4010A Min. Max.

Transcription

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

16 PWK01 Attachment Report Type Code ID 2-2 R Attachment Transmission Code ID 1-2 R A, B2, B3, B4, CT, DA, DG, D, EB, MT, NN, OB, OZ, PN, PO, PZ, RB, RR, RT AA, BM, EL, EM, FX PWK01 Attachment Report Type Code ID 2-2 R Attachment Transmission Code ID 1-2 R PWK02 PWK02 PWK03 Report Copies Needed N0 1-2 PWK03 Report Copies Needed N0 1-2 PWK04 Entity Identifier Code ID 2-3 PWK04 Entity Identifier Code ID 2-3 Code Added 03, 04, 05, 06, 07, 08, 09, 10, 11, 13, 15, 21, A3, A4, AM, A, B2, B3, B4, BR, B, BT, CB, CK, CT, D2, DA, DB, DG, DJ, D, 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, G, V5, XP AA, BM, EL, EM, Code Added FT, FX PWK05 Identification Code Qualifier ID 1-2 AC PWK05 Identification Code Qualifier ID 1-2 AC PWK06 Attachment Control Number AN 2-80 PWK06 Attachment Control Number AN 2-80 PWK07 Description AN 1-80 PWK07 Description AN 1-80 PWK08 ACTION INDICATED PWK08 ACTION INDICATED PWK09 Request Category Code ID 1-2 PWK09 Request Category Code ID 1-2 change to Not Used CN1 CONTRACT CN1 CONTRACT CN101 Contract Type Code ID 2-2 R 01, 02, 03, 04, 05, 06, 09 CN101 Contract Type Code ID 2-2 R 01, 02, 03, 04, 05, 06, 09 CN102 Contract Amount R 1-18 CN102 Contract Amount R 1-18 CN103 Contract Percentage R 1-6 CN103 Contract Percentage R 1-6 CN104 Contract Code AN 1-30 CN104 Contract Code AN 1-50 Increase from CN105 Terms Discount Percent R 1-6 CN105 Terms Discount Percent R 1-6 CN106 Contract Version Identifier AN 1-30 CN106 Contract Version Identifier AN 1-30 AMT PAYER ETIMATED AMOUNT DUE AMT01 Amount Qualifier Code ID 1-3 R C5 egment Deleted AMT02 Patient Responsibility Amount R 1-18 R AMT03 Credit/Debit Flag AMT PATIENT ETIMATED AMOUNT DUE AMT PATIENT ETIMATED AMOUNT DUE AMT01 Amount Qualifier Code ID 1-3 R F3 AMT01 Amount Qualifier Code ID 1-3 R F3 Page 16 of 93

17 AMT02 Patient Responsibility Amount R 1-18 R AMT02 Patient Responsibility Amount R 1-18 R AMT03 Credit/Debit Flag AMT03 Credit/Debit Flag AMT PATIENT PAID AMOUNT egment Deleted AMT01 Amount Qualifier Code ID 1-3 R F5 AMT02 Patient Paid Amount R 1-18 R AMT03 Credit/Debit Flag AMT CREDIT/DEBIT CARD MAXIMUM AMOUNT AMT01 Amount Qualifier Code ID 1-3 R MA Credit or Debit Card Maximum AMT02 Amount R 1-18 R AMT03 Credit/Debit Flag egment Deleted ERVICE AUTHORIZATION EXCEPTION CODE Qualifier ID 2-3 R 4N ervice Authorization Exception Code AN 1-30 R 1, 2, 3, 4, 5, 6, 7 02 ERVICE AUTHORIZATION EXCEPTION CODE Qualifier ID 2-3 R 4N ervice Authorization Exception Code AN 1-50 R 1, 2, 3, 4, 5, 6, Description AN Description AN ERENCE IDENTIFIER 04 ERENCE IDENTIFIER Increase from ERRAL NUMBER New egment Qualifier ID 2-3 R 9F Prior Authorization or 02 Referral Number AN 1-50 R 03 Description AN ERENCE IDENTIFIER PRIOR AUTHORIZATION PRIOR AUTHORIZATION # s change to 1 Code Deleted Qualifier ID 2-3 R 9F, G1 Qualifier ID 2-3 R G1 02 Prior Authorization Number AN 1-30 R 02 Prior Authorization or Referral Number AN 1-50 R Increase from Description AN Description AN ERENCE IDENTIFIER 04 ERENCE IDENTIFIER ORIGINAL ERENCE NUMBER (ICN/DCN) Qualifier ID 2-3 R F8 Claim Original Reference Number AN 1-30 R 02 PAYER CLAIM CONTROL NUMBER Qualifier ID 2-3 R F8 Claim Original Reference Number AN 1-50 R Description AN Description AN 1-80 Increase from Page 17 of 93

18 04 ERENCE IDENTIFIER 04 ERENCE IDENTIFIER REPRICED CLAIM NUMBER REPRICED CLAIM NUMBER Qualifier ID 2-3 R 9A Repriced Claim Reference Number AN 1-30 R 02 Qualifier ID 2-3 R 9A Repriced Claim Reference Number AN 1-50 R Description AN Description AN ERENCE IDENTIFIER 04 ERENCE IDENTIFIER ADJUTED REPRICED CLAIM NUMBER Qualifier ID 2-3 R 9C Adjusted Repriced Claim Reference Number AN 1-30 R 02 ADJUTED REPRICED CLAIM NUMBER Qualifier ID 2-3 R 9C Adjusted Repriced Claim Reference Number AN 1-50 R Description AN Description AN ERENCE IDENTIFIER 04 ERENCE IDENTIFIER INVETIGATIONAL DEVICE EXEMPTION NUMBER Qualifier ID 2-3 R LX Investigational Device Exemption Number AN 1-30 R 02 INVETIGATIONAL DEVICE EXEMPTION NUMBER Qualifier ID 2-3 R LX Investigational Device Exemption Number AN 1-50 R Description AN Description AN ERENCE IDENTIFIER 04 ERENCE IDENTIFIER CLAIM IDENTIFIER FOR TRANMIION INTERMEDIARIE Qualifier ID 2-3 R D9 CLAIM IDENTIFIER FOR TRANMIION INTERMEDIARIE Qualifier ID 2-3 R D9 02 Value Added Network Trace Number AN 1-30 R 02 Clearinghouse Trace Number AN 1-50 R 03 Description AN Description AN ERENCE IDENTIFIER 04 ERENCE IDENTIFIER DOCUMENT IDENTIFICATION CODE Qualifier ID 2-3 R DD 02 Document ControlIdentifier AN 1-30 R 03 Description AN ERENCE IDENTIFIER Increase from Increase from Increase from Increase from egment Deleted AUTO ACCIDENT TATE New egment Page 18 of 93

19 MEDICAL RECORD NUMBER Qualifier ID 2-3 R EA Qualifier ID 2-3 R LU 02 Auto Accident tate or Province AN 1-50 R 03 Description AN ERENCE IDENTIFIER MEDICAL RECORD NUMBER Qualifier ID 2-3 R EA 02 Medical Record Number AN 1-30 R 02 Medical Record Number AN 1-50 R Increase from Description AN Description AN ERENCE IDENTIFIER 04 ERENCE IDENTIFIER DEMONTRATION PROJECT IDENTIFIER Qualifier ID 2-3 R P4 Demonstration Project Identifier AN 1-30 R 02 DEMONTRATION PROJECT IDENTIFIER Qualifier ID 2-3 R P4 Demonstration Project Identifier AN 1-50 R Description AN Description AN ERENCE IDENTIFIER 04 ERENCE IDENTIFIER Increase from PEER REVIEW ORGANIZARION (PRO) APPROVAL NUMBER Qualifier ID 2-3 R G4 PEER REVIEW ORGANIZARION (PRO) APPROVAL NUMBER Qualifier ID 2-3 R G4 02 PRO Number AN 1-30 R 02 PRO Number AN 1-50 R Increase from Description AN Description AN ERENCE IDENTIFIER 04 ERENCE IDENTIFIER K3 FILE K3 FILE K301 Fixed Format Information AN 1-80 R K301 Fixed Format Information AN 1-80 R K302 Record Format Code ID 1-2 K302 Record Format Code ID 1-2 K303 COMPOITE UNIT OF MEAURE K303 COMPOITE UNIT OF MEAURE NTE CLAIM NOTE NTE CLAIM NOTE NTE01 Note Reference Code ID 3-3 R ALG, DCP, DGN, DME, MED, NTR, ODT, RHB, RLH, RNH, ET, FM, PT, UPI NTE01 Note Reference Code ID 3-3 R NTE02 Claim Note Text AN 1-80 R NTE02 Claim Note Text AN 1-80 R ALG, DCP, DGN, DME, MED, NTR, ODT, RHB, RLH, RNH, ET, FM, PT, UPI NTE BILLING NOTE NTE BILLING NOTE NTE01 Note Reference Code ID 3-3 R ADD NTE01 Note Reference Code ID 3-3 R ADD Page 19 of 93

20 NTE02 Billing Note Text AN 1-80 R NTE02 Billing Note Text AN 1-80 R CR6 HOME HEALTH CARE egment Deleted CR601 Prognosis Indicator ID 1-1 R 1, 2, 3, 4, 5, 6, 7, 8 CR602 ervice From Date DT 8-8 R CCYYMMDD CR603 Qualifier ID 2-3 RD8 CR604 Home Health Certification Period AN 1-35 CR605 Diagnosis Date DT 8-8 R CCYYMMDD CR606 killed Nursing Facility Indicator ID 1-1 R N, U, Y CR607 Medicare Coverage Indicator ID 1-1 R N, Y CR608 Certification Type Indicator ID 1-1 R I, R, CR609 urgery Date DT 8-8 CCYYMMDD CR610 Product or ervice ID Qualifier ID 2-2 HC, ID CR611 urgical Procedure Code AN 1-15 CR612 Physician Order Date DT 8-8 CCYYMMDD CR613 Last Visit Date DT 8-8 CCYYMMDD CR614 Physician Contact Date DT 8-8 CCYYMMDD CR615 Qualifier ID 2-3 RD8 CR616 Last Admission Period AN 1-35 Patient Discharge Facility Type Code ID 1-1 R A, B, C, D, E, F, G, H, L, M, O, R,, T CR617 CR618 Diagnosis Date DT 8-8 CCYYMMDD CR619 Diagnosis Date DT 8-8 CCYYMMDD CR620 Diagnosis Date DT 8-8 CCYYMMDD CR621 Diagnosis Date DT 8-8 CCYYMMDD CRC HOME HEALTH FUNCTIONAL LIMITATION CRC01 Code Category ID 2-2 R 75 Certification Condition CRC02 Indicator ID 1-1 R N, Y CRC03 Functional Limitations Code ID 2-2 R CRC04 Functional Limitations Code ID 2-2 CRC05 Functional Limitations Code ID 2-2 CRC06 Functional Limitations Code ID 2-2 CRC07 Functional Limitations Code ID 2-2 AA, AL, BL, CO, DY, EL, HL, LB, OL, PA, L egment Deleted Page 20 of 93

21 CRC HOME HEALTH FUNCTIONAL LIMITATION CRC01 Code Category ID 2-2 R 76 egment Deleted CRC02 Functional Limitations Code ID 1-1 R N, Y CRC03 Activities Permitted Code ID 2-2 R CRC04 Activities Permitted Code ID 2-2 CRC05 Activities Permitted Code ID 2-2 CRC06 Activities Permitted Code ID 2-2 CRC07 Activities Permitted Code ID 2-2 BR, CA, CB, CR, EP, IH, NR, PW, TR, UT, WA, WR CRC CRC01 HOME HEALTH MENTAL TATU Certification Condition Indicator ID 2-2 R 77 egment Deleted CRC02 Functional Limitations Code ID 1-1 R N, Y CRC03 Mental tatus Code ID 2-2 R AG, CM, DI, DP, FO, LE, MC, OT CRC04 Mental tatus Code ID 2-2 CRC05 Mental tatus Code ID 2-2 CRC06 Mental tatus Code ID 2-2 CRC07 Mental tatus Code ID 2-2 CRC EPDT ERRAL New egment CRC01 Code Category ID 2-2 R ZZ CRC02 Certification Condition Indicator ID 1-1 R N, Y CRC03 Condition Code ID 2-3 R AV, NU, 2, T CRC04 Condition Code ID 2-3 AV, NU, 2, T CRC05 Condition Code ID 2-3 AV, NU, 2, T CRC06 Condition Indicator ID 2-3 CRC07 Condition Indicator ID 2-3 HI PRINCIPAL DIAGNOI HI PRINCIPAL DIAGNOI 1 R 2300 R HI01 change to Required HI01 R HI01-1 Code List Qualifier Code ID 1-3 R BK HI01-1 Diagnosis Type Code ID 1-3 R ABK, BK HI01-2 Industry Code AN 1-30 R HI01-2 Principal Diagnosis Code AN 1-30 R HI01-3 HI01-3 HI01-4 Date Time Period AN 1-35 HI01-4 Date Time Period AN 1-35 HI01-5 Monetary Amount R 1-18 HI01-5 Monetary Amount R 1-18 HI01-6 Quantity R 1-15 HI01-6 Quantity R 1-15 HI01-7 Version Identifier AN 1-30 HI01-7 Version Identifier AN 1-30 Page 21 of 93

22 HI01-8 Industry code AN 1-30 New New HI01-9 indicator ID 1-1 N, U, W, Y change to Not Used HI02 HI02 change to Not Used HI02-1 Code List Qualifier Code ID 1-3 R BJ, ZZ HI02-1 Diagnosis Type Code ID 1-3 change to Not Used HI02-2 Industry Code AN 1-30 R HI02-2 Principal Diagnosis Code AN 1-30 HI02-3 HI02-3 HI02-4 Date Time Period AN 1-35 HI02-4 Date Time Period AN 1-35 HI02-5 Monetary Amount R 1-18 HI02-5 Monetary Amount R 1-18 HI02-6 Quantity R 1-15 HI02-6 Quantity R 1-15 HI02-7 Version Identifier AN 1-30 HI02-7 Version Identifier AN 1-30 HI02-8 Industry code AN 1-30 New New HI02-9 indicator ID 1-1 change to Not Used HI03 HI03 change to Not Used HI03-1 Code List Qualifier Code ID 1-3 R BN HI03-1 Diagnosis Type Code ID 1-3 change to Not Used HI03-2 Industry Code AN 1-30 R HI03-2 Principal Diagnosis Code AN 1-30 HI03-3 HI03-3 HI03-4 Date Time Period AN 1-35 HI03-4 Date Time Period AN 1-35 HI03-5 Monetary Amount R 1-18 HI03-5 Monetary Amount R 1-18 HI03-6 Quantity R 1-15 HI03-6 Quantity R 1-15 HI03-7 Version Identifier AN 1-30 HI03-7 Version Identifier AN 1-30 HI04 HI04 HI03-8 Industry code AN 1-30 New New HI03-9 indicator ID 1-1 HI04-1 Diagnosis Type Code ID 1-3 New HI04-2 Principal Diagnosis Code AN 1-30 New New HI04-3 HI04-4 Date Time Period AN 1-35 New HI04-5 Monetary Amount R 1-18 New HI04-6 Quantity R 1-15 New HI04-7 Version Identifier AN 1-30 New HI04-8 Industry code AN 1-30 New HI04-9 indicator ID 1-1 New Page 22 of 93

23 HI05 HI06 HI07 HI08 HI05 HI06 HI07 HI08 HI05-1 Diagnosis Type Code ID 1-3 New HI05-2 Principal Diagnosis Code AN 1-30 New New HI05-3 HI05-4 Date Time Period AN 1-35 New HI05-5 Monetary Amount R 1-18 New HI05-6 Quantity R 1-15 New HI05-7 Version Identifier AN 1-30 New HI05-8 Industry code AN 1-30 New HI05-9 indicator ID 1-1 New HI06-1 Diagnosis Type Code ID 1-3 New HI06-2 Principal Diagnosis Code AN 1-30 New New HI06-3 HI06-4 Date Time Period AN 1-35 New HI06-5 Monetary Amount R 1-18 New HI06-6 Quantity R 1-15 New HI06-7 Version Identifier AN 1-30 New HI06-8 Industry code AN 1-30 New HI06-9 indicator ID 1-1 New HI07-1 Diagnosis Type Code ID 1-3 New HI07-2 Principal Diagnosis Code AN 1-30 New New HI07-3 HI07-4 Date Time Period AN 1-35 New HI07-5 Monetary Amount R 1-18 New HI07-6 Quantity R 1-15 New New HI07-7 Version Identifier AN 1-30 HI07-8 Industry code AN 1-30 New HI07-9 indicator ID 1-1 New HI08-1 Diagnosis Type Code ID 1-3 New HI08-2 Principal Diagnosis Code AN 1-30 New New HI08-3 HI08-4 Date Time Period AN 1-35 New HI08-5 Monetary Amount R 1-18 New HI08-6 Quantity R 1-15 New HI08-7 Version Identifier AN 1-30 New Page 23 of 93

24 HI09 HI10 HI11 HI12 HI09 HI10 HI11 HI12 HI08-8 Industry code AN 1-30 New New HI08-9 indicator ID 1-1 HI09-1 Diagnosis Type Code ID 1-3 New HI09-2 Principal Diagnosis Code AN 1-30 New New HI09-3 HI09-4 Date Time Period AN 1-35 New HI09-5 Monetary Amount R 1-18 New HI09-6 Quantity R 1-15 New HI09-7 Version Identifier AN 1-30 New HI09-8 Industry code AN 1-30 New HI09-9 indicator ID 1-1 New HI10-1 Diagnosis Type Code ID 1-3 New HI10-2 Principal Diagnosis Code AN 1-30 New New HI10-3 HI10-4 Date Time Period AN 1-35 New HI10-5 Monetary Amount R 1-18 New HI10-6 Quantity R 1-15 New HI10-7 Version Identifier AN 1-30 New HI10-8 Industry code AN 1-30 New HI10-9 indicator ID 1-1 New HI11-1 Diagnosis Type Code ID 1-3 New HI11-2 Principal Diagnosis Code AN 1-30 New New HI11-3 HI11-4 Date Time Period AN 1-35 New HI11-5 Monetary Amount R 1-18 New HI11-6 Quantity R 1-15 New HI11-7 Version Identifier AN 1-30 New HI11-8 Industry code AN 1-30 New HI11-9 indicator ID 1-1 New HI12-1 Diagnosis Type Code ID 1-3 New HI12-2 Principal Diagnosis Code AN 1-30 New New HI12-3 HI12-4 Date Time Period AN 1-35 New HI12-5 Monetary Amount R 1-18 New Page 24 of 93

