA04 ecurity Information AN R IA04 ecurity Information AN R 01, 14, 20, 27, 28, IA05 Interchange ID Qualifier ID 2-2 R 29, 30, 33, ZZ IA05 Interchange ID Qualifier ID 2-2 R IA06 Interchange ender ID AN R IA06 Interchange ender ID AN R 01, 14, 20, 27, 28, 29, 30, 33, ZZ 01, 14, 20, 27, 28, 29, 30, 33, ZZ IA07 Interchange ID Qualifier ID 2-2 R 01, 14, 20, 27, 28, 29, 30, 33, ZZ IA07 Interchange ID Qualifier ID 2-2 R IA08 Interchange Receiver ID AN R IA08 Interchange Receiver ID AN R IA09 Interchange Date DT 6-6 R YYMMDD IA09 Interchange Date DT 6-6 R YYMMDD IA10 Interchange Time TM 4-4 R HHMM IA10 Interchange Time TM 4-4 R HHMM IA11 IA12 Interchange Control tandards ID 1-1 R IA11 Interchange Control Version Number ID 5-5 R IA12 Interchange Control tandards ID 1-1 R Interchange Control Version Number ID 5-5 R IA13 Interchange Control Number N0 9-9 R IA13 Interchange Control Number N0 9-9 R IA14 Acknowledgement Requested ID 1-1 R 0, 1 IA14 Acknowledgement Requested ID 1-1 R 0, 1 IA15 Indicator ID 1-1 R P, T IA15 Indicator ID 1-1 R P, T IA16 Component eparator AN 1-1 R IA16 FUNCTIONAL GROUP HEADER 1 R 1 G Component eparator AN 1-1 R FUNCTIONAL GROUP HEADER 1 R 1 G G01 Functional Identifier Code ID 2-2 R G01 Functional Identifier Code ID 2-2 R G02 Application ender Code AN 2-15 R G02 Application ender Code AN 2-15 R G03 Application Receiver Code AN 2-15 R G03 Application Receiver Code AN 2-15 R G04 Date DT 8-8 R CCYYMMDD G04 Date DT 8-8 R CCYYMMDD HHMM, HHMM, HHMMD, HHMMDD G05 Time TM 4-8 R HHMM, HHMM, HHMMD, HHMMDD G05 Time TM 4-8 R G06 Group Control Number N0 1-9 R G06 Group Control Number N0 1-9 R G07 Responsible Agency Code ID 1-2 R X G07 Responsible Agency Code ID 1-2 R X G08 Version Identifier Code AN 1-12 R X096A1 G08 Version Identifier Code AN 1-12 R X223 Code Change Page 1 of 93

2 T T01 T02 TRANACTION ET HEADER 1 R >1 T Transaction et Identifier Code ID 3-3 R 837 T01 Transaction et Control Number AN 4-9 R T02 T03 TRANACTION ET HEADER 1 R >1 Transaction et Identifier Code ID 3-3 R 837 Transaction et Control Number AN 4-9 R Implementation Convention Reference AN 1-35 R New BHT BEGINNING OF HIERARCHICAL TRANACTION 1 R 1 BHT BEGINNING OF HIERARCHICAL TRANACTION 1 R 1 BHT01 Hierarchical tructure Code ID 4-4 R 0019 BHT01 Hierarchical tructure Code ID 4-4 R 0019 BHT02 BHT03 BHT04 Transaction et Purpose Code ID 2-2 R 00, 18 BHT02 Originator Application Transaction ID AN 1-30 R BHT03 Transaction et Creation Date DT 8-8 R CCYYMMDD BHT04 HHMM, HHMM, HHMMD, HHMMDD Transaction et Purpose Code ID 2-2 R 00, 18 Originator Application Transaction ID AN 1-50 R Transaction et Creation Date DT 8-8 R CCYYMMDD HHMM, HHMM, HHMMD, HHMMDD Increase from Transaction et Creation Transaction et Creation BHT05 Time TM 4-8 R BHT05 Time TM 4-8 R BHT06 Claim or Encounter ID ID 2-2 R CH, RP BHT06 Claim or Encounter ID ID 2-2 R 31, CH, RP Code Added TRANMIION TYPE IDENTIFICATION 1 Qualifier ID 2-3 R AN 1-30 R 03 Description AN Reference Identifier egment Deleted NM1 UBMITTER NAME 1 R 1000A 1 NM1 UBMITTER NAME 1 R 1000A 1 NM101 Entity Identifier Code ID 2-3 R 41 NM101 Entity Identifier Code ID 2-3 R 41 NM102 Entity Type Qualifier ID 1-1 R 1, 2 NM102 Entity Type Qualifier ID 1-1 R 1, 2 ubmitter Last or Organization Name AN 1-35 R NM103 ubmitter Last or Organization Name AN 1-60 R Increase from NM103 NM104 ubmitter First Name AN 1-25 NM104 ubmitter First Name AN 1-35 Increase from NM105 ubmitter Middle Name AN 1-25 NM105 ubmitter Middle Name AN 1-25 NM106 Name Prefix AN 1-10 NM106 Name Prefix AN 1-10 NM107 Name uffix AN 1-10 NM107 Name uffix AN 1-10 NM108 Identification Code Qualifier ID 1-2 R 46 NM108 Identification Code Qualifier ID 1-2 R 46 NM109 ubmitter Identifier AN 2-80 R NM109 ubmitter Identifier AN 2-80 R NM110 Entity Relationship Code ID 2-2 NM110 Entity Relationship Code ID 2-2 NM111 Entity Identifier Code ID 2-3 NM111 Entity Identifier Code ID 2-3 NM112 Name Last or Organization Name AN 1-60 New Page 2 of 93