25 HI12-6 Quantity R 1-15 New HI12-7 Version Identifier AN 1-30 New HI12-8 Industry code AN 1-30 New New HI12-9 indicator ID 1-1 HI ADMITTING DIGNOI 1 R 2300 New egment HI01 R HI01-1 Diagnosis Type Code ID 1-3 R ABJ, BJ HI01-2 Admitting Diagnosis Code AN 1-30 R HI01-3 HI01-4 Date Time Period AN 1-35 HI01-5 Monetary Amount R 1-18 HI01-6 Quantity R 1-15 HI01-7 Version Identifier AN 1-30 HI01-8 Industry code AN 1-30 HI01-9 HI02 HI02-1 Diagnosis Type Code ID 1-3 HI02-2 Principal Diagnosis Code AN 1-30 HI02-3 HI02-4 Date Time Period AN 1-35 HI02-5 Monetary Amount R 1-18 HI02-6 Quantity R 1-15 HI02-7 Version Identifier AN 1-30 HI02-8 Industry code AN 1-30 HI02-9 indicator ID 1-1 HI03 HI03-1 Diagnosis Type Code ID 1-3 HI03-2 Principal Diagnosis Code AN 1-30 HI03-3 HI03-4 Date Time Period AN 1-35 HI03-5 Monetary Amount R 1-18 HI03-6 Quantity R 1-15 HI03-7 Version Identifier AN 1-30 HI03-8 Industry code AN 1-30 HI03-9 indicator ID 1-1 HI04 HI04-1 Diagnosis Type Code ID 1-3 HI04-2 Principal Diagnosis Code AN 1-30 Page 25 of 93

26 HI04-3 HI04-4 Date Time Period AN 1-35 HI04-5 Monetary Amount R 1-18 HI04-6 Quantity R 1-15 HI04-7 Version Identifier AN 1-30 HI04-8 Industry code AN 1-30 HI04-9 indicator ID 1-1 HI05 HI05-1 Diagnosis Type Code ID 1-3 HI05-2 Principal Diagnosis Code AN 1-30 HI05-3 HI05-4 Date Time Period AN 1-35 HI05-5 Monetary Amount R 1-18 HI05-6 Quantity R 1-15 HI05-7 Version Identifier AN 1-30 HI05-8 Industry code AN 1-30 HI05-9 indicator ID 1-1 HI06 HI06-1 Diagnosis Type Code ID 1-3 HI06-2 Principal Diagnosis Code AN 1-30 HI06-3 HI06-4 Date Time Period AN 1-35 HI06-5 Monetary Amount R 1-18 HI06-6 Quantity R 1-15 HI06-7 Version Identifier AN 1-30 HI06-8 Industry code AN 1-30 HI06-9 indicator ID 1-1 HI07 HI07-1 Diagnosis Type Code ID 1-3 HI07-2 Principal Diagnosis Code AN 1-30 HI07-3 HI07-4 Date Time Period AN 1-35 HI07-5 Monetary Amount R 1-18 HI07-6 Quantity R 1-15 HI07-7 Version Identifier AN 1-30 HI07-8 Industry code AN 1-30 HI07-9 indicator ID 1-1 HI08 Page 26 of 93

27 HI08-1 Diagnosis Type Code ID 1-3 HI08-2 Principal Diagnosis Code AN 1-30 HI08-3 HI08-4 Date Time Period AN 1-35 HI08-5 Monetary Amount R 1-18 HI08-6 Quantity R 1-15 HI08-7 Version Identifier AN 1-30 HI08-8 Industry code AN 1-30 HI08-9 indicator ID 1-1 HI09 HI09-1 Diagnosis Type Code ID 1-3 HI09-2 Principal Diagnosis Code AN 1-30 HI09-3 HI09-4 Date Time Period AN 1-35 HI09-5 Monetary Amount R 1-18 HI09-6 Quantity R 1-15 HI09-7 Version Identifier AN 1-30 HI09-8 Industry code AN 1-30 HI09-9 indicator ID 1-1 HI10 HI10-1 Diagnosis Type Code ID 1-3 HI10-2 Principal Diagnosis Code AN 1-30 HI10-3 HI10-4 Date Time Period AN 1-35 HI10-5 Monetary Amount R 1-18 HI10-6 Quantity R 1-15 HI10-7 Version Identifier AN 1-30 HI10-8 Industry code AN 1-30 HI10-9 indicator ID 1-1 HI11 HI11-1 Diagnosis Type Code ID 1-3 HI11-2 Principal Diagnosis Code AN 1-30 HI11-3 HI11-4 Date Time Period AN 1-35 HI11-5 Monetary Amount R 1-18 HI11-6 Quantity R 1-15 HI11-7 Version Identifier AN 1-30 HI11-8 Industry code AN 1-30 HI11-9 indicator ID 1-1 Page 27 of 93

28 HI12 HI12-1 Diagnosis Type Code ID 1-3 HI12-2 Principal Diagnosis Code AN 1-30 HI12-3 HI12-4 Date Time Period AN 1-35 HI12-5 Monetary Amount R 1-18 HI12-6 Quantity R 1-15 HI12-7 Version Identifier AN 1-30 HI12-8 Industry code AN 1-30 HI12-9 indicator ID 1-1 HI PATIENT REAON FOR VIIT 1 R 2300 HI01 R HI01-1 Diagnosis Type Code ID 1-3 R APR, PR HI01-2 Patient Reason For Visit AN 1-30 R HI01-3 HI01-4 Date Time Period AN 1-35 HI01-5 Monetary Amount R 1-18 HI01-6 Quantity R 1-15 HI01-7 Version Identifier AN 1-30 HI01-8 Industry code AN 1-30 HI01-9 HI02 HI02-1 Diagnosis Type Code ID 1-3 R APR, PR HI02-2 Patient Reason For Visit AN 1-30 R HI02-3 HI02-4 Date Time Period AN 1-35 HI02-5 Monetary Amount R 1-18 HI02-6 Quantity R 1-15 HI02-7 Version Identifier AN 1-30 HI02-8 Industry code AN 1-30 HI02-9 HI03 HI03-1 Diagnosis Type Code ID 1-3 R APR, PR HI03-2 Patient Reason For Visit AN 1-30 R HI03-3 HI03-4 Date Time Period AN 1-35 HI03-5 Monetary Amount R 1-18 New egment Page 28 of 93

29 HI03-6 Quantity R 1-15 HI03-7 Version Identifier AN 1-30 HI03-8 Industry code AN 1-30 HI03-9 HI04 HI04-1 Diagnosis Type Code ID 1-3 HI04-2 Principal Diagnosis Code AN 1-30 HI04-3 HI04-4 Date Time Period AN 1-35 HI04-5 Monetary Amount R 1-18 HI04-6 Quantity R 1-15 HI04-7 Version Identifier AN 1-30 HI04-8 Industry code AN 1-30 HI04-9 indicator ID 1-1 HI05 HI05-1 Diagnosis Type Code ID 1-3 HI05-2 Principal Diagnosis Code AN 1-30 HI05-3 HI05-4 Date Time Period AN 1-35 HI05-5 Monetary Amount R 1-18 HI05-6 Quantity R 1-15 HI05-7 Version Identifier AN 1-30 HI05-8 Industry code AN 1-30 HI05-9 indicator ID 1-1 HI06 HI06-1 Diagnosis Type Code ID 1-3 HI06-2 Principal Diagnosis Code AN 1-30 HI06-3 HI06-4 Date Time Period AN 1-35 HI06-5 Monetary Amount R 1-18 HI06-6 Quantity R 1-15 HI06-7 Version Identifier AN 1-30 HI06-8 Industry code AN 1-30 HI06-9 indicator ID 1-1 HI07 HI07-1 Diagnosis Type Code ID 1-3 HI07-2 Principal Diagnosis Code AN 1-30 HI07-3 Page 29 of 93

30 HI07-4 Date Time Period AN 1-35 HI07-5 Monetary Amount R 1-18 HI07-6 Quantity R 1-15 HI07-7 Version Identifier AN 1-30 HI07-8 Industry code AN 1-30 HI07-9 indicator ID 1-1 HI08 HI08-1 Diagnosis Type Code ID 1-3 HI08-2 Principal Diagnosis Code AN 1-30 HI08-3 HI08-4 Date Time Period AN 1-35 HI08-5 Monetary Amount R 1-18 HI08-6 Quantity R 1-15 HI08-7 Version Identifier AN 1-30 HI08-8 Industry code AN 1-30 HI08-9 indicator ID 1-1 HI09 HI09-1 Diagnosis Type Code ID 1-3 HI09-2 Principal Diagnosis Code AN 1-30 HI09-3 HI09-4 Date Time Period AN 1-35 HI09-5 Monetary Amount R 1-18 HI09-6 Quantity R 1-15 HI09-7 Version Identifier AN 1-30 HI09-8 Industry code AN 1-30 HI09-9 indicator ID 1-1 HI10 HI10-1 Diagnosis Type Code ID 1-3 HI10-2 Principal Diagnosis Code AN 1-30 HI10-3 HI10-4 Date Time Period AN 1-35 HI10-5 Monetary Amount R 1-18 HI10-6 Quantity R 1-15 HI10-7 Version Identifier AN 1-30 HI10-8 Industry code AN 1-30 HI10-9 indicator ID 1-1 HI11 HI11-1 Diagnosis Type Code ID 1-3 HI11-2 Principal Diagnosis Code AN 1-30 Page 30 of 93

31 HI11-3 HI11-4 Date Time Period AN 1-35 HI11-5 Monetary Amount R 1-18 HI11-6 Quantity R 1-15 HI11-7 Version Identifier AN 1-30 HI11-8 Industry code AN 1-30 HI11-9 indicator ID 1-1 HI12 HI12-1 Diagnosis Type Code ID 1-3 HI12-2 Principal Diagnosis Code AN 1-30 HI12-3 HI12-4 Date Time Period AN 1-35 HI12-5 Monetary Amount R 1-18 HI12-6 Quantity R 1-15 HI12-7 Version Identifier AN 1-30 HI12-8 Industry code AN 1-30 HI12-9 indicator ID 1-1 HI EXTERNAL CAUE OF INJURY 1 R 2300 HI01 R HI01-1 Diagnosis Type Code ID 1-3 R ABN, BN New egment HI01-2 External Cause of Injury Code AN 1-30 R HI01-3 HI01-4 Date Time Period AN 1-35 HI01-5 Monetary Amount R 1-18 HI01-6 Quantity R 1-15 HI01-7 Version Identifier AN 1-30 HI01-8 Industry code AN 1-30 HI01-9 indicator ID 1-1 N, U, W, Y HI02 HI02-1 Diagnosis Type Code ID 1-3 R ABN, BN HI02-2 External Cause of Injury Code AN 1-30 R HI02-3 HI02-4 Date Time Period AN 1-35 HI02-5 Monetary Amount R 1-18 HI02-6 Quantity R 1-15 HI02-7 Version Identifier AN 1-30 Page 31 of 93

32 HI02-8 Industry code AN 1-30 HI02-9 indicator ID 1-1 N, U, W, Y HI03 HI03-1 Diagnosis Type Code ID 1-3 R ABN, BN HI03-2 External Cause of Injury Code AN 1-30 R HI03-3 HI03-4 Date Time Period AN 1-35 HI03-5 Monetary Amount R 1-18 HI03-6 Quantity R 1-15 HI03-7 Version Identifier AN 1-30 HI03-8 Industry code AN 1-30 HI03-9 indicator ID 1-1 N, U, W, Y HI04 HI04-1 Diagnosis Type Code ID 1-3 R ABN, BN HI04-2 External Cause of Injury Code AN 1-30 R HI04-3 HI04-4 Date Time Period AN 1-35 HI04-5 Monetary Amount R 1-18 HI04-6 Quantity R 1-15 HI04-7 Version Identifier AN 1-30 HI04-8 Industry code AN 1-30 HI04-9 indicator ID 1-1 N, U, W, Y HI05 HI05-1 Diagnosis Type Code ID 1-3 R ABN, BN HI05-2 Diagnosis Code AN 1-30 R HI05-3 HI05-4 Date Time Period AN 1-35 HI05-5 Monetary Amount R 1-18 HI05-6 Quantity R 1-15 HI05-7 Version Identifier AN 1-30 HI05-8 Industry code AN 1-30 HI05-9 indicator ID 1-1 N, U, W, Y HI06 HI06-1 Diagnosis Type Code ID 1-3 R ABN, BN HI06-2 External Cause of Injury Code AN 1-30 R Page 32 of 93

33 HI06-3 HI06-4 Date Time Period AN 1-35 HI06-5 Monetary Amount R 1-18 HI06-6 Quantity R 1-15 HI06-7 Version Identifier AN 1-30 HI06-8 Industry code AN 1-30 HI06-9 indicator ID 1-1 N, U, W, Y HI07 HI07-1 Diagnosis Type Code ID 1-3 R ABN, BN HI07-2 External Cause of Injury Code AN 1-30 R HI07-3 HI07-4 Date Time Period AN 1-35 HI07-5 Monetary Amount R 1-18 HI07-6 Quantity R 1-15 HI07-7 Version Identifier AN 1-30 HI07-8 Industry code AN 1-30 HI07-9 indicator ID 1-1 N, U, W, Y HI08 HI08-1 Diagnosis Type Code ID 1-3 R ABN, BN HI08-2 External Cause of Injury Code AN 1-30 R HI08-3 HI08-4 Date Time Period AN 1-35 HI08-5 Monetary Amount R 1-18 HI08-6 Quantity R 1-15 HI08-7 Version Identifier AN 1-30 HI08-8 Industry code AN 1-30 HI08-9 indicator ID 1-1 N, U, W, Y HI09 HI09-1 Diagnosis Type Code ID 1-3 R ABN, BN HI09-2 External Cause of Injury Code AN 1-30 R HI09-3 HI09-4 Date Time Period AN 1-35 HI09-5 Monetary Amount R 1-18 HI09-6 Quantity R 1-15 HI09-7 Version Identifier AN 1-30 HI09-8 Industry code AN 1-30 Page 33 of 93

34 HI09-9 indicator ID 1-1 N, U, W, Y HI10 HI10-1 Diagnosis Type Code ID 1-3 R ABN, BN HI10-2 External Cause of Injury Code AN 1-30 R HI10-3 HI10-4 Date Time Period AN 1-35 HI10-5 Monetary Amount R 1-18 HI10-6 Quantity R 1-15 HI10-7 Version Identifier AN 1-30 HI10-8 Industry code AN 1-30 HI10-9 indicator ID 1-1 N, U, W, Y HI11 HI11-1 Diagnosis Type Code ID 1-3 R ABN, BN HI11-2 External Cause of Injury Code AN 1-30 R HI11-3 HI11-4 Date Time Period AN 1-35 HI11-5 Monetary Amount R 1-18 HI11-6 Quantity R 1-15 HI11-7 Version Identifier AN 1-30 HI11-8 Industry code AN 1-30 HI11-9 indicator ID 1-1 N, U, W, Y HI12 HI12-1 Diagnosis Type Code ID 1-3 R ABN, BN HI12-2 External Cause of Injury Code AN 1-30 R HI12-3 HI12-4 Date Time Period AN 1-35 HI12-5 Monetary Amount R 1-18 HI12-6 Quantity R 1-15 HI12-7 Version Identifier AN 1-30 HI12-8 Industry code AN 1-30 HI12-9 indicator ID 1-1 N, U, W, Y HI DIAGNOI RELATED GROUP (DRG) 1 R 2300 HI DIAGNOI RELATED GROUP (DRG) 1 R 2300 Page 34 of 93

35 R HI01 HI01 R HI01-1 Code List Qualifier Code ID 1-3 R DR HI01-1 Qualifier ID 1-3 R DR HI01-2 DRG Code AN 1-30 R HI01-2 DRG Code AN 1-30 R HI01-3 HI01-3 HI01-4 Date Time Period AN 1-35 HI01-4 Date Time Period AN 1-35 HI01-5 Monetary Amount R 1-18 HI01-5 Monetary Amount R 1-18 HI01-6 Quantity R 1-15 HI01-6 Quantity R 1-15 HI01-7 Version Identifier AN 1-30 HI01-7 Version Identifier AN 1-30 HI02 HI03 HI04 HI02 HI03 HI04 HI01-8 Industry code AN 1-30 New New HI01-9 HI02-1 Diagnosis Type Code ID 1-3 New HI02-2 Principal Diagnosis Code AN 1-30 New New HI02-3 HI02-4 Date Time Period AN 1-35 New HI02-5 Monetary Amount R 1-18 New HI02-6 Quantity R 1-15 New HI02-7 Version Identifier AN 1-30 New HI02-8 Industry code AN 1-30 New HI02-9 indicator ID 1-1 New HI03-1 Diagnosis Type Code ID 1-3 New HI03-2 Principal Diagnosis Code AN 1-30 New New HI03-3 HI03-4 Date Time Period AN 1-35 New HI03-5 Monetary Amount R 1-18 New HI03-6 Quantity R 1-15 New HI03-7 Version Identifier AN 1-30 New HI03-8 Industry code AN 1-30 New HI03-9 indicator ID 1-1 New HI04-1 Diagnosis Type Code ID 1-3 New HI04-2 Principal Diagnosis Code AN 1-30 New New HI04-3 HI04-4 Date Time Period AN 1-35 New HI04-5 Monetary Amount R 1-18 New HI04-6 Quantity R 1-15 New HI04-7 Version Identifier AN 1-30 New HI04-8 Industry code AN 1-30 New Page 35 of 93

36 HI05 HI06 HI07 HI08 HI04-9 HI05 HI06 HI07 HI08 indicator ID 1-1 New HI05-1 Diagnosis Type Code ID 1-3 New HI05-2 Principal Diagnosis Code AN 1-30 New New HI05-3 HI05-4 Date Time Period AN 1-35 New HI05-5 Monetary Amount R 1-18 New HI05-6 Quantity R 1-15 New HI05-7 Version Identifier AN 1-30 New HI05-8 Industry code AN 1-30 New HI05-9 indicator ID 1-1 New HI06-1 Diagnosis Type Code ID 1-3 New HI06-2 Principal Diagnosis Code AN 1-30 New New HI06-3 HI06-4 Date Time Period AN 1-35 New HI06-5 Monetary Amount R 1-18 New HI06-6 Quantity R 1-15 New HI06-7 Version Identifier AN 1-30 New HI06-8 Industry code AN 1-30 New HI06-9 indicator ID 1-1 New HI07-1 Diagnosis Type Code ID 1-3 New HI07-2 Principal Diagnosis Code AN 1-30 New New HI07-3 HI07-4 Date Time Period AN 1-35 New HI07-5 Monetary Amount R 1-18 New HI07-6 Quantity R 1-15 New HI07-7 Version Identifier AN 1-30 New HI07-8 Industry code AN 1-30 New HI07-9 indicator ID 1-1 New HI08-1 Diagnosis Type Code ID 1-3 New HI08-2 Principal Diagnosis Code AN 1-30 New New HI08-3 HI08-4 Date Time Period AN 1-35 New HI08-5 Monetary Amount R 1-18 New HI08-6 Quantity R 1-15 New Page 36 of 93

37 HI09 HI10 HI11 HI12 HI08-7 Version Identifier AN 1-30 New HI09 HI10 HI11 HI12 HI08-8 Industry code AN 1-30 New New HI08-9 indicator ID 1-1 HI09-1 Diagnosis Type Code ID 1-3 New HI09-2 Principal Diagnosis Code AN 1-30 New New HI09-3 HI09-4 Date Time Period AN 1-35 New HI09-5 Monetary Amount R 1-18 New HI09-6 Quantity R 1-15 New HI09-7 Version Identifier AN 1-30 New HI09-8 Industry code AN 1-30 New HI09-9 indicator ID 1-1 New HI10-1 Diagnosis Type Code ID 1-3 New HI10-2 Principal Diagnosis Code AN 1-30 New New HI10-3 HI10-4 Date Time Period AN 1-35 New HI10-5 Monetary Amount R 1-18 New HI10-6 Quantity R 1-15 New HI10-7 Version Identifier AN 1-30 New HI10-8 Industry code AN 1-30 New HI10-9 indicator ID 1-1 New HI11-1 Diagnosis Type Code ID 1-3 New HI11-2 Principal Diagnosis Code AN 1-30 New New HI11-3 HI11-4 Date Time Period AN 1-35 New HI11-5 Monetary Amount R 1-18 New HI11-6 Quantity R 1-15 New HI11-7 Version Identifier AN 1-30 New HI11-8 Industry code AN 1-30 New HI11-9 indicator ID 1-1 New HI12-1 Diagnosis Type Code ID 1-3 New HI12-2 Principal Diagnosis Code AN 1-30 New New HI12-3 HI12-4 Date Time Period AN 1-35 New Page 37 of 93

38 HI HI01 HI12-5 Monetary Amount R 1-18 New HI12-6 Quantity R 1-15 New HI12-7 Version Identifier AN 1-30 New OTHER DIAGNOI 2 R 2300 HI R HI01 HI12-8 Industry code AN 1-30 New New HI12-9 indicator ID 1-1 OTHER DIAGNOI 2 R 2300 R HI01-1 Code List Qualifier Code ID 1-3 R BF HI01-1 Diagnosis Type Code ID 1-3 R ABF, BF HI01-2 Other Diagnosis AN 1-30 R HI01-2 Other Diagnosis AN 1-30 R HI01-3 HI01-3 HI01-4 Date Time Period AN 1-35 HI01-4 Date Time Period AN 1-35 HI01-5 Monetary Amount R 1-18 HI01-5 Monetary Amount R 1-18 HI01-6 Quantity R 1-15 HI01-6 Quantity R 1-15 HI01-7 Version Identifier AN 1-30 HI01-7 Version Identifier AN 1-30 HI02 HI02 Code Added HI01-8 Industry code AN 1-30 New New HI01-9 indicator ID 1-1 N, U, W, Y HI02-1 Code List Qualifier Code ID 1-3 R BF HI02-1 Diagnosis Type Code ID 1-3 R ABF, BF HI02-2 Other Diagnosis AN 1-30 R HI02-2 Other Diagnosis AN 1-30 R HI02-3 HI02-3 HI02-4 Date Time Period AN 1-35 HI02-4 Date Time Period AN 1-35 HI02-5 Monetary Amount R 1-18 HI02-5 Monetary Amount R 1-18 HI02-6 Quantity R 1-15 HI02-6 Quantity R 1-15 HI02-7 Version Identifier AN 1-30 HI02-7 Version Identifier AN 1-30 HI03 HI03 Code Added HI02-8 Industry code AN 1-30 New New HI02-9 indicator ID 1-1 N, U, W, Y HI03-1 Code List Qualifier Code ID 1-3 R BF HI03-1 Diagnosis Type Code ID 1-3 R ABF, BF HI03-2 Other Diagnosis AN 1-30 R HI03-2 Other Diagnosis AN 1-30 R HI03-3 Code Added HI03-3 HI03-4 Date Time Period AN 1-35 HI03-4 Date Time Period AN 1-35 HI03-5 Monetary Amount R 1-18 HI03-5 Monetary Amount R 1-18 HI03-6 Quantity R 1-15 HI03-6 Quantity R 1-15 HI03-7 Version Identifier AN 1-30 HI03-7 Version Identifier AN 1-30 HI03-8 Industry code AN 1-30 New Page 38 of 93

39 HI04 HI03-9 HI04 indicator ID 1-1 N, U, W, Y HI04-1 Code List Qualifier Code ID 1-3 R BF HI04-1 Diagnosis Type Code ID 1-3 R ABF, BF HI04-2 Other Diagnosis AN 1-30 R HI04-2 Other Diagnosis AN 1-30 R HI04-3 HI04-3 HI04-4 Date Time Period AN 1-35 HI04-4 Date Time Period AN 1-35 HI04-5 Monetary Amount R 1-18 HI04-5 Monetary Amount R 1-18 HI04-6 Quantity R 1-15 HI04-6 Quantity R 1-15 HI04-7 Version Identifier AN 1-30 HI04-7 Version Identifier AN 1-30 HI05 HI05 New Code Added HI04-8 Industry code AN 1-30 New New HI04-9 indicator ID 1-1 N, U, W, Y HI05-1 Code List Qualifier Code ID 1-3 R BF HI05-1 Diagnosis Type Code ID 1-3 R ABF, BF HI05-2 Other Diagnosis AN 1-30 R HI05-2 Other Diagnosis AN 1-30 R HI05-3 HI05-3 HI05-4 Date Time Period AN 1-35 HI05-4 Date Time Period AN 1-35 HI05-5 Monetary Amount R 1-18 HI05-5 Monetary Amount R 1-18 HI05-6 Quantity R 1-15 HI05-6 Quantity R 1-15 HI05-7 Version Identifier AN 1-30 HI05-7 Version Identifier AN 1-30 HI06 HI06 Code Added HI05-8 Industry code AN 1-30 New New HI05-9 indicator ID 1-1 N, U, W, Y HI06-1 Code List Qualifier Code ID 1-3 R BF HI06-1 Diagnosis Type Code ID 1-3 R ABF, BF HI06-2 Other Diagnosis AN 1-30 R HI06-2 Other Diagnosis AN 1-30 R HI06-3 HI06-3 HI06-4 Date Time Period AN 1-35 HI06-4 Date Time Period AN 1-35 HI06-5 Monetary Amount R 1-18 HI06-5 Monetary Amount R 1-18 HI06-6 Quantity R 1-15 HI06-6 Quantity R 1-15 HI06-7 Version Identifier AN 1-30 HI06-7 Version Identifier AN 1-30 HI07 HI07 Code Added HI06-8 Industry code AN 1-30 New New HI06-9 indicator ID 1-1 N, U, W, Y HI07-1 Code List Qualifier Code ID 1-3 R BF HI07-1 Diagnosis Type Code ID 1-3 R ABF, BF HI07-2 Other Diagnosis AN 1-30 R HI07-2 Other Diagnosis AN 1-30 R Code Added Page 39 of 93

40 HI07-3 HI07-3 HI07-4 Date Time Period AN 1-35 HI07-4 Date Time Period AN 1-35 HI07-5 Monetary Amount R 1-18 HI07-5 Monetary Amount R 1-18 HI07-6 Quantity R 1-15 HI07-6 Quantity R 1-15 HI07-7 Version Identifier AN 1-30 HI07-7 Version Identifier AN 1-30 HI08 HI08 HI07-8 Industry code AN 1-30 New New HI07-9 indicator ID 1-1 N, U, W, Y HI08-1 Code List Qualifier Code ID 1-3 R BF HI08-1 Diagnosis Type Code ID 1-3 R ABF, BF HI08-2 Other Diagnosis AN 1-30 R HI08-2 Other Diagnosis AN 1-30 R HI08-3 HI08-3 HI08-4 Date Time Period AN 1-35 HI08-4 Date Time Period AN 1-35 HI08-5 Monetary Amount R 1-18 HI08-5 Monetary Amount R 1-18 HI08-6 Quantity R 1-15 HI08-6 Quantity R 1-15 HI08-7 Version Identifier AN 1-30 HI08-7 Version Identifier AN 1-30 HI09 HI09 Code Added HI08-8 Industry code AN 1-30 New New HI08-9 indicator ID 1-1 N, U, W, Y HI09-1 Code List Qualifier Code ID 1-3 R BF HI09-1 Diagnosis Type Code ID 1-3 R ABF, BF HI09-2 Other Diagnosis AN 1-30 R HI09-2 Other Diagnosis AN 1-30 R HI09-3 HI09-3 HI09-4 Date Time Period AN 1-35 HI09-4 Date Time Period AN 1-35 HI09-5 Monetary Amount R 1-18 HI09-5 Monetary Amount R 1-18 HI09-6 Quantity R 1-15 HI09-6 Quantity R 1-15 HI09-7 Version Identifier AN 1-30 HI09-7 Version Identifier AN 1-30 HI10 HI10 Code Added HI09-8 Industry code AN 1-30 New New HI09-9 indicator ID 1-1 N, U, W, Y HI10-1 Code List Qualifier Code ID 1-3 R BF HI10-1 Diagnosis Type Code ID 1-3 R ABF, BF HI10-2 Other Diagnosis AN 1-30 R HI10-2 Other Diagnosis AN 1-30 R HI10-3 Code Added HI10-3 HI10-4 Date Time Period AN 1-35 HI10-4 Date Time Period AN 1-35 HI10-5 Monetary Amount R 1-18 HI10-5 Monetary Amount R 1-18 HI10-6 Quantity R 1-15 HI10-6 Quantity R 1-15 HI10-7 Version Identifier AN 1-30 HI10-7 Version Identifier AN 1-30 HI10-8 Industry code AN 1-30 New Page 40 of 93

41 HI11 HI10-9 HI11 indicator ID 1-1 N, U, W, Y HI11-1 Code List Qualifier Code ID 1-3 R BF HI11-1 Diagnosis Type Code ID 1-3 R ABF, BF HI11-2 Other Diagnosis AN 1-30 R HI11-2 Other Diagnosis AN 1-30 R HI11-3 HI11-3 HI11-4 Date Time Period AN 1-35 HI11-4 Date Time Period AN 1-35 HI11-5 Monetary Amount R 1-18 HI11-5 Monetary Amount R 1-18 HI11-6 Quantity R 1-15 HI11-6 Quantity R 1-15 HI11-7 Version Identifier AN 1-30 HI11-7 Version Identifier AN 1-30 HI12 HI12 New Code Added HI11-8 Industry code AN 1-30 New New HI11-9 indicator ID 1-1 N, U, W, Y HI12-1 Code List Qualifier Code ID 1-3 R BF HI12-1 Diagnosis Type Code ID 1-3 R ABF, BF HI12-2 Other Diagnosis AN 1-30 R HI12-2 Other Diagnosis AN 1-30 R HI12-3 HI12-3 HI12-4 Date Time Period AN 1-35 HI12-4 Date Time Period AN 1-35 HI12-5 Monetary Amount R 1-18 HI12-5 Monetary Amount R 1-18 HI12-6 Quantity R 1-15 HI12-6 Quantity R 1-15 HI12-7 Version Identifier AN 1-30 HI12-7 Version Identifier AN 1-30 HI PRINCIPAL PROCEDURE 1 R 2300 HI R HI01 Code Added HI12-8 Industry code AN 1-30 New New HI12-9 indicator ID 1-1 N, U, W, Y PRINCIPAL PROCEDURE 1 R 2300 R HI01 HI01-1 Code List Qualifier Code ID 1-3 R BP HI01-1 Qualifier ID 1-3 R BBR, BR Code Change HI01-2 Principal Procedure Code AN 1-30 R HI01-2 Principal Procedure Code AN 1-30 R change to Not Used HI01-3 Qualifier ID 2-3 D8 HI01-3 change to Not Used HI01-4 Date Time Period AN 1-35 HI01-4 Date Time Period AN 1-35 HI01-5 Monetary Amount R 1-18 HI01-5 Monetary Amount R 1-18 HI01-6 Quantity R 1-15 HI01-6 Quantity R 1-15 HI01-7 Version Identifier AN 1-30 HI01-7 Version Identifier AN 1-30 HI01-8 Industry code AN 1-30 New New HI01-9 indicator ID 1-1 HI02 HI02 Page 41 of 93

42 HI03 HI04 HI05 HI02-1 Diagnosis Type Code ID 1-3 New HI03 HI04 HI05 HI02-2 Principal Diagnosis Code AN 1-30 New New HI02-3 HI02-4 Date Time Period AN 1-35 New HI02-5 Monetary Amount R 1-18 New HI02-6 Quantity R 1-15 New HI02-7 Version Identifier AN 1-30 New HI02-8 Industry code AN 1-30 New HI02-9 indicator ID 1-1 New HI03-1 Diagnosis Type Code ID 1-3 New HI03-2 Principal Diagnosis Code AN 1-30 New New HI03-3 HI03-4 Date Time Period AN 1-35 New HI03-5 Monetary Amount R 1-18 New HI03-6 Quantity R 1-15 New HI03-7 Version Identifier AN 1-30 New HI03-8 Industry code AN 1-30 New HI03-9 indicator ID 1-1 New HI04-1 Diagnosis Type Code ID 1-3 New HI04-2 Principal Diagnosis Code AN 1-30 New New HI04-3 HI04-4 Date Time Period AN 1-35 New HI04-5 Monetary Amount R 1-18 New HI04-6 Quantity R 1-15 New HI04-7 Version Identifier AN 1-30 New HI04-8 Industry code AN 1-30 New HI04-9 indicator ID 1-1 New HI05-1 Diagnosis Type Code ID 1-3 New HI05-2 Principal Diagnosis Code AN 1-30 New New HI05-3 HI05-4 Date Time Period AN 1-35 New HI05-5 Monetary Amount R 1-18 New HI05-6 Quantity R 1-15 New HI05-7 Version Identifier AN 1-30 New HI05-8 Industry code AN 1-30 New HI05-9 indicator ID 1-1 New Page 42 of 93

43 HI06 HI07 HI08 HI09 HI06 HI07 HI08 HI09 HI06-1 Diagnosis Type Code ID 1-3 New HI06-2 Principal Diagnosis Code AN 1-30 New New HI06-3 HI06-4 Date Time Period AN 1-35 New HI06-5 Monetary Amount R 1-18 New HI06-6 Quantity R 1-15 New HI06-7 Version Identifier AN 1-30 New HI06-8 Industry code AN 1-30 New HI06-9 indicator ID 1-1 New HI07-1 Diagnosis Type Code ID 1-3 New HI07-2 Principal Diagnosis Code AN 1-30 New New HI07-3 HI07-4 Date Time Period AN 1-35 New HI07-5 Monetary Amount R 1-18 New HI07-6 Quantity R 1-15 New HI07-7 Version Identifier AN 1-30 New HI07-8 Industry code AN 1-30 New HI07-9 indicator ID 1-1 New HI08-1 Diagnosis Type Code ID 1-3 New HI08-2 Principal Diagnosis Code AN 1-30 New New HI08-3 HI08-4 Date Time Period AN 1-35 New HI08-5 Monetary Amount R 1-18 New HI08-6 Quantity R 1-15 New HI08-7 Version Identifier AN 1-30 New HI08-8 Industry code AN 1-30 New HI08-9 indicator ID 1-1 New HI09-1 Diagnosis Type Code ID 1-3 New HI09-2 Principal Diagnosis Code AN 1-30 New New HI09-3 HI09-4 Date Time Period AN 1-35 New HI09-5 Monetary Amount R 1-18 New HI09-6 Quantity R 1-15 New HI09-7 Version Identifier AN 1-30 New HI09-8 Industry code AN 1-30 New Page 43 of 93

44 HI10 HI11 HI12 HI09-9 HI10 HI11 HI12 indicator ID 1-1 New HI10-1 Diagnosis Type Code ID 1-3 New HI10-2 Principal Diagnosis Code AN 1-30 New New HI10-3 HI10-4 Date Time Period AN 1-35 New HI10-5 Monetary Amount R 1-18 New HI10-6 Quantity R 1-15 New HI10-7 Version Identifier AN 1-30 New HI10-8 Industry code AN 1-30 New HI10-9 indicator ID 1-1 New HI11-1 Diagnosis Type Code ID 1-3 New HI11-2 Principal Diagnosis Code AN 1-30 New New HI11-3 HI11-4 Date Time Period AN 1-35 New HI11-5 Monetary Amount R 1-18 New HI11-6 Quantity R 1-15 New HI11-7 Version Identifier AN 1-30 New HI11-8 Industry code AN 1-30 New HI11-9 indicator ID 1-1 New HI12-1 Diagnosis Type Code ID 1-3 New HI12-2 Principal Diagnosis Code AN 1-30 New New HI12-3 HI12-4 Date Time Period AN 1-35 New HI12-5 Monetary Amount R 1-18 New HI12-6 Quantity R 1-15 New HI12-7 Version Identifier AN 1-30 New HI12-8 Industry code AN 1-30 New HI12-9 indicator ID 1-1 New HI HI01 OTHER PROCEDURE 2 R 2300 HI R HI01 OTHER PROCEDURE 2 R 2300 R HI01-1 Code List Qualifier Code ID 1-3 R BO, BQ HI01-1 Qualifier Code ID 1-3 R BBQ, BQ HI01-2 Procedure Code AN 1-30 R HI01-2 Procedure Code AN 1-30 R Code Change Page 44 of 93