3 PER UBMITTER EDI CONTACT 2 R 1000A PER UBMITTER EDI CONTACT 2 R 1000A PER01 Contact Function Code ID 2-2 R IC PER01 Contact Function Code ID 2-2 R IC PER02 ubmitter Contact Name AN 1-60 R PER02 ubmitter Contact Name AN 1-60 change to ituational Communication Number Communication Number Code deleted PER03 Qualifier ID 2-2 R ED, EM, FX. TE PER03 Qualifier ID 2-2 R EM, FX. TE PER04 Communication Number AN 1-80 R PER04 Communication Number AN R Increase from Communication Number ED, EM, EX, FX, Communication Number Code deleted PER05 Qualifier ID 2-2 TE PER05 Qualifier ID 2-2 EM, EX, FX, TE PER06 Communication Number AN 1-80 PER06 Communication Number AN Increase from Communication Number ED, EM, EX, FX, Communication Number Code deleted PER07 Qualifier ID 2-2 TE PER07 Qualifier ID 2-2 EM, EX, FX, TE PER08 Communication Number AN 1-80 PER08 Communication Number AN Increase from PER09 Contact Inquiry Reference AN 1-20 PER09 Contact Inquiry Reference AN 1-20 NM1 RECEIVER NAME 1 R 1000B 1 NM1 RECEIVER NAME 1 R 1000B 1 NM101 Entity Identifier Code ID 2-3 R 40 NM101 Entity Identifier Code ID 2-3 R 40 NM102 Entity Type Qualifier ID 1-1 R 2 NM102 Entity Type Qualifier ID 1-1 R 2 NM103 Receiver Name AN 1-35 R NM103 Receiver Name AN 1-60 R Increase from NM104 Name First AN 1-25 NM104 Name First AN 1-35 Increase from NM105 Name Middle AN 1-25 NM105 Name Middle AN 1-25 NM106 Name Prefix AN 1-10 NM106 Name Prefix AN 1-10 NM107 Name uffix AN 1-10 NM107 Name uffix AN 1-10 NM108 Identification Code Qualifier ID 1-2 R 46 NM108 Identification Code Qualifier ID 1-2 R 46 NM109 Receiver Primary Identifier AN 2-80 R NM109 Receiver Primary Identifier AN 2-80 R NM110 Entity Relationship Code ID 2-2 NM110 Entity Relationship Code ID 2-2 NM111 Entity Identifier Code ID 2-3 NM111 Entity Identifier Code ID 2-3 Name Last or Organization New NM112 Name AN 1-60 BILLING/PAY-TO HL PROVIDER HIERARCHICAL LEVEL 1 R 2000A >1 HL BILLING PROVIDER HIERARCHICAL LEVEL 1 R 2000A >1 HL01 Hierarchical ID Number AN 1-12 R HL01 Hierarchical ID Number AN 1-12 R Hierarchical Parent ID Number AN 1-12 HL02 Hierarchical Parent ID Number AN 1-12 HL02 HL03 Hierarchical Level Code ID 1-2 R 20 HL03 Hierarchical Level Code ID 1-2 R 20 HL04 Hierarchical Child Code ID 1-1 R 1 HL04 Hierarchical Child Code ID 1-1 R 1 BILLING/PAY-TO PRV PROVIDER PECIALTY A PRV BILLING PROVIDER PECIALTY A PRV01 Provider Code ID 1-3 R BI, PT PRV01 Provider Code ID 1-3 R BI Code Deleted Code Change PRV02 Qualifier ID 2-3 R ZZ PRV02 Qualifier ID 2-3 R PXC PRV03 Provider Taxonomy Code AN 1-30 R PRV03 Provider Taxonomy Code AN 1-50 R Increase from PRV04 tate or Province Code ID 2-2 PRV04 tate or Province Code ID 2-2 Page 3 of 93