45 change to Required HI01-3 Qualifier ID 2-3 D8 HI01-3 Qualifier ID 2-3 R D8 change to Required HI01-4 Date Time Period AN 1-35 CCYYMMDD HI01-4 Date Time Period AN 1-35 R CCYYMMDD HI01-5 Monetary Amount R 1-18 HI01-5 Monetary Amount R 1-18 HI01-6 Quantity R 1-15 HI01-6 Quantity R 1-15 HI01-7 Version Identifier AN 1-30 HI01-7 Version Identifier AN 1-30 HI01-8 Industry code AN 1-30 New HI01-9 New HI02 HI02 HI02-1 Code List Qualifier Code ID 1-3 R BO, BQ HI02-1 Qualifier Code ID 1-3 R BBQ, BQ Code Change HI02-2 Procedure Code AN 1-30 R HI02-2 Procedure Code AN 1-30 R change to Required HI02-3 Qualifier ID 2-3 D8 HI02-3 Qualifier ID 2-3 R D8 change to Required HI02-4 Date Time Period AN 1-35 CCYYMMDD HI02-4 Date Time Period AN 1-35 R CCYYMMDD HI02-5 Monetary Amount R 1-18 HI02-5 Monetary Amount R 1-18 HI02-6 Quantity R 1-15 HI02-6 Quantity R 1-15 HI02-7 Version Identifier AN 1-30 HI02-7 Version Identifier AN 1-30 HI02-8 Industry code AN 1-30 New New HI02-9 HI03 HI03 HI03-1 Code List Qualifier Code ID 1-3 R BO, BQ HI03-1 Qualifier Code ID 1-3 R BBQ, BQ Code Change HI03-2 Procedure Code AN 1-30 R HI03-2 Procedure Code AN 1-30 R change to Required HI03-3 Qualifier ID 2-3 D8 HI03-3 Qualifier ID 2-3 R D8 change to Required HI03-4 Date Time Period AN 1-35 CCYYMMDD HI03-4 Date Time Period AN 1-35 R CCYYMMDD HI03-5 Monetary Amount R 1-18 HI03-5 Monetary Amount R 1-18 HI03-6 Quantity R 1-15 HI03-6 Quantity R 1-15 HI03-7 Version Identifier AN 1-30 HI03-7 Version Identifier AN 1-30 HI03-8 Industry code AN 1-30 New New HI03-9 HI04 HI04 HI04-1 Code List Qualifier Code ID 1-3 R BO, BQ HI04-1 Qualifier Code ID 1-3 R BBQ, BQ HI04-2 Procedure Code AN 1-30 R HI04-2 Procedure Code AN 1-30 R HI04-3 Qualifier ID 2-3 D8 HI04-3 Qualifier ID 2-3 R D8 HI04-4 Date Time Period AN 1-35 CCYYMMDD HI04-4 Date Time Period AN 1-35 R CCYYMMDD HI04-5 Monetary Amount R 1-18 HI04-5 Monetary Amount R 1-18 Code Change change to Required change to Required Page 45 of 93

46 HI04-6 Quantity R 1-15 HI04-6 Quantity R 1-15 HI04-7 Version Identifier AN 1-30 HI04-7 Version Identifier AN 1-30 HI05 HI04-8 Industry code AN 1-30 New New HI04-9 HI05 HI05-1 Code List Qualifier Code ID 1-3 R BO, BQ HI05-1 Qualifier Code ID 1-3 R BBQ, BQ Code Change HI05-2 Procedure Code AN 1-30 R HI05-2 Procedure Code AN 1-30 R change to Required HI05-3 Qualifier ID 2-3 D8 HI05-3 Qualifier ID 2-3 R D8 change to Required HI05-4 Date Time Period AN 1-35 CCYYMMDD HI05-4 Date Time Period AN 1-35 R CCYYMMDD HI05-5 Monetary Amount R 1-18 HI05-5 Monetary Amount R 1-18 HI05-6 Quantity R 1-15 HI05-6 Quantity R 1-15 HI05-7 Version Identifier AN 1-30 HI05-7 Version Identifier AN 1-30 HI05-8 Industry code AN 1-30 New New HI05-9 HI06 HI06 HI06-1 Code List Qualifier Code ID 1-3 R BO, BQ HI06-1 Qualifier Code ID 1-3 R BBQ, BQ Code Change HI06-2 Procedure Code AN 1-30 R HI06-2 Procedure Code AN 1-30 R change to Required HI06-3 Qualifier ID 2-3 D8 HI06-3 Qualifier ID 2-3 R D8 change to Required HI06-4 Date Time Period AN 1-35 CCYYMMDD HI06-4 Date Time Period AN 1-35 R CCYYMMDD HI06-5 Monetary Amount R 1-18 HI06-5 Monetary Amount R 1-18 HI06-6 Quantity R 1-15 HI06-6 Quantity R 1-15 HI06-7 Version Identifier AN 1-30 HI06-7 Version Identifier AN 1-30 HI06-8 Industry code AN 1-30 New New HI06-9 HI07 HI07 HI07-1 Code List Qualifier Code ID 1-3 R BO, BQ HI07-1 Qualifier Code ID 1-3 R BBQ, BQ Code Change HI07-2 Procedure Code AN 1-30 R HI07-2 Procedure Code AN 1-30 R change to Required HI07-3 Qualifier ID 2-3 D8 HI07-3 Qualifier ID 2-3 R D8 change to Required HI07-4 Date Time Period AN 1-35 CCYYMMDD HI07-4 Date Time Period AN 1-35 R CCYYMMDD HI07-5 Monetary Amount R 1-18 HI07-5 Monetary Amount R 1-18 HI07-6 Quantity R 1-15 HI07-6 Quantity R 1-15 HI07-7 Version Identifier AN 1-30 HI07-7 Version Identifier AN 1-30 HI07-8 Industry code AN 1-30 New New HI07-9 Page 46 of 93

47 HI08 HI08 HI08-1 Code List Qualifier Code ID 1-3 R BO, BQ HI08-1 Qualifier Code ID 1-3 R BBQ, BQ Code Change HI08-2 Procedure Code AN 1-30 R HI08-2 Procedure Code AN 1-30 R change to Required HI08-3 Qualifier ID 2-3 D8 HI08-3 Qualifier ID 2-3 R D8 change to Required HI08-4 Date Time Period AN 1-35 CCYYMMDD HI08-4 Date Time Period AN 1-35 R CCYYMMDD HI08-5 Monetary Amount R 1-18 HI08-5 Monetary Amount R 1-18 HI08-6 Quantity R 1-15 HI08-6 Quantity R 1-15 HI08-7 Version Identifier AN 1-30 HI08-7 Version Identifier AN 1-30 HI08-8 Industry code AN 1-30 New New HI08-9 HI09 HI09 HI09-1 Code List Qualifier Code ID 1-3 R BO, BQ HI09-1 Qualifier Code ID 1-3 R BBQ, BQ Code Change HI09-2 Procedure Code AN 1-30 R HI09-2 Procedure Code AN 1-30 R change to Required HI09-3 Qualifier ID 2-3 D8 HI09-3 Qualifier ID 2-3 R D8 change to Required HI09-4 Date Time Period AN 1-35 CCYYMMDD HI09-4 Date Time Period AN 1-35 R CCYYMMDD HI09-5 Monetary Amount R 1-18 HI09-5 Monetary Amount R 1-18 HI09-6 Quantity R 1-15 HI09-6 Quantity R 1-15 HI09-7 Version Identifier AN 1-30 HI09-7 Version Identifier AN 1-30 HI09-8 Industry code AN 1-30 New New HI09-9 HI10 HI10 HI10-1 Code List Qualifier Code ID 1-3 R BO, BQ HI10-1 Qualifier Code ID 1-3 R BBQ, BQ Code Change HI10-2 Procedure Code AN 1-30 R HI10-2 Procedure Code AN 1-30 R change to Required HI10-3 Qualifier ID 2-3 D8 HI10-3 Qualifier ID 2-3 R D8 change to Required HI10-4 Date Time Period AN 1-35 CCYYMMDD HI10-4 Date Time Period AN 1-35 R CCYYMMDD HI10-5 Monetary Amount R 1-18 HI10-5 Monetary Amount R 1-18 HI10-6 Quantity R 1-15 HI10-6 Quantity R 1-15 HI10-7 Version Identifier AN 1-30 HI10-7 Version Identifier AN 1-30 HI10-8 Industry code AN 1-30 New New HI10-9 HI11 HI11 HI11-1 Code List Qualifier Code ID 1-3 R BO, BQ HI11-1 Qualifier Code ID 1-3 R BBQ, BQ HI11-2 Procedure Code AN 1-30 R HI11-2 Procedure Code AN 1-30 R Code Change Page 47 of 93

48 change to Required HI11-3 Qualifier ID 2-3 D8 HI11-3 Qualifier ID 2-3 R D8 change to Required HI11-4 Date Time Period AN 1-35 CCYYMMDD HI11-4 Date Time Period AN 1-35 R CCYYMMDD HI11-5 Monetary Amount R 1-18 HI11-5 Monetary Amount R 1-18 HI11-6 Quantity R 1-15 HI11-6 Quantity R 1-15 HI11-7 Version Identifier AN 1-30 HI11-7 Version Identifier AN 1-30 HI11-8 Industry code AN 1-30 New HI11-9 New HI12 HI12 HI12-1 Code List Qualifier Code ID 1-3 R BO, BQ HI12-1 Qualifier Code ID 1-3 R BBQ, BQ Code Change HI12-2 Procedure Code AN 1-30 R HI12-2 Procedure Code AN 1-30 R change to Required HI12-3 Qualifier ID 2-3 D8 HI12-3 Qualifier ID 2-3 R D8 change to Required HI12-4 Date Time Period AN 1-35 CCYYMMDD HI12-4 Date Time Period AN 1-35 R CCYYMMDD HI12-5 Monetary Amount R 1-18 HI12-5 Monetary Amount R 1-18 HI12-6 Quantity R 1-15 HI12-6 Quantity R 1-15 HI12-7 Version Identifier AN 1-30 HI12-7 Version Identifier AN 1-30 HI12-8 Industry code AN 1-30 New New HI12-9 HI OCCURRENCE PAN HI R HI01 OCCURRENCE PAN 2 R 2300 R change to Required HI01 HI01-1 Code List Qualifier Code ID 1-3 R BI HI01-1 Qualifier ID 1-3 R BI HI01-2 Occurrence pan Code AN 1-30 R HI01-2 Occurrence pan Code AN 1-30 R HI01-3 Qualifier ID 2-3 R RD8 HI01-3 Qualifier ID 2-3 R RD8 HI01-4 Date Time Period AN 1-35 R CCYYMMDD- CCYYMMDD HI01-4 Date Time Period AN 1-35 R HI01-5 Monetary Amount R 1-18 HI01-5 Monetary Amount R 1-18 HI01-6 Quantity R 1-15 HI01-6 Quantity R 1-15 HI01-7 Version Identifier AN 1-30 HI01-7 Version Identifier AN 1-30 HI02 CCYYMMDD- CCYYMMDD HI01-8 Industry code AN 1-30 New New HI01-9 HI02 HI02-1 Code List Qualifier Code ID 1-3 R BI HI02-1 Qualifier ID 1-3 R BI HI02-2 Occurrence pan Code AN 1-30 R HI02-2 Occurrence pan Code AN 1-30 R HI02-3 Qualifier ID 2-3 R RD8 HI02-3 HI02-4 Date Time Period AN 1-35 R Qualifier ID 2-3 R RD8 CCYYMMDD- CCYYMMDD HI02-4 Date Time Period AN 1-35 R CCYYMMDD- CCYYMMDD Page 48 of 93

49 HI02-5 Monetary Amount R 1-18 HI02-5 Monetary Amount R 1-18 HI02-6 Quantity R 1-15 HI02-6 Quantity R 1-15 HI02-7 Version Identifier AN 1-30 HI02-7 Version Identifier AN 1-30 HI03 HI02-8 Industry code AN 1-30 New New HI02-9 HI03 HI03-1 Code List Qualifier Code ID 1-3 R BI HI03-1 Qualifier ID 1-3 R BI HI03-2 Occurrence pan Code AN 1-30 R HI03-2 Occurrence pan Code AN 1-30 R HI03-3 Qualifier ID 2-3 R RD8 HI03-3 Qualifier ID 2-3 R RD8 HI03-4 Date Time Period AN 1-35 R CCYYMMDD- CCYYMMDD HI03-4 Date Time Period AN 1-35 R HI03-5 Monetary Amount R 1-18 HI03-5 Monetary Amount R 1-18 HI03-6 Quantity R 1-15 HI03-6 Quantity R 1-15 HI03-7 Version Identifier AN 1-30 HI03-7 Version Identifier AN 1-30 CCYYMMDD- CCYYMMDD HI03-8 Industry code AN 1-30 HI03-8 Industry code AN 1-30 New New HI03-9 HI03-9 HI04 HI04 HI04-1 Code List Qualifier Code ID 1-3 R BI HI04-1 Qualifier ID 1-3 R BI HI04-2 Occurrence pan Code AN 1-30 R HI04-2 Occurrence pan Code AN 1-30 R HI04-3 Qualifier ID 2-3 R RD8 HI04-3 Qualifier ID 2-3 R RD8 HI04-4 Date Time Period AN 1-35 R CCYYMMDD- CCYYMMDD HI04-4 Date Time Period AN 1-35 R HI04-5 Monetary Amount R 1-18 HI04-5 Monetary Amount R 1-18 HI04-6 Quantity R 1-15 HI04-6 Quantity R 1-15 HI04-7 Version Identifier AN 1-30 HI04-7 Version Identifier AN 1-30 HI05 CCYYMMDDCCY YMMDD HI04-8 Industry code AN 1-30 New New HI04-9 HI05 HI05-1 Code List Qualifier Code ID 1-3 R BI HI05-1 Qualifier ID 1-3 R BI HI05-2 Occurrence pan Code AN 1-30 R HI05-2 Occurrence pan Code AN 1-30 R HI05-3 Qualifier ID 2-3 R RD8 HI05-3 Qualifier ID 2-3 R RD8 HI05-4 Date Time Period AN 1-35 R CCYYMMDD- CCYYMMDD HI05-4 Date Time Period AN 1-35 R HI05-5 Monetary Amount R 1-18 HI05-5 Monetary Amount R 1-18 HI05-6 Quantity R 1-15 HI05-6 Quantity R 1-15 HI05-7 Version Identifier AN 1-30 HI05-7 Version Identifier AN 1-30 HI06 HI06 CCYYMMDD- CCYYMMDD HI05-8 Industry code AN 1-30 New New HI05-9 Page 49 of 93

50 HI06-1 Code List Qualifier Code ID 1-3 R BI HI06-1 Qualifier ID 1-3 R BI HI06-2 Occurrence pan Code AN 1-30 R HI06-2 Occurrence pan Code AN 1-30 R HI06-3 Qualifier ID 2-3 R RD8 HI06-3 Qualifier ID 2-3 R RD8 HI06-4 Date Time Period AN 1-35 R CCYYMMDD- CCYYMMDD HI06-4 Date Time Period AN 1-35 R HI06-5 Monetary Amount R 1-18 HI06-5 Monetary Amount R 1-18 HI06-6 Quantity R 1-15 HI06-6 Quantity R 1-15 HI06-7 Version Identifier AN 1-30 HI06-7 Version Identifier AN 1-30 HI07 CCYYMMDD- CCYYMMDD HI06-8 Industry code AN 1-30 New New HI06-9 HI07 HI07-1 Code List Qualifier Code ID 1-3 R BI HI07-1 Qualifier ID 1-3 R BI HI07-2 Occurrence pan Code AN 1-30 R HI07-2 Occurrence pan Code AN 1-30 R HI07-3 Qualifier ID 2-3 R RD8 HI07-3 Qualifier ID 2-3 R RD8 HI07-4 Date Time Period AN 1-35 R CCYYMMDD- CCYYMMDD HI07-4 Date Time Period AN 1-35 R HI07-5 Monetary Amount R 1-18 HI07-5 Monetary Amount R 1-18 HI07-6 Quantity R 1-15 HI07-6 Quantity R 1-15 HI07-7 Version Identifier AN 1-30 HI07-7 Version Identifier AN 1-30 HI08 CCYYMMDD- CCYYMMDD HI07-8 Industry code AN 1-30 New New HI07-9 HI08 HI08-1 Code List Qualifier Code ID 1-3 R BI HI08-1 Qualifier ID 1-3 R BI HI08-2 Occurrence pan Code AN 1-30 R HI08-2 Occurrence pan Code AN 1-30 R HI08-3 Qualifier ID 2-3 R RD8 HI08-3 Qualifier ID 2-3 R RD8 HI08-4 Date Time Period AN 1-35 R CCYYMMDD- CCYYMMDD HI08-4 Date Time Period AN 1-35 R HI08-5 Monetary Amount R 1-18 HI08-5 Monetary Amount R 1-18 HI08-6 Quantity R 1-15 HI08-6 Quantity R 1-15 HI08-7 Version Identifier AN 1-30 HI08-7 Version Identifier AN 1-30 HI09 CCYYMMDD- CCYYMMDD HI08-8 Industry code AN 1-30 New New HI08-9 HI09 HI09-1 Code List Qualifier Code ID 1-3 R BI HI09-1 Qualifier ID 1-3 R BI HI09-2 Occurrence pan Code AN 1-30 R HI09-2 Occurrence pan Code AN 1-30 R HI09-3 Qualifier ID 2-3 R RD8 HI09-3 Qualifier ID 2-3 R RD8 HI09-4 Date Time Period AN 1-35 R CCYYMMDD- CCYYMMDD HI09-4 Date Time Period AN 1-35 R HI09-5 Monetary Amount R 1-18 HI09-5 Monetary Amount R 1-18 HI09-6 Quantity R 1-15 HI09-6 Quantity R 1-15 CCYYMMDD- CCYYMMDD Page 50 of 93

51 HI09-7 Version Identifier AN 1-30 HI09-7 Version Identifier AN 1-30 HI10 HI09-8 Industry code AN 1-30 New New HI09-9 HI10 HI10-1 Code List Qualifier Code ID 1-3 R BI HI10-1 Qualifier ID 1-3 R BI HI10-2 Occurrence pan Code AN 1-30 R HI10-2 Occurrence pan Code AN 1-30 R HI10-3 Qualifier ID 2-3 R RD8 HI10-3 Qualifier ID 2-3 R RD8 HI10-4 Date Time Period AN 1-35 R CCYYMMDD- CCYYMMDD HI10-4 Date Time Period AN 1-35 R HI10-5 Monetary Amount R 1-18 HI10-5 Monetary Amount R 1-18 HI10-6 Quantity R 1-15 HI10-6 Quantity R 1-15 HI10-7 Version Identifier AN 1-30 HI10-7 Version Identifier AN 1-30 HI11 CCYYMMDD- CCYYMMDD HI10-8 Industry code AN 1-30 New New HI10-9 HI11 HI11-1 Code List Qualifier Code ID 1-3 R BI HI11-1 Qualifier ID 1-3 R BI HI11-2 Occurrence pan Code AN 1-30 R HI11-2 Occurrence pan Code AN 1-30 R HI11-3 Qualifier ID 2-3 R RD8 HI11-3 Qualifier ID 2-3 R RD8 HI11-4 Date Time Period AN 1-35 R CCYYMMDD- CCYYMMDD HI11-4 Date Time Period AN 1-35 R HI11-5 Monetary Amount R 1-18 HI11-5 Monetary Amount R 1-18 HI11-6 Quantity R 1-15 HI11-6 Quantity R 1-15 HI11-7 Version Identifier AN 1-30 HI11-7 Version Identifier AN 1-30 HI12 CCYYMMDD- CCYYMMDD HI11-8 Industry code AN 1-30 New New HI11-9 HI12 HI12-1 Code List Qualifier Code ID 1-3 R BI HI12-1 Qualifier ID 1-3 R BI HI12-2 Occurrence pan Code AN 1-30 R HI12-2 Occurrence pan Code AN 1-30 R HI12-3 Qualifier ID 2-3 R RD8 HI12-3 Qualifier ID 2-3 R RD8 HI12-4 Date Time Period AN 1-35 R CCYYMMDD- CCYYMMDD HI12-4 Date Time Period AN 1-35 R HI12-5 Monetary Amount R 1-18 HI12-5 Monetary Amount R 1-18 HI12-6 Quantity R 1-15 HI12-6 Quantity R 1-15 HI12-7 Version Identifier AN 1-30 HI12-7 Version Identifier AN 1-30 CCYYMMDD- CCYYMMDD HI12-8 Industry code AN 1-30 New New HI12-9 HI OCCURRENCE 2 R 2300 HI OCCURRENCE 2 R 2300 Page 51 of 93

52 R HI01 HI01 R HI01-1 Code List Qualifier Code ID 1-3 R BH HI01-1 Qualifier ID 1-3 R BH HI01-2 Occurrence Code AN 1-30 R HI01-2 Occurrence Code AN 1-30 R Qualifier ID 2-3 R D8 HI01-3 Qualifier ID 2-3 R D8 HI01-3 HI01-4 Date Time Period AN 1-35 R CCYYMMDD HI01-4 Date Time Period AN 1-35 R CCYYMMDD HI01-5 Monetary Amount R 1-18 HI01-5 Monetary Amount R 1-18 HI01-6 Quantity R 1-15 HI01-6 Quantity R 1-15 HI01-7 Version Identifier AN 1-30 HI01-7 Version Identifier AN 1-30 HI01-8 Industry code AN 1-30 New New HI01-9 HI02 HI02 HI02-1 Code List Qualifier Code ID 1-3 R BH HI02-1 Qualifier ID 1-3 R BH HI02-2 Occurrence Code AN 1-30 R HI02-2 Occurrence Code AN 1-30 R Qualifier ID 2-3 R D8 HI02-3 Qualifier ID 2-3 R D8 HI02-3 HI02-4 Date Time Period AN 1-35 R CCYYMMDD HI02-4 Date Time Period AN 1-35 R CCYYMMDD HI02-5 Monetary Amount R 1-18 HI02-5 Monetary Amount R 1-18 HI02-6 Quantity R 1-15 HI02-6 Quantity R 1-15 HI02-7 Version Identifier AN 1-30 HI02-7 Version Identifier AN 1-30 HI02-8 Industry code AN 1-30 New New HI02-9 HI03 HI03 HI03-1 Code List Qualifier Code ID 1-3 R BH HI03-1 Qualifier ID 1-3 R BH HI03-2 Occurrence Code AN 1-30 R HI03-2 Occurrence Code AN 1-30 R Qualifier ID 2-3 R D8 HI03-3 Qualifier ID 2-3 R D8 HI03-3 HI03-4 Date Time Period AN 1-35 R CCYYMMDD HI03-4 Date Time Period AN 1-35 R CCYYMMDD HI03-5 Monetary Amount R 1-18 HI03-5 Monetary Amount R 1-18 HI03-6 Quantity R 1-15 HI03-6 Quantity R 1-15 HI03-7 Version Identifier AN 1-30 HI03-7 Version Identifier AN 1-30 HI03-8 Industry code AN 1-30 New New HI03-9 HI04 HI04 HI04-1 Code List Qualifier Code ID 1-3 R BH HI04-1 Qualifier ID 1-3 R BH HI04-2 Occurrence Code AN 1-30 R HI04-2 Occurrence Code AN 1-30 R Qualifier ID 2-3 R D8 HI04-3 Qualifier ID 2-3 R D8 HI04-3 HI04-4 Date Time Period AN 1-35 R CCYYMMDD HI04-4 Date Time Period AN 1-35 R CCYYMMDD HI04-5 Monetary Amount R 1-18 HI04-5 Monetary Amount R 1-18 HI04-6 Quantity R 1-15 HI04-6 Quantity R 1-15 HI04-7 Version Identifier AN 1-30 HI04-7 Version Identifier AN 1-30 HI04-8 Industry code AN 1-30 New Page 52 of 93

53 New HI04-9 HI05 HI05 HI05-1 Code List Qualifier Code ID 1-3 R BH HI05-1 Qualifier ID 1-3 R BH HI05-2 Occurrence Code AN 1-30 R HI05-2 Occurrence Code AN 1-30 R Qualifier ID 2-3 R D8 HI05-3 Qualifier ID 2-3 R D8 HI05-3 HI05-4 Date Time Period AN 1-35 R CCYYMMDD HI05-4 Date Time Period AN 1-35 R CCYYMMDD HI05-5 Monetary Amount R 1-18 HI05-5 Monetary Amount R 1-18 HI05-6 Quantity R 1-15 HI05-6 Quantity R 1-15 HI05-7 Version Identifier AN 1-30 HI05-7 Version Identifier AN 1-30 HI05-8 Industry code AN 1-30 New New HI05-9 HI06 HI06 HI06-1 Code List Qualifier Code ID 1-3 R BH HI06-1 Qualifier ID 1-3 R BH HI06-2 Occurrence Code AN 1-30 R HI06-2 Occurrence Code AN 1-30 R Qualifier ID 2-3 R D8 HI06-3 Qualifier ID 2-3 R D8 HI06-3 HI06-4 Date Time Period AN 1-35 R CCYYMMDD HI06-4 Date Time Period AN 1-35 R CCYYMMDD HI06-5 Monetary Amount R 1-18 HI06-5 Monetary Amount R 1-18 HI06-6 Quantity R 1-15 HI06-6 Quantity R 1-15 HI06-7 Version Identifier AN 1-30 HI06-7 Version Identifier AN 1-30 HI06-8 Industry code AN 1-30 New New HI06-9 HI07 HI07 HI07-1 Code List Qualifier Code ID 1-3 R BH HI07-1 Qualifier ID 1-3 R BH HI07-2 Occurrence Code AN 1-30 R HI07-2 Occurrence Code AN 1-30 R Qualifier ID 2-3 R D8 HI07-3 Qualifier ID 2-3 R D8 HI07-3 HI07-4 Date Time Period AN 1-35 R CCYYMMDD HI07-4 Date Time Period AN 1-35 R CCYYMMDD HI07-5 Monetary Amount R 1-18 HI07-5 Monetary Amount R 1-18 HI07-6 Quantity R 1-15 HI07-6 Quantity R 1-15 HI07-7 Version Identifier AN 1-30 HI07-7 Version Identifier AN 1-30 HI07-8 Industry code AN 1-30 New New HI07-9 HI08 HI08 HI08-1 Code List Qualifier Code ID 1-3 R BH HI08-1 Qualifier ID 1-3 R BH HI08-2 Occurrence Code AN 1-30 R HI08-2 Occurrence Code AN 1-30 R Qualifier ID 2-3 R D8 HI08-3 Qualifier ID 2-3 R D8 HI08-3 HI08-4 Date Time Period AN 1-35 R CCYYMMDD HI08-4 Date Time Period AN 1-35 R CCYYMMDD HI08-5 Monetary Amount R 1-18 HI08-5 Monetary Amount R 1-18 HI08-6 Quantity R 1-15 HI08-6 Quantity R 1-15 Page 53 of 93

54 HI08-7 Version Identifier AN 1-30 HI08-7 Version Identifier AN 1-30 HI09 HI08-8 Industry code AN 1-30 New New HI08-9 HI09 HI09-1 Code List Qualifier Code ID 1-3 R BH HI09-1 Qualifier ID 1-3 R BH HI09-2 Occurrence Code AN 1-30 R HI09-2 Occurrence Code AN 1-30 R Qualifier ID 2-3 R D8 HI09-3 Qualifier ID 2-3 R D8 HI09-3 HI09-4 Date Time Period AN 1-35 R CCYYMMDD HI09-4 Date Time Period AN 1-35 R CCYYMMDD HI09-5 Monetary Amount R 1-18 HI09-5 Monetary Amount R 1-18 HI09-6 Quantity R 1-15 HI09-6 Quantity R 1-15 HI09-7 Version Identifier AN 1-30 HI09-7 Version Identifier AN 1-30 HI09-8 Industry code AN 1-30 New New HI09-9 HI10 HI10 HI10-1 Code List Qualifier Code ID 1-3 R BH HI10-1 Qualifier ID 1-3 R BH HI10-2 Occurrence Code AN 1-30 R HI10-2 Occurrence Code AN 1-30 R Qualifier ID 2-3 R D8 HI10-3 Qualifier ID 2-3 R D8 HI10-3 HI10-4 Date Time Period AN 1-35 R CCYYMMDD HI10-4 Date Time Period AN 1-35 R CCYYMMDD HI10-5 Monetary Amount R 1-18 HI10-5 Monetary Amount R 1-18 HI10-6 Quantity R 1-15 HI10-6 Quantity R 1-15 HI10-7 Version Identifier AN 1-30 HI10-7 Version Identifier AN 1-30 HI10-8 Industry code AN 1-30 New New HI10-9 HI11 HI11 HI11-1 Code List Qualifier Code ID 1-3 R BH HI11-1 Qualifier ID 1-3 R BH HI11-2 Occurrence Code AN 1-30 R HI11-2 Occurrence Code AN 1-30 R Qualifier ID 2-3 R D8 HI11-3 Qualifier ID 2-3 R D8 HI11-3 HI11-4 Date Time Period AN 1-35 R CCYYMMDD HI11-4 Date Time Period AN 1-35 R CCYYMMDD HI11-5 Monetary Amount R 1-18 HI11-5 Monetary Amount R 1-18 HI11-6 Quantity R 1-15 HI11-6 Quantity R 1-15 HI11-7 Version Identifier AN 1-30 HI11-7 Version Identifier AN 1-30 HI11-8 Industry code AN 1-30 New New HI11-9 HI12 HI12 HI12-1 Code List Qualifier Code ID 1-3 R BH HI12-1 Qualifier ID 1-3 R BH HI12-2 Occurrence Code AN 1-30 R HI12-2 Occurrence Code AN 1-30 R HI12-3 Qualifier ID 2-3 R D8 HI12-3 Qualifier ID 2-3 R D8 HI12-4 Date Time Period AN 1-35 R CCYYMMDD HI12-4 Date Time Period AN 1-35 R CCYYMMDD Page 54 of 93

55 HI12-5 Monetary Amount R 1-18 HI12-5 Monetary Amount R 1-18 HI12-6 Quantity R 1-15 HI12-6 Quantity R 1-15 HI12-7 Version Identifier AN 1-30 HI12-7 Version Identifier AN 1-30 HI12-8 Industry code AN 1-30 New New HI12-9 HI VALUE 2 R 2300 HI VALUE 2 R 2300 R HI01 HI01 R HI01-1 Code List Qualifier Code ID 1-3 R BE HI01-1 Qualifier ID 1-3 R BE HI01-2 Value Code AN 1-30 R HI01-2 Value Code AN 1-30 R HI01-3 HI01-3 HI01-4 Date Time Period AN 1-35 HI01-4 Date Time Period AN 1-35 Value Code Associated HI01-5 Amount R 1-18 R HI01-5 Value Code Amount R 1-18 R HI01-6 Quantity R 1-15 HI01-6 Quantity R 1-15 HI01-7 Version Identifier AN 1-30 HI01-7 Version Identifier AN 1-30 HI01-8 Industry code AN 1-30 New HI01-9 New HI02 HI02 HI02-1 Code List Qualifier Code ID 1-3 R BE HI02-1 Qualifier ID 1-3 R BE HI02-2 Value Code AN 1-30 R HI02-2 Value Code AN 1-30 R HI02-3 HI02-3 HI02-4 Date Time Period AN 1-35 HI02-4 Date Time Period AN 1-35 Value Code Associated HI02-5 Amount R 1-18 R HI02-5 Value Code Amount R 1-18 R HI02-6 Quantity R 1-15 HI02-6 Quantity R 1-15 HI02-7 Version Identifier AN 1-30 HI02-7 Version Identifier AN 1-30 HI02-8 Industry code AN 1-30 New HI02-9 New HI03 HI03 HI03-1 Code List Qualifier Code ID 1-3 R BE HI03-1 Qualifier ID 1-3 R BE HI03-2 Value Code AN 1-30 R HI03-2 Value Code AN 1-30 R HI03-3 HI03-3 HI03-4 Date Time Period AN 1-35 HI03-4 Date Time Period AN 1-35 Value Code Associated HI03-5 Amount R 1-18 R HI03-5 Value Code Amount R 1-18 R HI03-6 Quantity R 1-15 HI03-6 Quantity R 1-15 HI03-7 Version Identifier AN 1-30 HI03-7 Version Identifier AN 1-30 HI03-8 Industry code AN 1-30 New HI03-9 New Page 55 of 93

56 HI04 HI04 HI04-1 Code List Qualifier Code ID 1-3 R BE HI04-1 Qualifier ID 1-3 R BE HI04-2 Value Code AN 1-30 R HI04-2 Value Code AN 1-30 R HI04-3 HI04-3 HI04-4 Date Time Period AN 1-35 HI04-4 Date Time Period AN 1-35 Value Code Associated HI04-5 Amount R 1-18 R HI04-5 Value Code Amount R 1-18 R HI04-6 Quantity R 1-15 HI04-6 Quantity R 1-15 HI04-7 Version Identifier AN 1-30 HI04-7 Version Identifier AN 1-30 HI04-8 Industry code AN 1-30 New HI04-9 New HI05 HI05 HI05-1 Code List Qualifier Code ID 1-3 R BE HI05-1 Qualifier ID 1-3 R BE HI05-2 Value Code AN 1-30 R HI05-2 Value Code AN 1-30 R HI05-3 HI05-3 HI05-4 Date Time Period AN 1-35 HI05-4 Date Time Period AN 1-35 Value Code Associated HI05-5 Amount R 1-18 R HI05-5 Value Code Amount R 1-18 R HI05-6 Quantity R 1-15 HI05-6 Quantity R 1-15 HI05-7 Version Identifier AN 1-30 HI05-7 Version Identifier AN 1-30 HI05-8 Industry code AN 1-30 New HI05-9 New HI06 HI06 HI06-1 Code List Qualifier Code ID 1-3 R BE HI06-1 Qualifier ID 1-3 R BE HI06-2 Value Code AN 1-30 R HI06-2 Value Code AN 1-30 R HI06-3 HI06-3 HI06-4 Date Time Period AN 1-35 HI06-4 Date Time Period AN 1-35 Value Code Associated HI06-5 Amount R 1-18 R HI06-5 Value Code Amount R 1-18 R HI06-6 Quantity R 1-15 HI06-6 Quantity R 1-15 HI06-7 Version Identifier AN 1-30 HI06-7 Version Identifier AN 1-30 HI06-8 Industry code AN 1-30 New HI06-9 New HI07 HI07 HI07-1 Code List Qualifier Code ID 1-3 R BE HI07-1 Qualifier ID 1-3 R BE HI07-2 Value Code AN 1-30 R HI07-2 Value Code AN 1-30 R HI07-3 HI07-3 HI07-4 Date Time Period AN 1-35 HI07-4 Date Time Period AN 1-35 Page 56 of 93

57 Value Code Associated HI07-5 Amount R 1-18 R HI07-5 Value Code Amount R 1-18 R HI07-6 Quantity R 1-15 HI07-6 Quantity R 1-15 HI07-7 Version Identifier AN 1-30 HI07-7 Version Identifier AN 1-30 HI07-8 Industry code AN 1-30 New HI07-9 New HI08 HI08 HI08-1 Code List Qualifier Code ID 1-3 R BE HI08-1 Qualifier ID 1-3 R BE HI08-2 Value Code AN 1-30 R HI08-2 Value Code AN 1-30 R HI08-3 HI08-3 HI08-4 Date Time Period AN 1-35 HI08-4 Date Time Period AN 1-35 Value Code Associated HI08-5 Amount R 1-18 R HI08-5 Value Code Amount R 1-18 R HI08-6 Quantity R 1-15 HI08-6 Quantity R 1-15 HI08-7 Version Identifier AN 1-30 HI08-7 Version Identifier AN 1-30 HI08-8 Industry code AN 1-30 New HI08-9 New HI09 HI09 HI09-1 Code List Qualifier Code ID 1-3 R BE HI09-1 Qualifier ID 1-3 R BE HI09-2 Value Code AN 1-30 R HI09-2 Value Code AN 1-30 R HI09-3 HI09-3 HI09-4 Date Time Period AN 1-35 HI09-4 Date Time Period AN 1-35 Value Code Associated HI09-5 Amount R 1-18 R HI09-5 Value Code Amount R 1-18 R HI09-6 Quantity R 1-15 HI09-6 Quantity R 1-15 HI09-7 Version Identifier AN 1-30 HI09-7 Version Identifier AN 1-30 HI09-8 Industry code AN 1-30 New HI09-9 New HI10 HI10 HI10-1 Code List Qualifier Code ID 1-3 R BE HI10-1 Qualifier ID 1-3 R BE HI10-2 Value Code AN 1-30 R HI10-2 Value Code AN 1-30 R HI10-3 HI10-3 HI10-4 Date Time Period AN 1-35 HI10-4 Date Time Period AN 1-35 Value Code Associated HI10-5 Amount R 1-18 R HI10-5 Value Code Amount R 1-18 R HI10-6 Quantity R 1-15 HI10-6 Quantity R 1-15 HI10-7 Version Identifier AN 1-30 HI10-7 Version Identifier AN 1-30 HI10-8 Industry code AN 1-30 New HI10-9 New Page 57 of 93