4 PRV05 PROVIDER PECIALTY PRV05 PROVIDER PECIALTY PRV06 Provider Organization Code ID 3-3 PRV06 Provider Organization Code ID 3-3 FOREIGN CURRENCY A CUR FOREIGN CURRENCY A CUR CUR01 Entity Identifier Code ID 2-3 R 85 CUR01 Entity Identifier Code ID 2-3 R 85 CUR02 Currency Code ID 3-3 R CUR02 Currency Code ID 3-3 R CUR03 Exchange Rate R 4-10 CUR03 Exchange Rate R 4-10 CUR04 Entity Identifier Code ID 2-3 CUR04 Entity Identifier Code ID 2-3 CUR05 Currency Code ID 3-3 CUR05 Currency Code ID 3-3 Currency Market/Exchange Code ID 3-3 CUR06 Currency Market/Exchange Code ID 3-3 CUR06 CUR07 Date/Time Qualifier ID 3-3 CUR07 Date/Time Qualifier ID 3-3 CUR08 Date DT 8-8 CUR08 Date DT 8-8 CUR09 Time TM 4-8 CUR09 Time TM 4-8 CUR10 Date/Time Qualifier ID 3-3 CUR10 Date/Time Qualifier ID 3-3 CUR11 Date DT 8-8 CUR11 Date DT 8-8 CUR12 Time TM 4-8 CUR12 Time TM 4-8 CUR13 Date/Time Qualifier ID 3-3 CUR13 Date/Time Qualifier ID 3-3 CUR14 Date DT 8-8 CUR14 Date DT 8-8 CUR15 Time TM 4-8 CUR15 Time TM 4-8 CUR16 Date/Time Qualifier ID 3-3 CUR16 Date/Time Qualifier ID 3-3 CUR17 Date DT 8-8 CUR17 Date DT 8-8 CUR18 Time TM 4-8 CUR18 Time TM 4-8 CUR19 Date/Time Qualifier ID 3-3 CUR19 Date/Time Qualifier ID 3-3 CUR20 Date DT 8-8 CUR20 Date DT 8-8 CUR21 Time TM 4-8 CUR21 Time TM 4-8 NM1 Billing Provider Name 1 R 2010AA 1 NM1 Billing Provider Name 1 R 2010AA 1 NM101 Entity Identifier Code ID 2-3 R 85 NM101 Entity Identifier Code ID 2-3 R 85 NM102 Entity Type Qualifier ID 1-1 R 2 NM102 Entity Type Qualifier ID 1-1 R 2 Billing Provider Last Billing Provider Last Increase from NM103 or Organizational Name AN 1-35 R NM103 or Organizational Name AN 1-60 R NM104 Name First AN 1-25 NM104 Billing Provider First Name AN 1-35 Increase from NM105 Name Middle AN 1-25 NM105 Billing Provider Middle Name AN 1-25 NM106 Name Prefix AN 1-10 NM106 Name Prefix AN 1-10 NM107 Name uffix AN 1-10 NM107 Billing Provider Name uffix AN 1-10 NM108 Identification Code Qualifier ID 1-2 R 24, 34, XX NM108 Identification Code Qualifier ID 1-2 XX NM109 Billing Provider Identifier AN 2-80 NM109 Billing Provider Identifier AN 2-80 NM110 Entity Relationship Code ID 2-2 NM110 Entity Relationship Code ID 2-2 NM111 Entity Identifier Code ID 2-3 NM111 Entity Identifier Code ID 2-3 Name Last or Organization NM112 Name AN 1-60 Code Deleted change to ituational New Page 4 of 93

5 N3 BILLING PROVIDER ADDRE 1 R 2010AA N3 BILLING PROVIDER ADDRE 1 R 2010AA N301 Billing Provider Address Line AN 1-55 R N301 Billing Provider Address Line AN 1-55 R N302 Billing Provider Address Line AN 1-55 N302 Billing Provider Address Line AN 1-55 N4 BILLING PROVIDER CITY/TATE/ZIP CODE 1 R 2010AA N4 BILLING PROVIDER CITY/TATE/ZIP CODE 1 R 2010AA N401 Billing Provider City Name AN 2-30 R N401 Billing Provider City Name AN 2-30 R N402 Billing Provider tate or Province Code ID 2-2 R N402 Billing Provider Postal Zone or ZIP Code ID 3-15 R N403 Billing Provider tate or Province Code ID 2-2 Billing Provider Postal Zone or ZIP Code ID 3-15 change to ituational change to ituational N403 N404 Country Code ID 2-3 N404 Country Code ID 2-3 N405 Location Qualifier ID 1-2 N405 Location Qualifier ID 1-2 N406 Location Identifier AN 1-30 N406 Location Identifier AN 1-30 N407 Country ubdivision Code ID 1-3 New BILLING PROVIDER TAX IDENTIFICATION 8 R 2010AA Qualifier ID 2-3 R 0B, 1A, 1B, 1C, 1D, 1G, 1H, 1J, B3, BQ, EI, FH, G2, G5, LU, Y, X5 Billing Provider Additional Identifier AN 1-30 R 02 BILLING PROVIDER TAX IDENTIFICATION 1 R 2010AA Qualifier ID 2-3 R EI Billing Provider Additional Identifier AN 1-50 R Description AN Description AN ERENCE IDENTIFIER 04 ERENCE IDENTIFIER # s change to 1 Code Deleted Increase from CREDIT/DEBIT CARD BILLING AA Qualifier ID 2-3 R Billing Provider Additional 02 Identifier AN 1-30 R 03 Description AN ERENCE IDENTIFIER 06, 8U, EM, IJ, LU, RB, T, TT egment Deleted PER BILLING PROVIDER CONTACT AA PER BILLING PROVIDER CONTACT AA PER01 Contact Function Code ID 2-2 R IC PER01 Contact Function Code ID 2-2 R IC PER02 Billing Provider Contact Name AN 1-60 R PER02 Billing Provider Contact Name AN 1-60 change to ituational PER03 Communication Number Qualifier ID 2-2 R EM, FX, TE PER03 Communication Number Qualifier ID 2-2 R EM, FX, TE PER04 Communication Number AN 1-80 R PER04 Communication Number AN R Increase from PER05 Communication Number Qualifier ID 2-2 EM, EX, FX, TE PER05 Communication Number Qualifier ID 2-2 EM, EX, FX, TE Page 5 of 93

6 PER06 Communication Number AN 1-80 PER06 Communication Number AN Increase from Communication Number Qualifier ID 2-2 EM, EX, FX, TE PER07 Communication Number Qualifier ID 2-2 EM, EX, FX, TE PER07 PER08 Communication Number AN 1-80 PER08 Communication Number AN Increase from PER09 Contact Inquiry Reference AN 1-20 PER09 Contact Inquiry Reference AN 1-20 NM1 PAY-TO PROVIDER NAME AB 1 NM1 PAY-TO ADDRE NAME AB 1 NM101 Entity Identifier Code ID 2-3 R 87 NM101 Entity Identifier Code ID 2-3 R 87 NM102 Entity Type Qualifier ID 1-1 R 2 NM102 Entity Type Qualifier ID 1-1 R 2 Pay-to Provider Last or Pay-to Provider Last or Increase from NM103 Organization Name AN 1-35 NM103 Organization Name AN 1-60 NM104 Name First AN 1-25 NM104 Pay-to Provider First Name AN 1-35 Increase from NM105 Name Middle AN 1-25 NM105 Pay-to Provider Middle Name AN 1-25 NM106 Name Prefix AN 1-10 NM106 Name Prefix AN 1-10 NM107 Name uffix AN 1-10 NM107 Pay-to Provider Name uffix AN 1-10 NM108 Identification Code Qualifier ID , 34, XX NM108 Identification Code Qualifier ID 1-2 Code Deleted NM109 Pay-to Provider Identifier AN 2-80 NM109 Pay-to Provider Identifier AN 2-80 NM110 Entity Relationship Code ID 2-2 NM110 Entity Relationship Code ID 2-2 NM111 Entity Identifier Code ID 2-3 NM111 Entity Identifier Code ID 2-3 NM112 Name Last or Organization Name AN 1-60 New N3 PAY-TO PROVIDER ADDRE 1 R 2010AB N3 PAY-TO PROVIDER ADDRE 1 R 2010AB N301 Pay-to Provider Address Line AN 1-55 R N301 Pay-to Provider Address Line AN 1-55 R N302 Pay-to Provider Address Line AN 1-55 N302 Pay-to Provider Address Line AN 1-55 PAY-TO PROVIDER CITY/TATE/ZIP CODE 1 R 2010AB N4 PAY-TO PROVIDER CITY/TATE/ZIP CODE 1 R 2010AB N4 N401 Pay-to Provider City Name AN 2-30 R N401 Pay-to Provider City Name AN 2-30 R N402 Pay-to Provider tate Code ID 2-2 R N402 Pay-to Provider tate Code ID 2-2 change to ituational N403 Pay-to Provider Postal Zone or ZIP Code ID 3-15 R N403 Pay-to Provider Postal Zone or ZIP Code ID 3-15 change to ituational N404 Pay-to Provider Country Code ID 2-3 N404 Pay-to Provider Country Code ID 2-3 N405 Location Qualifier ID 1-2 N405 Location Qualifier ID 1-2 N406 Location Identifier AN 1-30 N406 Location Identifier AN 1-30 N407 Country ubdivision Code ID 1-3 New PAY-TO PROVIDER ECONDARY IDENTIFICATION AB 0B, 1A, 1B, 1C, 1D, 1G, 1H, 1J, B3, BQ, EI, FH, G2, G5, LU, Y, X5 egment Deleted Page 6 of 93

7 Qualifier ID 2-3 R 02 Billing Provider Additional Identifier AN 1-30 R 03 Description AN ERENCE IDENTIFIER NM1 PAY TO PLAN NAME AC 1 New egment NM101 Entity Identifier Code ID 2-3 R PE NM102 Entity Type Qualifier ID 1-1 R 2 NM103 Pay to Plan Organizational Name AN 1-60 R NM104 Name First AN 1-35 NM105 Name Middle AN 1-25 NM106 Name Prefix AN 1-10 NM107 Name uffix AN 1-10 NM108 Identification Code Qualifier ID 1-2 R PI, XV NM109 Identification Code AN 2-80 R NM110 Entity Relationship Code ID 2-2 NM111 Entity Identifier Code ID 2-3 NM112 Name Last or Organization Name AN 1-60 N3 PAY-TO PLAN ADDRE 1 R 2010AC New egment N301 Pay-to Plan Address Line AN 1-55 R N302 Pay-to Plan Address Line AN 1-55 N4 PAY-TO PLAN CITY/TATE/ZIP CODE 1 R 2010AC N401 Pay-to Plan City Name AN 2-30 R N402 Pay-to Plan tate Code ID 2-2 Pay-to Plan Postal Zone or N403 ZIP Code ID 3-15 N404 Pay-to Plan Country Code ID 2-3 N405 Location Qualifier ID 1-2 N406 Location Identifier AN 1-30 N407 Country ubdivision Code ID 1-3 ECONDARY IDENTIFICATION AC Qualifier ID 2-3 R 2U, FY, NF 02 AN 1-50 R 03 Description AN ERENCE IDENTIFIER New egment New egment PAY-TO PLAN TAX IDENTIFICATION 1 R 2010AC New egment Page 7 of 93