58 HI11 HI11 HI11-1 Code List Qualifier Code ID 1-3 R BE HI11-1 Qualifier ID 1-3 R BE HI11-2 Value Code AN 1-30 R HI11-2 Value Code AN 1-30 R HI11-3 HI11-3 HI11-4 Date Time Period AN 1-35 HI11-4 Date Time Period AN 1-35 Value Code Associated HI11-5 Amount R 1-18 R HI11-5 Value Code Amount R 1-18 R HI11-6 Quantity R 1-15 HI11-6 Quantity R 1-15 HI11-7 Version Identifier AN 1-30 HI11-7 Version Identifier AN 1-30 HI11-8 Industry code AN 1-30 New HI11-9 New HI12 HI12 HI12-1 Code List Qualifier Code ID 1-3 R BE HI12-1 Qualifier ID 1-3 R BE HI12-2 Value Code AN 1-30 R HI12-2 Value Code AN 1-30 R HI12-3 HI12-3 HI12-4 Date Time Period AN 1-35 HI12-4 Date Time Period AN 1-35 Value Code Associated HI12-5 Amount R 1-18 R HI12-5 Value Code Amount R 1-18 R HI12-6 Quantity R 1-15 HI12-6 Quantity R 1-15 HI12-7 Version Identifier AN 1-30 HI12-7 Version Identifier AN 1-30 HI12-8 Industry code AN 1-30 New HI12-9 New HI CONDITION 2 R 2300 HI CONDITION 2 R 2300 R HI01 HI01 R HI01-1 Code List Qualifier Code ID 1-3 R BG HI01-1 Qualifier ID 1-3 R BG HI01-2 Condition Code AN 1-30 R HI01-2 Condition Code AN 1-30 R HI01-3 HI01-3 HI01-4 Date Time Period AN 1-35 HI01-4 Date Time Period AN 1-35 HI01-5 Monetary Amount R 1-18 HI01-5 Monetary Amount R 1-18 HI01-6 Quantity R 1-15 HI01-6 Quantity R 1-15 HI01-7 Version Identifier AN 1-30 HI01-7 Version Identifier AN 1-30 HI02 HI01-8 Industry code AN 1-30 New New HI01-9 HI02 HI02-1 Code List Qualifier Code ID 1-3 R BG HI02-1 Qualifier ID 1-3 R BG HI02-2 Condition Code AN 1-30 R HI02-2 Condition Code AN 1-30 R HI02-3 HI02-3 Page 58 of 93

59 HI02-4 Date Time Period AN 1-35 HI02-4 Date Time Period AN 1-35 HI02-5 Monetary Amount R 1-18 HI02-5 Monetary Amount R 1-18 HI02-6 Quantity R 1-15 HI02-6 Quantity R 1-15 HI02-7 Version Identifier AN 1-30 HI02-7 Version Identifier AN 1-30 HI03 HI02-8 Industry code AN 1-30 New New HI02-9 HI03 HI03-1 Code List Qualifier Code ID 1-3 R BG HI03-1 Qualifier ID 1-3 R BG HI03-2 Condition Code AN 1-30 R HI03-2 Condition Code AN 1-30 R HI03-3 HI03-3 HI03-4 Date Time Period AN 1-35 HI03-4 Date Time Period AN 1-35 HI03-5 Monetary Amount R 1-18 HI03-5 Monetary Amount R 1-18 HI03-6 Quantity R 1-15 HI03-6 Quantity R 1-15 HI03-7 Version Identifier AN 1-30 HI03-7 Version Identifier AN 1-30 HI04 HI03-8 Industry code AN 1-30 New New HI03-9 HI04 HI04-1 Code List Qualifier Code ID 1-3 R BG HI04-1 Qualifier ID 1-3 R BG HI04-2 Condition Code AN 1-30 R HI04-2 Condition Code AN 1-30 R HI04-3 HI04-3 HI04-4 Date Time Period AN 1-35 HI04-4 Date Time Period AN 1-35 HI04-5 Monetary Amount R 1-18 HI04-5 Monetary Amount R 1-18 HI04-6 Quantity R 1-15 HI04-6 Quantity R 1-15 HI04-7 Version Identifier AN 1-30 HI04-7 Version Identifier AN 1-30 HI05 HI04-8 Industry code AN 1-30 New New HI04-9 HI05 HI05-1 Code List Qualifier Code ID 1-3 R BG HI05-1 Qualifier ID 1-3 R BG HI05-2 Condition Code AN 1-30 R HI05-2 Condition Code AN 1-30 R HI05-3 HI05-3 HI05-4 Date Time Period AN 1-35 HI05-4 Date Time Period AN 1-35 HI05-5 Monetary Amount R 1-18 HI05-5 Monetary Amount R 1-18 HI05-6 Quantity R 1-15 HI05-6 Quantity R 1-15 HI05-7 Version Identifier AN 1-30 HI05-7 Version Identifier AN 1-30 HI06 HI05-8 Industry code AN 1-30 New New HI05-9 HI06 HI06-1 Code List Qualifier Code ID 1-3 R BG HI06-1 Qualifier ID 1-3 R BG HI06-2 Condition Code AN 1-30 R HI06-2 Condition Code AN 1-30 R Page 59 of 93

60 HI06-3 HI06-3 HI06-4 Date Time Period AN 1-35 HI06-4 Date Time Period AN 1-35 HI06-5 Monetary Amount R 1-18 HI06-5 Monetary Amount R 1-18 HI06-6 Quantity R 1-15 HI06-6 Quantity R 1-15 HI06-7 Version Identifier AN 1-30 HI06-7 Version Identifier AN 1-30 HI07 HI06-8 Industry code AN 1-30 New New HI06-9 HI07 HI07-1 Code List Qualifier Code ID 1-3 R BG HI07-1 Qualifier ID 1-3 R BG HI07-2 Condition Code AN 1-30 R HI07-2 Condition Code AN 1-30 R HI07-3 HI07-3 HI07-4 Date Time Period AN 1-35 HI07-4 Date Time Period AN 1-35 HI07-5 Monetary Amount R 1-18 HI07-5 Monetary Amount R 1-18 HI07-6 Quantity R 1-15 HI07-6 Quantity R 1-15 HI07-7 Version Identifier AN 1-30 HI07-7 Version Identifier AN 1-30 HI08 HI07-8 Industry code AN 1-30 New New HI07-9 HI08 HI08-1 Code List Qualifier Code ID 1-3 R BG HI08-1 Qualifier ID 1-3 R BG HI08-2 Condition Code AN 1-30 R HI08-2 Condition Code AN 1-30 R HI08-3 HI08-3 HI08-4 Date Time Period AN 1-35 HI08-4 Date Time Period AN 1-35 HI08-5 Monetary Amount R 1-18 HI08-5 Monetary Amount R 1-18 HI08-6 Quantity R 1-15 HI08-6 Quantity R 1-15 HI08-7 Version Identifier AN 1-30 HI08-7 Version Identifier AN 1-30 HI09 HI08-8 Industry code AN 1-30 New New HI08-9 HI09 HI09-1 Code List Qualifier Code ID 1-3 R BG HI09-1 Qualifier ID 1-3 R BG HI09-2 Condition Code AN 1-30 R HI09-2 Condition Code AN 1-30 R HI09-3 HI09-3 HI09-4 Date Time Period AN 1-35 HI09-4 Date Time Period AN 1-35 HI09-5 Monetary Amount R 1-18 HI09-5 Monetary Amount R 1-18 HI09-6 Quantity R 1-15 HI09-6 Quantity R 1-15 HI09-7 Version Identifier AN 1-30 HI09-7 Version Identifier AN 1-30 HI10 HI10 HI09-8 Industry code AN 1-30 New New HI09-9 Page 60 of 93

61 HI10-1 Code List Qualifier Code ID 1-3 R BG HI10-1 Qualifier ID 1-3 R BG HI10-2 Condition Code AN 1-30 R HI10-2 Condition Code AN 1-30 R HI10-3 HI10-3 HI10-4 Date Time Period AN 1-35 HI10-4 Date Time Period AN 1-35 HI10-5 Monetary Amount R 1-18 HI10-5 Monetary Amount R 1-18 HI10-6 Quantity R 1-15 HI10-6 Quantity R 1-15 HI10-7 Version Identifier AN 1-30 HI10-7 Version Identifier AN 1-30 HI11 HI10-8 Industry code AN 1-30 New New HI10-9 HI11 HI11-1 Code List Qualifier Code ID 1-3 R BG HI11-1 Qualifier ID 1-3 R BG HI11-2 Condition Code AN 1-30 R HI11-2 Condition Code AN 1-30 R HI11-3 HI11-3 HI11-4 Date Time Period AN 1-35 HI11-4 Date Time Period AN 1-35 HI11-5 Monetary Amount R 1-18 HI11-5 Monetary Amount R 1-18 HI11-6 Quantity R 1-15 HI11-6 Quantity R 1-15 HI11-7 Version Identifier AN 1-30 HI11-7 Version Identifier AN 1-30 HI12 HI11-8 Industry code AN 1-30 New New HI11-9 HI12 HI12-1 Code List Qualifier Code ID 1-3 R BG HI12-1 Qualifier ID 1-3 R BG HI12-2 Condition Code AN 1-30 R HI12-2 Condition Code AN 1-30 R HI12-3 HI12-3 HI12-4 Date Time Period AN 1-35 HI12-4 Date Time Period AN 1-35 HI12-5 Monetary Amount R 1-18 HI12-5 Monetary Amount R 1-18 HI12-6 Quantity R 1-15 HI12-6 Quantity R 1-15 HI12-7 Version Identifier AN 1-30 HI12-7 Version Identifier AN 1-30 HI TREATMENT CODE 2 R 2300 HI R HI01 HI12-8 Industry code AN 1-30 New New HI12-9 TREATMENT CODE 2 R 2300 R HI01 HI01-1 Code List Qualifier Code ID 1-3 R TC HI01-1 Qualifier ID 1-3 R TC HI01-2 Treatment Code AN 1-30 R HI01-2 Treatment Code AN 1-30 R HI01-3 HI01-3 HI01-4 Date Time Period AN 1-35 HI01-4 Date Time Period AN 1-35 HI01-5 Monetary Amount R 1-18 HI01-5 Monetary Amount R 1-18 HI01-6 Quantity R 1-15 HI01-6 Quantity R 1-15 HI01-7 Version Identifier AN 1-30 HI01-7 Version Identifier AN 1-30 Page 61 of 93

62 HI02 HI01-8 Industry code AN 1-30 New New HI01-9 HI02 HI02-1 Code List Qualifier Code ID 1-3 R TC HI02-1 Qualifier ID 1-3 R TC HI02-2 Treatment Code AN 1-30 R HI02-2 Treatment Code AN 1-30 R HI02-3 HI02-3 HI02-4 Date Time Period AN 1-35 HI02-4 Date Time Period AN 1-35 HI02-5 Monetary Amount R 1-18 HI02-5 Monetary Amount R 1-18 HI02-6 Quantity R 1-15 HI02-6 Quantity R 1-15 HI02-7 Version Identifier AN 1-30 HI02-7 Version Identifier AN 1-30 HI03 HI02-8 Industry code AN 1-30 New New HI02-9 HI03 HI03-1 Code List Qualifier Code ID 1-3 R TC HI03-1 Qualifier ID 1-3 R TC HI03-2 Treatment Code AN 1-30 R HI03-2 Treatment Code AN 1-30 R HI03-3 HI03-3 HI03-4 Date Time Period AN 1-35 HI03-4 Date Time Period AN 1-35 HI03-5 Monetary Amount R 1-18 HI03-5 Monetary Amount R 1-18 HI03-6 Quantity R 1-15 HI03-6 Quantity R 1-15 HI03-7 Version Identifier AN 1-30 HI03-7 Version Identifier AN 1-30 HI04 HI03-8 Industry code AN 1-30 New New HI03-9 HI04 HI04-1 Code List Qualifier Code ID 1-3 R TC HI04-1 Qualifier ID 1-3 R TC HI04-2 Treatment Code AN 1-30 R HI04-2 Treatment Code AN 1-30 R HI04-3 HI04-3 HI04-4 Date Time Period AN 1-35 HI04-4 Date Time Period AN 1-35 HI04-5 Monetary Amount R 1-18 HI04-5 Monetary Amount R 1-18 HI04-6 Quantity R 1-15 HI04-6 Quantity R 1-15 HI04-7 Version Identifier AN 1-30 HI04-7 Version Identifier AN 1-30 HI05 HI04-8 Industry code AN 1-30 New New HI04-9 HI05 HI05-1 Code List Qualifier Code ID 1-3 R TC HI05-1 Qualifier ID 1-3 R TC HI05-2 Treatment Code AN 1-30 R HI05-2 Treatment Code AN 1-30 R HI05-3 HI05-3 HI05-4 Date Time Period AN 1-35 HI05-4 Date Time Period AN 1-35 HI05-5 Monetary Amount R 1-18 HI05-5 Monetary Amount R 1-18 Page 62 of 93

63 HI05-6 Quantity R 1-15 HI05-6 Quantity R 1-15 HI05-7 Version Identifier AN 1-30 HI05-7 Version Identifier AN 1-30 HI06 HI05-8 Industry code AN 1-30 New New HI05-9 HI06 HI06-1 Code List Qualifier Code ID 1-3 R TC HI06-1 Qualifier ID 1-3 R TC HI06-2 Treatment Code AN 1-30 R HI06-2 Treatment Code AN 1-30 R HI06-3 HI06-3 HI06-4 Date Time Period AN 1-35 HI06-4 Date Time Period AN 1-35 HI06-5 Monetary Amount R 1-18 HI06-5 Monetary Amount R 1-18 HI06-6 Quantity R 1-15 HI06-6 Quantity R 1-15 HI06-7 Version Identifier AN 1-30 HI06-7 Version Identifier AN 1-30 HI07 HI06-8 Industry code AN 1-30 New New HI06-9 HI07 HI07-1 Code List Qualifier Code ID 1-3 R TC HI07-1 Qualifier ID 1-3 R TC HI07-2 Treatment Code AN 1-30 R HI07-2 Treatment Code AN 1-30 R HI07-3 HI07-3 HI07-4 Date Time Period AN 1-35 HI07-4 Date Time Period AN 1-35 HI07-5 Monetary Amount R 1-18 HI07-5 Monetary Amount R 1-18 HI07-6 Quantity R 1-15 HI07-6 Quantity R 1-15 HI07-7 Version Identifier AN 1-30 HI07-7 Version Identifier AN 1-30 HI08 HI07-8 Industry code AN 1-30 New New HI07-9 HI08 HI08-1 Code List Qualifier Code ID 1-3 R TC HI08-1 Qualifier ID 1-3 R TC HI08-2 Treatment Code AN 1-30 R HI08-2 Treatment Code AN 1-30 R HI08-3 HI08-3 HI08-4 Date Time Period AN 1-35 HI08-4 Date Time Period AN 1-35 HI08-5 Monetary Amount R 1-18 HI08-5 Monetary Amount R 1-18 HI08-6 Quantity R 1-15 HI08-6 Quantity R 1-15 HI08-7 Version Identifier AN 1-30 HI08-7 Version Identifier AN 1-30 HI09 HI08-8 Industry code AN 1-30 New New HI08-9 HI09 HI09-1 Code List Qualifier Code ID 1-3 R TC HI09-1 Qualifier ID 1-3 R TC HI09-2 Treatment Code AN 1-30 R HI09-2 Treatment Code AN 1-30 R HI09-3 HI09-3 Page 63 of 93

64 HI09-4 Date Time Period AN 1-35 HI09-4 Date Time Period AN 1-35 HI09-5 Monetary Amount R 1-18 HI09-5 Monetary Amount R 1-18 HI09-6 Quantity R 1-15 HI09-6 Quantity R 1-15 HI09-7 Version Identifier AN 1-30 HI09-7 Version Identifier AN 1-30 HI10 HI09-8 Industry code AN 1-30 New New HI09-9 HI10 HI10-1 Code List Qualifier Code ID 1-3 R TC HI10-1 Qualifier ID 1-3 R TC HI10-2 Treatment Code AN 1-30 R HI10-2 Treatment Code AN 1-30 R HI10-3 HI10-3 HI10-4 Date Time Period AN 1-35 HI10-4 Date Time Period AN 1-35 HI10-5 Monetary Amount R 1-18 HI10-5 Monetary Amount R 1-18 HI10-6 Quantity R 1-15 HI10-6 Quantity R 1-15 HI10-7 Version Identifier AN 1-30 HI10-7 Version Identifier AN 1-30 HI11 HI10-8 Industry code AN 1-30 New New HI10-9 HI11 HI11-1 Code List Qualifier Code ID 1-3 R TC HI11-1 Qualifier ID 1-3 R TC HI11-2 Treatment Code AN 1-30 R HI11-2 Treatment Code AN 1-30 R HI11-3 HI11-3 HI11-4 Date Time Period AN 1-35 HI11-4 Date Time Period AN 1-35 HI11-5 Monetary Amount R 1-18 HI11-5 Monetary Amount R 1-18 HI11-6 Quantity R 1-15 HI11-6 Quantity R 1-15 HI11-7 Version Identifier AN 1-30 HI11-7 Version Identifier AN 1-30 HI12 HI11-8 Industry code AN 1-30 New New HI11-9 HI12 HI12-1 Code List Qualifier Code ID 1-3 R TC HI12-1 Qualifier ID 1-3 R TC HI12-2 Treatment Code AN 1-30 R HI12-2 Treatment Code AN 1-30 R HI12-3 HI12-3 HI12-4 Date Time Period AN 1-35 HI12-4 Date Time Period AN 1-35 HI12-5 Monetary Amount R 1-18 HI12-5 Monetary Amount R 1-18 HI12-6 Quantity R 1-15 HI12-6 Quantity R 1-15 HI12-7 Version Identifier AN 1-30 HI12-7 Version Identifier AN 1-30 HI12-8 Industry code AN 1-30 New New HI12-9 QTY CLAIM QUANTITY egment Deleted QTY01 Quantity Qualifier ID 2-2 R CA, CD, LA, NA QTY02 Claim Days Count R 1-15 R Page 64 of 93