8 Qualifier ID 2-3 R EI 02 AN 1-50 R 03 Description AN ERENCE IDENTIFIER HL UBCRIBER HIERARCHICAL LEVEL 1 R 2000B >1 HL UBCRIBER HIERARCHICAL LEVEL 1 R 2000B >1 HL01 Hierarchical ID Number AN 1-12 R HL01 Hierarchical ID Number AN 1-12 R Hierarchical Parent ID Number AN 1-12 R HL02 Hierarchical Parent ID Number AN 1-12 R HL02 HL03 Hierarchical Level Code ID 1-2 R 22 HL03 Hierarchical Level Code ID 1-2 R 22 HL04 Hierarchical Child Code ID 1-1 R 0, 1 HL04 Hierarchical Child Code ID 1-1 R 0, 1 BR BR01 UBCRIBER 1 R 2000B BR Payer Responsibility equence Number Code ID 1-1 R P,, T BR01 UBCRIBER 1 R 2000B Payer Responsibility equence Number Code ID 1-1 R BR02 Individual Relationship Code ID BR02 Individual Relationship Code ID Insured Group or Policy Number AN 1-30 BR03 Insured Group or Policy Number AN 1-50 BR03 BR04 Insured Group Name AN 1-60 BR04 Insured Group Name AN 1-60 BR05 Insurance Type Code ID 1-3 BR05 Insurance Type Code ID 1-3 A, B, C, D, E, F, G, H, P,, T, U Code Added Increase from BR06 Coordination of Benefits BR06 Coordination of Benefits BR07 Yes/No Condition or Response BR07 Yes/No Condition or Response BR08 Employment tatus Code ID 2-2 BR08 Employment tatus Code ID 2-2 BR09 Claim Filing Indicator Code ID , 10, 11, 12, 13, 14, 15, 16, AM, BL, CH, CI, D, HM, LI, LM, MA, MB, MC, OF, TV, VA, WC, ZZ BR09 Claim Filing Indicator Code ID , 12, 13, 14, 15, Code Change 16, 17, AM, BL, CH, CI, D, FI, HM, LM, MA, MB, MC, OF, TV, VA, WC, ZZ NM1 UBCRIBER NAME 1 R 2010BA 1 NM1 UBCRIBER NAME 1 R 2010BA 1 NM101 Entity Identifier Code ID 2-3 R IL NM101 Entity Identifier Code ID 2-3 R IL NM102 Entity Type Qualifier ID 1-1 R 1, 2 NM102 Entity Type Qualifier ID 1-1 R 1, 2 NM103 ubscriber Last Name AN 1-35 R NM103 ubscriber Last Name AN 1-60 R Increase from NM104 ubscriber First Name AN 1-25 NM104 ubscriber First Name AN 1-35 Increase from NM105 ubscriber Middle Name AN 1-25 NM105 ubscriber Middle Name AN 1-25 NM106 Name Prefix AN 1-10 NM106 Name Prefix AN 1-10 NM107 ubscriber Name uffix AN 1-10 NM107 ubscriber Name uffix AN 1-10 Code Change change to Required NM108 Identification Code Qualifier ID 1-2 MI, ZZ NM108 Identification Code Qualifier ID 1-2 R II, MI change to Required NM109 ubscriber Primary Identifier AN 2-80 NM109 ubscriber Primary Identifier AN 2-80 R NM110 Entity Relationship Code ID 2-2 NM110 Entity Relationship Code ID 2-2 Page 8 of 93

9 NM111 Entity Identifier Code ID 2-3 NM111 Entity Identifier Code ID 2-3 NM112 Name Last or Organization Name AN 1-60 New N3 UBCRIBER ADDRE BA N3 UBCRIBER ADDRE BA N301 ubscriber Address Line AN 1-55 R N301 ubscriber Address Line AN 1-55 R N302 ubscriber Address Line AN 1-55 N302 ubscriber Address Line AN 1-55 N4 UBCRIBER CITY/TATE/ZIP CODE BA N4 UBCRIBER CITY/TATE/ZIP CODE BA N401 ubscriber City Name AN 2-30 R N401 ubscriber City Name AN 2-30 R N402 ubscriber tate Code ID 2-2 R N402 ubscriber tate Code ID 2-2 ubscriber Postal Zone or ZIP Code ID 3-15 R N403 ubscriber Postal Zone or ZIP Code ID 3-15 change to ituational change to ituational N403 N404 ubscriber Country Code ID 2-3 N404 ubscriber Country Code ID 2-3 N405 Location Qualifier ID 1-2 N405 Location Qualifier ID 1-2 N406 Location Identifier AN 1-30 N406 Location Identifier AN 1-30 N407 Country ubdivision Code ID 1-3 New DMG UBCRIBER DEMOGRAPHIC BA DMG Qualifier ID 2-3 R D8 DMG01 UBCRIBER DEMOGRAPHIC BA Qualifier ID 2-3 R D8 DMG01 DMG02 ubscriber Birth Date AN 1-35 R CCYYMMDD DMG02 ubscriber Birth Date AN 1-35 R CCYYMMDD DMG03 ubscriber Gender Code ID 1-1 R F, M, U DMG03 ubscriber Gender Code ID 1-1 R F, M, U DMG04 Marital tatus DMG04 Marital tatus DMG05 Race or Ethnicity DMG05 Race or Ethnicity DMG06 Citizenship tatus Code ID 1-2 DMG06 Citizenship tatus Code ID 1-2 DMG07 Country Code ID 2-3 DMG07 Country Code ID 2-3 DMG08 Basis of Verification Code ID 1-2 DMG08 Basis of Verification Code ID 1-2 DMG09 Quantity R 1-15 DMG09 Quantity R 1-15 DMG10 Code List Qualifier Code ID 1-3 New DMG11 Industry Code AN 1-30 New UBCRIBER ECONDARY IDENTIFICATION BA Qualifier ID 2-3 R 1W, 23, IG, Y ubscriber upplemental Identifier AN 1-30 R 02 UBCRIBER ECONDARY IDENTIFICATION BA Qualifier ID 2-3 R Y ubscriber upplemental Identifier AN 1-50 R Description AN Description AN ERENCE IDENTIFIER 04 ERENCE IDENTIFIER Code Deleted Increase rom CAUALTY CLAIM NUMBER BA Qualifier ID 2-3 R Y4 CAUALTY CLAIM NUMBER BA Qualifier ID 2-3 R Y4 Page 9 of 93

10 Property Casualty Claim Number AN 1-30 R 02 Property Casualty Claim Number AN 1-50 R Description AN Description AN ERENCE IDENTIFIER 04 ERENCE IDENTIFIER NM1 CREDIT/DEBIT CARD ACCOUNT HOLDER NAME BB 1 NM101 Entity Identifier Code ID 2-3 R AO NM102 Entity Type Qualifier ID 1-1 R 1, 2 Credit or Debt Card Holder NM103 Last or Organization Name AN 1-35 R Credit or Debt Card Holder NM104 First Name AN 1-25 Credit or Debt Card Holder NM105 Middle Name AN 1-25 NM106 Name Prefix AN 1-10 Credit or Debt Card Holder NM107 Name uffix AN 1-10 Increase rom egment Deleted NM108 Identification Code Qualifier ID 1-2 R MI NM109 Payer Identifier AN 2-80 R NM110 Entity Relationship Code ID 2-2 NM111 Entity Identifier Code ID 2-3 CREDIT/DEBT CARD BB Qualifier ID 2-3 R AB, BB Credit or Debt Card 02 Authorization Number AN 1-30 R 03 Description AN ERENCE IDENTIFIER egment Deleted NM1 PAYER NAME 1 R 2010BC 1 NM1 PAYER NAME 1 R 2010BB 1 Change NM101 Entity Identifier Code ID 2-3 R PR NM101 Entity Identifier Code ID 2-3 R PR NM102 Entity Type Qualifier ID 1-1 R 2 NM102 Entity Type Qualifier ID 1-1 R 2 NM103 Payer Name AN 1-35 R NM103 Payer Name AN 1-60 R Increase from NM104 Name First AN 1-25 NM104 Name First AN 1-35 Increase from NM105 Name Middle AN 1-25 NM105 Name Middle AN 1-25 NM106 Name Prefix AN 1-10 NM106 Name Prefix AN 1-10 NM107 Name uffix AN 1-10 NM107 Name uffix AN 1-10 NM108 Identification Code Qualifier ID 1-2 R PI, XV NM108 Identification Code Qualifier ID 1-2 R PI, XV NM109 Payer Identifier AN 2-80 R NM109 Payer Identifier AN 2-80 R NM110 Entity Relationship Code ID 2-2 NM110 Entity Relationship Code ID 2-2 NM111 Entity Identifier Code ID 2-3 NM111 Entity Identifier Code ID 2-3 NM112 Name Last or Organization Name AN 1-60 New N3 PAYER ADDRE BC N3 PAYER ADDRE BB Change Page 10 of 93

11 N301 Payer Address Line AN 1-55 R N301 Payer Address Line AN 1-55 R N302 Payer Address Line AN 1-55 N302 Payer Address Line AN 1-55 N4 PAYER CITY/TATE/ZIP CODE 1 R 2010BC N4 PAYER CITY/TATE/ZIP CODE 1 R 2010BB N401 Payer City Name AN 2-30 R N401 Payer City Name AN 2-30 R N402 Payer tate Code ID 2-2 R N402 Payer tate Code ID 2-2 Payer Postal Zone or ZIP Code ID 3-15 R N403 Payer Postal Zone or ZIP Code ID 3-15 Change change to ituational change to ituational N403 N404 Payer Country Code ID 2-3 N404 Payer Country Code ID 2-3 N405 Location Qualifier ID 1-2 N405 Location Qualifier ID 1-2 N406 Location Identifier AN 1-30 N406 Location Identifier AN 1-30 N407 Country ubdivision Code ID 1-3 New PAYER ECONDARY IDENTIFICATION BC Qualifier ID 2-3 R 2U, FY, NF, TJ PAYER ECONDARY IDENTIFICATION BB Qualifier ID 2-3 R 2U, EI, FY, NF Change Code Change 02 Payer Additional Identifier AN 1-30 R 02 Payer Additional Identifier AN 1-50 R Increase from Description AN Description AN ERENCE IDENTIFIER 04 ERENCE IDENTIFIER BILLING PROVIDER ECONDARY IDENTIFICATION BB Qualifier ID 2-3 R G2, LU 02 Payer Additional Identifier AN 1-50 R 03 Description AN ERENCE IDENTIFIER egment Added NM1 REPONIBLE PARTY NAME BD 1 NM101 Entity Identifier Code ID 2-3 R QD NM102 Entity Type Qualifier ID 1-1 R NM103 Payer Name AN 1-35 R NM104 Name First AN 1-25 NM105 Name Middle AN 1-25 NM106 Name Prefix AN 1-10 NM107 Name uffix AN 1-10 NM108 Identification Code Qualifier ID 1-2 NM109 Identification Code AN 2-80 NM110 Entity Relationship Code ID 2-2 NM111 Entity Identifier Code ID 2-3 egment Deleted N3 REPONIBLE PARTY ADDRE BC egment Deleted Page 11 of 93