65 QTY03 COMPOITE UNIT OF MEAURE R QTY03-1 Unit or Basis for Measurement Code ID 2-2 R DA QTY03-2 Exponent R 1-15 QTY03-3 Multiplier R 1-10 QTY03-4 Unit or Basis for Measurement Code ID 2-2 QTY03-5 Exponent R 1-15 QTY03-6 Multiplier R 1-10 QTY03-7 Unit or Basis for Measurement Code ID 2-2 QTY03-8 Exponent R 1-15 QTY03-9 Multiplier R 1-10 QTY03-10 Unit or Basis for Measurement Code ID 2-2 QTY03-11 Exponent R 1-15 QTY03-12 Multiplier R 1-10 QTY03-13 Unit or Basis for Measurement Code ID 2-2 QTY03-14 Exponent R 1-15 QTY03-15 Multiplier R 1-10 QTY04 Free-Form Message AN 1-30 HCP CLAIM PRICING/REPRICING HCP CLAIM PRICING/REPRICING HCP01 Pricing Methodology ID 2-2 R 00, 01, 02, 03, 04, 05, 06, 07, 08, 09, 10,11, 12, 13, 14 HCP01 Pricing Methodology ID 2-2 R HCP02 Repriced Allowed Amount R 1-18 R HCP02 Repriced Allowed Amount R 1-18 R HCP03 Repriced aving Amount R 1-18 HCP03 Repriced aving Amount R 1-18 HCP04 HCP05 HCP06 Repricing Organization Identifier AN 1-30 HCP04 Repricing Per Diem or Flat Rate Amount R 1-9 HCP05 Repriced Approved DRG Code AN 1-30 HCP06 Repricing Organization Identifier AN 1-50 Repricing Per Diem or Flat Rate Amount R 1-9 Ambulatory Patient Group Code AN 1-50 Ambulatory Patient Group Amount R 1-18 HCP07 Repriced Approved Amount R 1-18 HCP07 HCP08 Product/ervice ID AN 1-48 HCP08 Product/ervice ID AN 1-48 HCP09 Product/ervice ID Qualifier ID 2-2 HC HCP09 Product/ervice ID Qualifier ID , 01, 02, 03, 04, 05, 06, 07, 08, 09, 10,11, 12, 13, 14 HCP10 Product/ervice ID AN 1-48 HCP10 Product/ervice ID AN 1-48 Unit or Basis for Unit or Basis for HCP11 Measurement Code ID 2-2 DA, UN HCP11 Measurement Code ID 2-2 DA, UN HCP12 Quantity R 1-15 HCP12 Quantity R 1-15 Increase from Increase from change to Not Used change to Not Used Page 65 of 93

66 T1, T2, T3, T4, T5, T6 HCP13 Reject Reason Code ID 2-2 T1, T2, T3, T4, T5, T6 HCP13 Reject Reason Code ID 2-2 HCP14 Policy Compliance Code ID 1-2 1, 2, 3, 4, 5 HCP14 Policy Compliance Code ID 1-2 1, 2, 3, 4, 5 HCP15 Exception Code ID 1-2 1, 2, 3, 4, 5, 6 HCP15 Exception Code ID 1-2 1, 2, 3, 4, 5, 6 CR7 HOME HEALTH CARE PLAN CR701 Disipline Type Code ID 2-2 R Vsits Prior to Recertification CR702 Date Count NO 1-9 R Total Visits Projected This CR703 Certification Count NO 1-9 R AI, M, OT, PT, N, T egment Deleted HD HOME CARE ERVICE DELIVERY HD01 Visits ID 2-2 HD02 Number of Visits R 1-15 HD03 Frequency Period ID 2-2 DA, MO, Q1, WK HD04 Frequency Count R 1-6 HD05 Duration of Visits Units ID 1-2 7, 35 Duration of Visits, Number of HD06 Units NO 1-3 egment Deleted 1, 2, 3, 4, 5, 6, 7, 8, 9, A, B, C, D, E, F, G, J, K, L, N, O,, A, B, C, HD07 hip, Delivery or Caledar Pattern Code ID 1-2 D, G, L, P, X, Y, Z, W, HD08 Delivery Pattern Time Code ID 1-1 D, E, F ATTENDING PHYICIAN ATTENDING PROVIDER NM1 NAME A 1 NM1 NAME A 1 NM101 Entity Identifier Code ID 2-3 R 71 NM101 Entity Identifier Code ID 2-3 R 71 NM102 Entity Type Qualifier ID 1-1 R 1, 2 NM102 Entity Type Qualifier ID 1-1 R 1 Code Deleted NM103 Name Last AN 1-35 R NM103 Last Name AN 1-60 R Increase from NM104 NameFirst AN 1-25 NM104 First Name AN 1-35 Increase NM105 Name Middle AN 1-25 NM105 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 24, 34, XX NM108 Identification Code Qualifier ID 1-2 XX Code Deleted change to ituational NM109 Provider Identifier AN 2-80 R NM109 Provider Identifier AN 2-80 change to ituational 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 Page 66 of 93

67 NM112 Name Last or Organization Name AN 1-60 New PRV ATTENDING PHYICIAN PECIALTY A PRV ATTENDING PROVIDER PECIALTY A PRV01 Provider Code ID 1-3 R AT, U PRV01 Provider Code ID 1-3 R AT 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 PRV05 PROVIDER PECIALTY PRV05 PROVIDER PECIALTY PRV06 Provider Organization Code ID 3-3 PRV06 Provider Organization Code ID 3-3 ATTENDING PHYICIAN ECONDARY IDENTIFICATION A Qualifier ID 2-3 R 0B, 1A, 1B, 1C, 1D, 1G, 1H, EI, G2, LU, N5, Y, X5 ATTENDING PROVIDER ECONDARY IDENTIFICATION A Qualifier ID 2-3 R 0B, 1G, G2, LU 02 Attending Physician econdary Identifier AN 1-30 R 02 econdary Identifier AN 1-50 R 03 Description AN Description AN ERENCE IDENTIFIER 04 ERENCE IDENTIFIER OPERATING PHYICIAN NAME B 1 NM1 OPERATING PHYICIAN NAME B 1 # s change to 4 Code Deleted Increase from NM1 NM101 Entity Identifier Code ID 2-3 R 72 NM101 Entity Identifier Code ID 2-3 R 72 NM102 Entity Type Qualifier ID 1-1 R 1 NM102 Entity Type Qualifier ID 1-1 R 1 NM103 Last or Organization Name AN 1-35 R NM103 Last or Organization Name AN 1-60 R Increase from NM104 Name First AN 1-25 R NM104 First Name AN 1-35 NM105 Middle Name AN 1-25 NM105 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 24, 34, XX NM108 Identification Code Qualifier ID 1-2 XX NM109 Identifier AN 2-80 R NM109 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 ituational change to ituational New Page 67 of 93

68 OPERATING PHYICIAN ECONDARY IDENTIFICATION B Qualifier ID 2-3 R OPERATING PHYICIAN ECONDARY IDENTIFICATION B 0B, 1A, 1B, 1C, 1D, 1G, 1H, EI, G2, LU, N5, Y, X5 Qualifier ID 2-3 R 0B, 1G, G2, LU # s change to 4 Code Deleted 02 econdary Identifier AN 1-30 R 02 econdary Identifier AN 1-50 R Increase from Description AN Description AN ERENCE IDENTIFIER 04 ERENCE IDENTIFIER OTHER OPERATING NM1 OTHER PROVIDER NAME C 1 NM1 PHYICIAN NAME C 1 NM101 Entity Identifier Code ID 2-3 R 73 NM101 Entity Identifier Code ID 2-3 R ZZ Code Change NM102 Entity Type Qualifier ID 1-1 R 1, 2 NM102 Entity Type Qualifier ID 1-1 R 1 Code Deleted NM103 Last or Organization Name AN 1-35 R NM103 Last or Organization Name AN 1-60 R Increase from NM104 First Name AN 1-25 R NM104 First Name AN 1-35 Increase from change to ituational NM105 Middle Name AN 1-25 NM105 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 24, 34, XX NM108 Identification Code Qualifier ID 1-2 XX Code Deleted change to ituational NM109 Identifier AN 2-80 NM109 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 OTHER PROVIDER ECONDARY IDENTIFICATION C Qualifier ID 2-3 R 0B, 1A, 1B, 1C, 1D, 1G, 1H, EI, G2, LU, N5, Y, X5 Rendering Provider econdary Identifier AN 1-30 R 02 OPERATING PHYICIAN ECONDARY IDENTIFICATION C Qualifier ID 2-3 R 0B, 1G, G2, LU Rendering Provider econdary Identifier AN 1-50 R Description AN Description AN ERENCE IDENTIFIER 04 ERENCE IDENTIFIER Name Chnge # of s change to 4 Code Deleted Increase from NM1 RENDERING PHYICIAN NAME D 1 NM101 Entity Identifier Code ID 2-3 R 82 NM102 Entity Type Qualifier ID 1-1 R 1 Rendering Provider Last or NM103 Organization Name AN 1-60 R New egment Page 68 of 93

69 NM104 Rendering Provider First Name AN 1-35 NM105 Rendering Provider Middle Name AN 1-25 NM106 Name Prefix AN 1-10 NM107 Rendering Provider Name uffix AN 1-10 NM108 Identification Code Qualifier ID 1-2 XX NM109 Rendering Provider Identifier AN 2-80 NM110 Entity Relationship Code ID 2-2 NM111 Entity Identifier Code ID 2-3 NM112 Name Last or Organization Name AN 1-60 RENDERING PHYICIAN ECONDARY IDENTIFICATION D Qualifier ID 2-3 R 0B, 1G, G2, LU Rendering Provider 02 econdary Identifier AN 1-50 R 03 Description AN ERENCE IDENTIFIER New egment ERVICE FACILITY NM1 ERVICE FACILITY NAME E 1 NM1 LOCATION E 1 NM101 Entity Identifier Code ID 2-3 R FA NM101 Entity Identifier Code ID 2-3 R 77 Code Change NM102 Entity Type Qualifier ID 1-1 R 2 NM102 Entity Type Qualifier ID 1-1 R 2 NM103 Laboratory or Facility Name AN 1-35 R NM103 Laboratory or Facility 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 Code Deleted NM108 Identification Code Qualifier ID , 34, XX NM108 Identification Code Qualifier ID 1-2 XX Laboratory or Facility Primary Identifier AN 2-80 NM109 Laboratory or Facility Primary Identifier AN 2-80 NM109 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 N301 ERVICE FACILITY ADDRE 1 R 2310E N3 Laboratory or Facility Address Line AN 1-55 R N301 ERVICE FACILITY LOCATION ADDRE 1 R 2310E Laboratory or Facility Address Line AN 1-55 R Page 69 of 93

70 N302 Laboratory or Facility Address Line AN 1-55 N302 Laboratory or Facility Address Line AN 1-55 N4 N401 N402 N403 ERVICE FACILITY CITY/TATE/ZIP CODE 1 R 2310E N4 Laboratory or Facility City Name AN 2-30 R N401 Laboratory or Facility tate or Province Code ID 2-2 R N402 Laboratory or Facility Postal Zone or ZIP Code ID 3-15 R N403 Laboratory/Facility Country Code ID 2-3 N404 ERVICE FACILITY LOCATION CITY/TATE/ZIP 1 R 2310E Laboratory or Facility City Name AN 2-30 R Laboratory or Facility tate or Province Code ID 2-2 Laboratory or Facility Postal Zone ZIP Code ID 3-15 Laboratory/Facility Country Code ID 2-3 change to ituational change to ituational N404 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 ERVICE FACILITY ECONDARY IDENTIFICATION E Qualifier ID 2-3 R 0B, 1A, 1B, 1C, 1D, 1G, 1H, EI, G2, LU, N5, Y, X5 Laboratory or Facility econdary Identifier AN 1-30 R 02 ERVICE FACILITY LOCATION ECONDARY IDENTIFICATION E Qualifier ID 2-3 R 0B, G2, LU Laboratory or Facility econdary Identifier AN 1-50 R Description AN Description AN ERENCE IDENTIFIER 04 ERENCE IDENTIFIER NM1 ERRING PROVIDER NAME F 1 NM101 Entity Identifier Code ID 2-3 R DN NM102 Entity Type Qualifier ID 1-1 R 1 # of s change to 3 Code Deleted Increase from New egment NM103 Referring Provider Last Name AN 1-60 R NM104 Referring Provider First Name AN 1-35 NM105 Referring Provider Middle Name AN 1-25 NM106 Name Prefix AN 1-10 NM107 Referring Provider Name uffix AN 1-10 NM108 Identification Code Qualifier ID 1-2 XX NM109 Referring Provider Identifier AN 2-80 NM110 Entity Relationship Code ID 2-2 NM111 Entity Identifier Code ID 2-3 NM112 Name Last or Organization Name AN 1-60 Page 70 of 93

71 ERRING PROVIDER ECONDARY IDENTIFICATION F Qualifier ID 2-3 R 0B, 1G, G2 Referring Provider econdary 02 Identifier AN 1-50 R 03 Description AN ERENCE IDENTIFIER New egment BR BR01 OTHER UBCRIBER BR Payer Responsibility equence Number Code ID 1-1 R P,, T BR01 BR02 Individual Relationship Code ID 2-2 R Insured Group or Policy Number AN 1-30 BR03 OTHER UBCRIBER Payer Responsibility equence Number Code ID 1-1 R 01, 04, 05, 07, 10, 15, 17, 18, 19, 20, 21, 22, 23, 24, 29, 32, 33, 36, 39, 40, 41, 43, 53, G8 BR02 Individual Relationship Code ID 2-2 R Insured Group or Policy Number AN 1-50 BR03 BR04 Other Insured Group Name AN 1-60 BR04 Other Insured Group Name AN 1-60 BR05 Insurance Type Code ID 1-3 BR05 Insurance Type Code ID 1-3 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 1-2 CA CLAIM LEVEL ADJUTMENT CA Claim Adjustment Group Code ID 1-2 R 09, 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 1-2 CO, CR, OA, PI, PR CLAIM LEVEL ADJUTMENT Claim Adjustment Group Code ID 1-2 R CA01 CA01 CA02 Adjustment Reason Code ID 1-5 R CA02 Adjustment Reason Code ID 1-5 R CA03 Adjustment Amount R 1-18 R CA03 Adjustment Amount R 1-18 R CA04 Adjustment Quantity R 1-15 CA04 Adjustment Quantity R 1-15 CA05 Adjustment Reason Code ID 1-5 CA05 Adjustment Reason Code ID 1-5 CA06 Adjustment Amount R 1-18 CA06 Adjustment Amount R 1-18 CA07 Adjustment Quantity R 1-15 CA07 Adjustment Quantity R 1-15 CA08 Adjustment Reason Code ID 1-5 CA08 Adjustment Reason Code ID 1-5 CA09 Adjustment Amount R 1-18 CA09 Adjustment Amount R 1-18 A, B, C, D, E, F, G, H, P,, T, U 01, 18, 19, 20, 21, 39, 40, 53, G8 Code Added Code Deleted Increase from Code Change 11, 12, 13, 14, 15, 16, 17, AM, BL, CH, CI, D, FI, HM, LM, MA, MB, MC, OF, TV, VA, WC, ZZ CO, CR, OA, PI, PR Page 71 of 93

72 CA10 Adjustment Quantity R 1-15 CA10 Adjustment Quantity R 1-15 CA11 Adjustment Reason Code ID 1-5 CA11 Adjustment Reason Code ID 1-5 CA12 Adjustment Amount R 1-18 CA12 Adjustment Amount R 1-18 CA13 Adjustment Quantity R 1-15 CA13 Adjustment Quantity R 1-15 CA14 Adjustment Reason Code ID 1-5 CA14 Adjustment Reason Code ID 1-5 CA15 Adjustment Amount R 1-18 CA15 Adjustment Amount R 1-18 CA16 Adjustment Quantity R 1-15 CA16 Adjustment Quantity R 1-15 CA17 Adjustment Reason Code ID 1-5 CA17 Adjustment Reason Code ID 1-5 CA18 Adjustment Amount R 1-18 CA18 Adjustment Amount R 1-18 CA19 Adjustment Quantity R 1-15 CA19 Adjustment Quantity R 1-15 AMT PAYER PRIOR PAYMENT AMT COB PAYER PAID AMOUNT AMT01 Amount Qualifier Code ID 1-3 R C4 AMT01 Amount Qualifier Code ID 1-3 R D Code Change Other Payer Patient Paid AMT02 Amount R 1-18 R AMT02 Payer Paid Amount R 1-18 R AMT03 Credit/Debit Flag AMT03 Credit/Debit Flag AMT COORDINATION OF BENEFIT (COB) TOTAL ALLOWED AMOUNT AMT01 Amount Qualifier Code ID 1-3 R B6 AMT02 Allowed Amount R 1-18 R AMT03 Credit/Debit Flag AMT COORDINATION OF BENEFIT (COB) TOTAL UBMITED CHARGE AMT01 Amount Qualifier Code ID 1-3 R T3 egment Deleted egment Deleted Coordination of Benefits Total AMT02 ubmitted Charge Amount R 1-18 R AMT03 Credit/Debit Flag AMT DIAGNOTIC RELATED GROUP (DRG) OUTLIER AMOUNT AMT01 Amount Qualifier Code ID 1-3 R ZZ AMT02 Claim DRG Outlier Amount R 1-18 R AMT03 Credit/Debit Flag AMT COORDINATION OF BENEFIT (COB) TOTAL MEDICARE PAID AMOUNT AMT01 Amount Qualifier Code ID 1-3 R N1 AMT02 Total Medicare Paid Amout R 1-18 R AMT03 Credit/Debit Flag egment Deleted egment Deleted AMT MEDICARE PAID AMOUNT - 100% egment Deleted Page 72 of 93