12 N301 N302 N4 Responsible Party Address Line AN 1-55 R Responsible Party Address Line AN 1-55 REPONIBLE PARTY CITY/TATE/ZIP CODE 1 R 2010BC egment Deleted N401 Responsible Party City Name AN 2-30 R N402 Responsible Party tate Code ID 2-2 R N403 Responsible Party ZIP Code ID 3-15 R N404 Responsible Party Country Code ID 2-3 N405 Location Qualifier ID 1-2 N406 Location Identifier AN 1-30 HL PATIENT HIERARCHICAL LEVEL C >1 HL PATIENT HIERARCHICAL LEVEL C >1 HL01 Hierarchical ID Number AN 1-12 R HL01 Hierarchical ID Number AN 1-12 R Hierarchical Parent ID Number AN 1-12 R HL02 Hierarchical Parent ID Number AN 1-12 R HL02 HL03 Hierarchical Level Code ID 1-2 R 23 HL03 Hierarchical Level Code ID 1-2 R 23 HL04 Hierarchical Child Code ID 1-1 R 0 HL04 Hierarchical Child Code ID 1-1 R 0 PAT PATIENT 1 R 2000C PAT PATIENT 1 R 2000C PAT01 Individual Relationship Code ID 2-2 R 01, 04, 05, 07, 10, 15, 17, 19, 20, 21, 22, 23, 24, 29, 32, 33, 36, 39, 40, 41, 43, 53, G8 PAT01 Individual Relationship Code ID 2-2 R PAT02 Patient Location PAT02 Patient Location PAT03 Employment tatus Code ID 2-2 PAT03 Employment tatus Code ID 2-2 PAT04 tudent tatus PAT04 tudent tatus PAT05 PAT05 PAT06 Patient Death Date AN 1-35 PAT06 Patient Death Date AN 1-35 PAT07 Unit or Basis for Measurement Code ID 2-2 PAT07 Unit or Basis for Measurement Code ID 2-2 PAT08 Patient Weight R 1-10 PAT08 Patient Weight R 1-10 PAT09 Pregnancy Indicator ID 1-1 PAT09 Pregnancy Indicator ID , 19, 20, 21, 39, 40, 53, G8 Code Deleted NM1 PATIENT NAME 1 R 2010CA 1 NM1 PATIENT NAME 1 R 2010CA 1 NM101 Entity Identifier Code ID 2-3 R QC NM101 Entity Identifier Code ID 2-3 R QC NM102 Entity Type Qualifier ID 1-1 R 1 NM102 Entity Type Qualifier ID 1-1 R 1 NM103 Patient Last Name AN 1-35 R NM103 Patient Last Name AN 1-60 R Increase from Page 12 of 93

13 NM104 Patient First Name AN 1-25 R NM104 Patient First Name AN 1-35 NM105 Patient Middle Name AN 1-25 NM105 Patient Middle Name AN 1-25 NM106 Name Prefix AN 1-10 NM106 Name Prefix AN 1-10 NM107 Patient Name uffix AN 1-10 NM107 Patient Name uffix AN 1-10 NM108 Identification Code Qualifier ID 1-2 MI, ZZ NM108 Identification Code Qualifier ID 1-2 NM109 Patient Primary Identifier AN 2-80 NM109 Patient Primary Identifier AN 2-80 NM110 Entity Relationship Code ID 2-2 NM110 Entity Relationship Code ID 2-2 NM111 Entity Identifier Code ID 2-3 NM111 Entity Identifier Code ID 2-3 Name Last or Organization NM112 Name AN 1-60 Increase from change to ituational Code Deleted change to Not Used change to Not Used New N3 PATIENT ADDRE 1 R 2010CA N3 PATIENT ADDRE 1 R 2010CA N301 Patient Address Line AN 1-55 R N301 Patient Address Line AN 1-55 R N302 Patient Address Line AN 1-55 N302 Patient Address Line AN 1-55 N4 PATIENT CITY/TATE/ZIP CODE 1 R 2010CA N4 PATIENT CITY/TATE/ZIP CODE 1 R 2010CA N401 Patient City Name AN 2-30 R N401 Patient City Name AN 2-30 R N402 Patient tate Code ID 2-2 R N402 Patient tate Code ID 2-2 Patient Postal Zone or ZIP Code ID 3-15 R N403 Patient Postal Zone or ZIP Code ID 3-15 change to ituational change to ituational N403 N404 Patient Country Code ID 2-3 N404 Patient Country Code ID 2-3 N405 Location Qualifier ID 1-2 N405 Location Qualifier ID 1-2 N406 Location Identifier AN 1-30 N406 Location Identifier AN 1-30 N407 Country ubdivision Code ID 1-3 New DMG PATIENT DEMOGRAPHIC 1 R 2010CA DMG Qualifier ID 2-3 R D8 DMG01 PATIENT DEMOGRAPHIC 1 R 2010CA Qualifier ID 2-3 R D8 DMG01 DMG02 Patient Birth Date AN 1-35 R CCYYMMDD DMG02 Patient Birth Date AN 1-35 R CCYYMMDD DMG03 Patient Gender Code ID 1-1 R F, M, U DMG03 Patient Gender Code ID 1-1 R F, M, U DMG04 Marital tatus DMG04 Marital tatus DMG05 Race or Ethnicity DMG05 Race or Ethnicity DMG06 Citizenship tatus Code ID 1-2 DMG06 Citizenship tatus Code ID 1-2 DMG07 Country Code ID 2-3 DMG07 Country Code ID 2-3 DMG08 Basis of Verification Code ID 1-2 DMG08 Basis of Verification Code ID 1-2 DMG09 Quantity R 1-15 DMG09 Quantity R 1-15 DMG10 Code List Qualifier Code ID 1-3 New DMG11 Industry Code AN 1-30 New PATIENT ECONDARY IDENTIFICATION NUMBER CA egment Deleted Page 13 of 93

14 Qualifier ID 2-3 R 1W, 23, IG, Y 02 Patient econdary Identifier AN 1-30 R 03 Description AN ERENCE IDENTIFIER PROPERTY AND CAUALTY CLAIM NUMBER CA Qualifier ID 2-3 R Y4 Property Casualty Claim Number AN 1-30 R 02 PROPERTY AND CAUALTY CLAIM NUMBER CA Qualifier ID 2-3 R Y4 Property Casualty Claim Number AN 1-50 R Description AN Description AN ERENCE IDENTIFIER 04 ERENCE IDENTIFIER CLM CLAIM 1 R CLM CLAIM 1 R CLM01 Patient Account Number AN 1-38 R CLM01 Patient Account Number AN 1-38 R CLM02 Total Claim Charge Amount R 1-18 R CLM02 Total Claim Charge Amount R 1-18 R CLM03 Claim Filing Indicator Code ID 1-2 CLM03 Claim Filing Indicator Code ID 1-2 CLM04 CLM05 Non-Institutional Claim Type Code ID 1-2 CLM04 HEALTH CARE ERVICE LOCATION R CLM05 Non-Institutional Claim Type Code ID 1-2 HEALTH CARE ERVICE LOCATION R CLM05-1 Facility Type Code AN 1-2 R CLM05-1 Facility Type Code AN 1-2 R CLM05-2 Facility Code Qualifier ID 1-2 R A CLM05-2 Facility Code Qualifier ID 1-2 R A CLM05-3 Claim Frequency Code ID 1-1 R CLM05-3 Claim Frequency Code ID 1-1 R CLM06 Provider or upplier ignature Indicator ID 1-1 N, Y CLM06 Provider or upplier ignature Indicator ID 1-1 N, Y CLM07 Medicare Assignment Code ID 1-1 R A, C CLM07 Medicare Assignment Code ID 1-1 R A, B, C CLM08 Benefits Assignment Certification Indicator ID 1-1 R N CLM08 Benefits Assignment Certification Indicator ID 1-1 R N, W, Y CLM09 Release of Information Code ID 1-1 R A, I, M, N, O, Y CLM09 Release of Information Code ID 1-1 R I, Y CLM10 CLM11 Patient ignature ource CLM10 RELATED CAUE CLM11 Patient ignature ource Code ID 1-1 P RELATED CAUE CLM12 pecial Program Indicator ID 2-3 CLM12 pecial Program Indicator ID , 03, 05, 09 Yes/No Condition or Yes/No Condition or CLM13 Response CLM13 Response CLM14 Level of ervice Code ID 1-3 CLM14 Level of ervice Code ID 1-3 CLM15 Yes/No Condition or Response CLM15 Yes/No Condition or Response Increase from Code Added Code Added Code Deleted change to ituational Code Added change to ituational Code Added Page 14 of 93

15 CLM16 Participation Agreement ID 1-1 CLM16 Participation Agreement ID 1-1 CLM17 Claim tatus Code ID 1-2 CLM17 Claim tatus Code ID 1-2 CLM18 CLM19 Yes/No Condition or Response Code ID 1-1 R N, Y CLM18 Claim ubmission Reason Code ID 2-2 CLM19 CLM20 Delay Reason Code ID 1-2 Yes/No Condition or Response Claim ubmission Reason Code ID 2-2 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 CLM20 Delay Reason Code ID 1-2 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 15 change to Not Used Code Added DTP DATE - DICHARGE HOUR DTP DATE - DICHARGE HOUR DTP01 Date Time Qualifier ID 3-3 R 96 DTP01 Date Time Qualifier ID 3-3 R 96 DTP02 Qualifier ID 2-3 R TM DTP02 Qualifier ID 2-3 R TM DTP03 Discharge Hour AN 1-35 R HHMM DTP03 Discharge Time AN 1-35 R HHMM DTP DATE - TATEMENT DATE 1 R 2300 DTP DATE - TATEMENT DATE DTP01 Date Time Qualifier ID 3-3 R 434 DTP01 Date Time Qualifier ID 3-3 R 434 DTP02 Qualifier ID 2-3 R D8, RD8 DTP02 DTP03 tatement From or To Date AN 1-35 R Qualifier ID 2-3 R RD8 CCYYMMDDCCY YMMDD DTP03 tatement From and To Date AN 1-35 R CCYYMMDDCCY YMMDD DTP DATE - ADMIION DATE/HOUR DTP DATE - ADMIION DATE/HOUR DTP01 Date Time Qualifier ID 3-3 R 435 DTP01 Date Time Qualifier ID 3-3 R 435 DTP02 Qualifier ID 2-3 R DT DTP02 DTP03 Admission Date and Hour AN 1-35 R Qualifier ID 2-3 R D8, DT CCYYMMDDHHM M DTP03 Admission Date and Hour AN 1-35 R change to ituational Code Deleted Code Added CCYYMMDD, Code Added CCYYMMDDHHM M INTITUTIONAL CLAIM CODE CL1 DTP DATE - REPRICER RECEIVED DATE DTP01 Date Time Qualifier ID 3-3 R 050 DTP02 Qualifier ID 2-3 R D8 DTP03 Order Date AN 1-35 R CCYYMMDD INTITUTIONAL CLAIM CODE CL1 CL101 Admission Type Code ID 1-1 CL101 Admission Type Code ID 1-1 CL102 Admission ource Code ID 1-1 CL102 Admission ource Code ID 1-1 CL103 Patient tatus Code ID 1-2 CL103 Patient tatus Code ID 1-2 R CL104 Nursing Home Code ID 1-1 NU CL104 Nursing Home Code ID 1-1 NU New egment change to Required PWK CLAIM UPPLEMENTAL PWK CLAIM UPPLEMENTAL Page 15 of 93

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