73 AMT01 Amount Qualifier Code ID 1-3 R KF Medicare Paid at 100% AMT02 Amount R 1-18 R AMT03 Credit/Debit Flag AMT MEDICARE PAID AMOUNT - 80% AMT01 Amount Qualifier Code ID 1-3 R PG Medicare Paid at 80% AMT02 Amount R 1-18 R AMT03 Credit/Debit Flag AMT COORDINATION OF BENEFIT (COB) MEDICARE A TRUT FUND PAID AMOUNT AMT01 Amount Qualifier Code ID 1-3 R AA Paid From Part A Medicare AMT02 Trust Fund Amount R 1-18 R AMT03 Credit/Debit Flag AMT COORDINATION OF BENEFIT (COB) MEDICARE B TRUT FUND PAID AMOUNT AMT01 Amount Qualifier Code ID 1-3 R B1 Paid From Part B Medicare AMT02 Trust Fund Amount R 1-18 R AMT03 Credit/Debit Flag AMT COORDINATION OF BENEFIT (COB) TOTAL NON-COVERED AMOUNT AMT01 Amount Qualifier Code ID 1-3 R A8 egment Deleted egment Deleted egment Deleted egment Deleted AMT02 Non-Covered Charge Amount R 1-18 R AMT03 Credit/Debit Flag AMT COORDINATION OF BENEFIT (COB) TOTAL DENIED AMOUNT AMT01 Amount Qualifier Code ID 1-3 R YT Claim Total Denied Charge AMT02 Amount R 1-18 R AMT03 Credit/Debit Flag egment Deleted AMT REMAINING PATIENT LIABILITY AMT01 Amount Qualifier Code ID 1-3 R EAF New egment Page 73 of 93

74 Remaining Patient Liability AMT02 Amount R 1-18 R AMT03 Credit/Debit Flag AMT COB TOTAL NON- COVERED AMOUNT AMT01 Amount Qualifier Code ID 1-3 R A8 AMT02 Non-Covered Amount R 1-18 R AMT03 Credit/Debit Flag New egment DMG OTHER UBCRIBER DEMOGRAPHIC DMG01 Qualifier ID 2-3 R D8 DMG02 Other Insured Birth Date AN 1-35 R DMG03 Gender Code ID 1-1 R F, M, U DMG04 Marital tatus DMG05 Race or Ethnicity DMG06 Citizenship tatus Code ID 1-2 DMG07 Country Code ID 2-3 DMG08 Basis of Veification Code ID 1-2 DMG09 Quantity R 1-15 egment Deleted OI OTHER INURANCE COVERAGE 1 R 2320 OI OTHER INURANCE COVERAGE 1 R 2320 OI01 Claim Filing Indicator Code ID 1-2 OI01 Claim Filing Indicator Code ID 1-2 OI02 OI03 Claim ubmission Reason Code ID 2-2 OI02 Benefits Assignment Certification Indicator ID 1-1 R N, Y OI03 Patient ignature ource OI04 Claim ubmission Reason Code ID 2-2 Benefits Assignment Certification Indicator ID 1-1 R N, W, Y Patient ignature ource OI04 OI05 Provider Agreement OI05 Provider Agreement OI06 Release of Information Code ID 1-1 R A, I, M, N, O, Y OI06 Release of Information Code ID 1-1 R I, Y MIA MEDICARE INPATIENT ADJUDICATION MIA INPATIENT ADJUDICATION MIA01 Covered Days or Visits Count R 1-15 R MIA01 Covered Days or Visits Count R 1-15 MIA02 Lifetime Reserve Days Count R 1-15 MIA02 Amount R 1-18 MIA03 Lifetime Psychiatric Days R 1-15 MIA03 Lifetime Psychiatric Days R 1-15 Remaining Patient Liability MIA04 Claim DRG Amount R 1-18 MIA04 Amount R 1-18 Code Added Code Deleted change to ituational change to Not Used Increase from Page 74 of 93

75 MIA05 Remark Code AN 1-30 MIA05 Claim Payment Remark Code AN 1-50 MIA06 Claim Disproportionate hare Amount R 1-18 MIA06 Claim MP Pass-through Amount R 1-18 MIA07 Claim Disproportionate hare Amount R 1-18 Claim MP Pass-through Amount R 1-18 MIA07 MIA08 Claim PP Capital Amount R 1-18 MIA08 Claim PP Capital Amount R 1-18 MIA09 MIA10 PP-Capital FP DRG Amount R 1-18 MIA09 PP-Capital HP DRG Amount R 1-18 MIA10 PP-Capital DH DRG Amount R 1-18 MIA11 PP-Capital FP DRG Amount R 1-18 PP-Capital HP DRG Amount R 1-18 PP-Capital DH DRG Amount R 1-18 MIA11 MIA12 Old Capital Amount R 1-18 MIA12 Old Capital Amount R 1-18 MIA13 PP-Capital IME Amount R 1-18 MIA13 PP-Capital IME Amount R 1-18 PP-Operating Hospital PP-Operating Hospital MIA14 pecific DRG Amount R 1-18 MIA14 pecific DRG Amount R 1-18 MIA15 Cost Report Day Count R 1-15 MIA15 Cost Report Day Count R 1-15 MIA16 MIA17 MIA18 MIA19 PP-Operating Federal pecific DRG Amount R 1-18 MIA16 Claim PP Capital Outlier Amount R 1-18 MIA17 Claim Indirect Teaching Amount R 1-18 MIA18 Non-Payable Professional Component Amount R 1-18 MIA19 PP-Operating Federal pecific DRG Amount R 1-18 Claim PP Capital Outlier Amount R 1-18 Claim Indirect Teaching Amount R 1-18 Non-Payable Professional Component Billed Amount R 1-18 MIA20 Remark Code AN 1-30 MIA20 Claim Payment Remark Code AN 1-50 MIA21 Remark Code AN 1-30 MIA21 Claim Payment Remark Code AN 1-50 MIA22 Remark Code AN 1-30 MIA22 Claim Payment Remark Code AN 1-50 MIA23 Remark Code AN 1-30 MIA23 Claim Payment Remark Code AN 1-50 MIA24 PP-Capital Exception Amount R 1-18 MIA24 PP-Capital Exception Amount R 1-18 Increase from Increase from Increase from Increase from Increase from MOA MEDICARE OUTPATIENT ADJUDICATION MOA MEDICARE OUTPATIENT ADJUDICATION MOA01 Reimbursement Rate R 1-10 MOA01 Reimbursement Rate R 1-10 Claim HCPC Payable MOA02 Amount R 1-18 MOA02 HCPC Payable Amount R 1-18 MOA03 Remark Code AN 1-30 MOA03 Remark Code AN 1-50 Increase from MOA04 Remark Code AN 1-30 MOA04 Remark Code AN 1-50 Increase from MOA05 Remark Code AN 1-30 MOA05 Remark Code AN 1-50 Increase from MOA06 Remark Code AN 1-30 MOA06 Remark Code AN 1-50 Increase from MOA07 Remark Code AN 1-30 MOA07 Remark Code AN 1-50 Increase from Page 75 of 93

76 MOA08 MOA09 Claim ERD Payment Amount R 1-18 MOA08 Non-Payable Professional Component Amount R 1-18 MOA09 End tage Renal Disease Payment Amount R 1-18 Non-Payable Professional Component Billed Amount R 1-18 OTHER UBCRIBER NAME 1 R 2330A 1 NM1 OTHER UBCRIBER NAME 1 R 2330A 1 NM1 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 Other Insured Last Name AN 1-35 R NM103 Other Insured Last Name AN 1-60 R Increase from NM104 Other Insured First Name AN 1-25 NM104 Other Insured First Name AN 1-35 Increase from NM105 Other Insured Middle Name AN 1-25 NM105 Other Insured Middle Name AN 1-25 NM106 Name Prefix AN 1-10 NM106 Name Prefix AN 1-10 NM107 Other Insured Name uffix AN 1-10 NM107 Other Insured Name uffix AN 1-10 NM108 Identification Code Qualifier ID 1-2 R MI, ZZ NM108 Identification Code Qualifier ID 1-2 R II, MI Code Change NM109 Other Insured Identifier AN 2-80 R NM109 Other Insured 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 OTHER UBCRIBER ADDRE A N3 OTHER UBCRIBER ADDRE A N301 Other Insured Address Line AN 1-55 R N301 Other Insured Address Line AN 1-55 R N302 Other Insured Address Line AN 1-55 N302 Other Insured Address Line AN 1-55 N4 OTHER UBCRIBER CITY/TATE/ZIP CODE A N4 OTHER UBCRIBER CITY/TATE/ZIP CODE 1 R 2330A N401 Other Insured City Name AN 2-30 R N401 Other Insured City Name AN 2-30 R N402 Other Insured tate Code ID 2-2 R N402 Other Insured tate Code ID 2-2 Other Insured Postal Zone or ZIP Code ID 3-15 R N403 Other Insured 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 OTHER UBCRIBER ECONDARY IDENTIFICATION A Qualifier ID 2-3 R 1W, 23,!G, Y Other Insured Additional Identifier AN 1-30 R 02 OTHER UBCRIBER ECONDARY IDENTIFICATION A Qualifier ID 2-3 R Y Other Insured Additional Identifier AN 1-50 R Description AN Description AN ERENCE IDENTIFIER 04 ERENCE IDENTIFIER # of change to 2 Code Deleted Increase from Page 76 of 93

77 NM1 OTHER PAYER NAME 1 R 2330B 1 NM1 OTHER PAYER NAME 1 R 2330B 1 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 Other Payer Last or Organization Name AN 1-35 R NM103 Other Payer Last or Organization Name AN 1-60 R Increase from NM103 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 Other Payer Primary Identifier AN 2-80 R NM109 Other Payer 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 NM112 Name Last or Organization Name AN 1-60 New N3 OTHER PAYER ADDRE B N3 OTHER PAYER ADDRE B N301 Other Payer Address Line AN 1-55 R N301 Other Payer Address Line AN 1-55 R N302 Other Payer Address Line AN 1-55 N302 Other Payer Address Line AN 1-55 N4 OTHER PAYER CITY/TATE/ZIP CODE B N4 OTHER PAYER CITY/TATE/ZIP CODE 1 R 2330B N401 Other Payer City Name AN 2-30 R N401 Other Payer City Name AN 2-30 R N402 Other Payer tate Code ID 2-2 R N402 Other Payer tate Code ID 2-2 Other Payer Postal Zone or ZIP Code ID 3-15 R N403 Other Payer Postal Zone or ZIP Code ID 3-15 change to Required change to ituational change to ituational N403 N404 Payer Country Code ID 2-3 N404 Other 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 DTP CLAIM ADJUDICATION DATE B DTP DATE - CLAIM CHECK OR REMITTANCE DATE B DTP01 Date Time Qualifier ID 3-3 R 573 DTP01 Date Time Qualifier ID 3-3 R 573 DTP02 Qualifier ID 2-3 R D8 DTP02 Qualifier ID 2-3 R D8 DTP03 Adjudication or Payment Date AN 1-35 R CCYYMMDD DTP03 Adjudication or Payment Date AN 1-35 R CCYYMMDD OTHER PAYER ECONDARY IDENTIFICATION AND ERENCE NUMBER B Qualifier ID 2-3 R 2U, F8, FY, NF, TJ Other Payer econdary Identifier AN 1-30 R 02 OTHER PAYER ECONDARY IDENTIFICATION B Qualifier ID 2-3 R 2U, EI, FY, NF Other Payer econdary Identifier AN 1-50 R Description AN Description AN 1-80 Code Change Increase from Page 77 of 93

78 04 ERENCE IDENTIFIER 04 ERENCE IDENTIFIER OTHER PAYER PRIOR AUTHORIZATION OR ERRAL NUMBER B Qualifier ID 2-3 R 9F, G1 Authorization or Referral Number AN 1-30 R 02 OTHER PAYER PRIOR AUTHORIZATION NUMBER B Qualifier ID 2-3 R G1 Other Payer Prior Authorization Number AN 1-50 R Description AN Description AN ERENCE IDENTIFIER 04 ERENCE IDENTIFIER Code Change Increase from OTHER PAYER ERRAL NUMBER B Qualifier ID 2-3 R 9F New egment 02 Other Payer Referral Number AN 1-50 R 03 Description AN ERENCE IDENTIFIER OTHER PAYER CLAIM ADJUTMENT INDICATOR B Qualifier ID 2-3 R T4 Other Payer Claim 02 Adjustment Indicator AN 1-50 R 03 Description AN ERENCE IDENTIFIER OTHER PAYER CLAIM CONTROL NUMBER B Qualifier ID 2-3 R F8 Other Payer Claim Control 02 Number AN 1-50 R 03 Description AN ERENCE IDENTIFIER New egment New egment NM1 OTHER PAYER PATIENT C 1 NM101 Entity Identifier Code ID 2-3 R QC NM102 Entity Type Qualifier ID 1-1 R 1 Name Last or Organization NM103 Name AN 1-35 NM104 Name First AN 1-25 NM105 Name Middle AN 1-25 NM106 Name Prefix AN 1-10 NM107 Name uffix AN 1-10 egment Deleted Page 78 of 93

79 NM108 Identification Code Qualifier ID 1-2 R EI, MI NM109 Other Payer Patient Primary Identifier AN 2-80 R NM110 Entity Relationship Code ID 2-2 NM111 Entity Identifier Code ID 2-3 OTHER PAYER PATIENT IDENTIFICATION NUMBER C Qualifier ID 2-3 R 1W, IG, Y Other Payer Patient 02 econdary Identifier AN 1-30 R 03 Description AN ERENCE IDENTIFIER egment Deleted OTHER PAYER ATTENDING OTHER PAYER ATTENDING Change NM1 PROVIDER D 1 NM1 PROVIDER C 1 NM101 Entity Identifier Code ID 2-3 R 71 NM101 Entity Identifier Code ID 2-3 R 71 NM102 Entity Type Qualifier ID 1-1 R 1, 2 NM102 Entity Type Qualifier ID 1-1 R 1 Code Deleted Name Last or Organization Name Last or Organization Increase from NM103 Name AN 1-35 NM103 Name AN 1-60 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 NM108 Identification Code Qualifier ID 1-2 NM109 Identification Code AN 2-80 NM109 Other Payer 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 NM112 Name Last or Organization Name AN 1-60 New OTHER PAYER ATTENDING PROVIDER ECONDARY IDENTIFICATION 3 R 2330D Qualifier ID 2-3 R 1A, 1B, 1C, 1D, 1G, 1H, EI, G2, LU, N5 OTHER PAYER ATTENDING PROVIDER ECONDARY IDENTIFICATION 4 R 2330C Qualifier ID 2-3 R 0B, 1G, G2, LU Change # s change to 4 Code Change 02 econdary Identifier AN 1-30 R 02 econdary Identifier AN 1-50 R Increase from Description AN Description AN ERENCE IDENTIFIER 04 ERENCE IDENTIFIER OTHER PAYER OPERATING PROVIDER E 1 NM1 OTHER PAYER OPERATING PROVIDER D 1 NM1 NM101 Entity Identifier Code ID 2-3 R 72 NM101 Entity Identifier Code ID 2-3 R 72 NM102 Entity Type Qualifier ID 1-1 R 1 NM102 Entity Type Qualifier ID 1-1 R 1 NM103 Name Last or Organization Name AN 1-35 NM103 Name Last or Organization Name AN 1-60 Change Increase from Page 79 of 93

80 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 NM108 Identification Code Qualifier ID 1-2 NM109 Other Payer Primary Identifier AN 2-80 NM109 Other Payer 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 NM112 Name Last or Organization Name AN 1-60 OTHER PAYER OPERATING PROVIDER IDENTIFICATION 3 R 2330E Qualifier ID 2-3 R 1A, 1B, 1C, 1D, 1G, 1H, EI, G2, LU, N5 OTHER PAYER OPERATING PROVIDER ECONDARY IDENTIFICATION 4 R 2330D Qualifier ID 2-3 R 0B, 1G, G2, LU Change # s change to 4 Code Change 02 econdary Identifier AN 1-30 R 02 econdary Identifier AN 1-50 R Increase from Description AN Description AN ERENCE IDENTIFIER 04 ERENCE IDENTIFIER NM1 OTHER PAYER OTHER PROVIDER F 1 NM1 OTHER PAYER OTHER OPERATING PROVIDER E 1 Change NM101 Entity Identifier Code ID 2-3 R 73 NM101 Entity Identifier Code ID 2-3 R ZZ Code Change NM102 Entity Type Qualifier ID 1-1 R 1, 2 NM102 Entity Type Qualifier ID 1-1 R 1 Code Deleted Name Last or Organization Name Last or Organization Increase from NM103 Name AN 1-35 NM103 Name AN 1-60 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 NM108 Identification Code Qualifier ID 1-2 NM109 Other Payer Primary Identifier AN 2-80 NM109 Other Payer 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 NM112 Name Last or Organization Name AN 1-60 New OTHER PAYER OTHER PROVIDER IDENTIFICATION 3 R 2330F OTHER PAYER OTHER OPERATING PROVIDER ECONDARY IDENTIFICATION 4 R 2330E Change # s change to 4 1A, 1B, 1C, 1D, Code Change Qualifier ID 2-3 R 1G, 1H, EI, G2, LU, N5, Y Qualifier ID 2-3 R 0B, 1G, G2, LU 02 econdary Identifier AN 1-30 R 02 econdary Identifier AN 1-50 R Increase from Page 80 of 93

81 03 Description AN Description AN ERENCE IDENTIFIER 04 ERENCE IDENTIFIER NM1 OTHER PAYER ERVICE FACILITY PROVIDER H 1 NM1 OTHER PAYER ERVICE FACILITY LOCATION F 1 Change NM101 Entity Identifier Code ID 2-3 R FA NM101 Entity Identifier Code ID 2-3 R 77 Code Change NM102 Entity Type Qualifier ID 1-1 R 2 NM102 Entity Type Qualifier ID 1-1 R 2 Name Last or Organization Name Last or Organization Increase from NM103 Name AN 1-35 NM103 Name AN 1-60 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 NM108 Identification Code Qualifier ID 1-2 NM109 Other Payer Primary Identifier AN 2-80 NM109 Other Payer 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 NM112 Name Last or Organization Name AN 1-60 NM112 Name Last or Organization Name AN 1-60 OTHER PAYER ERVICE FACILITY PROVIDER IDENTIFICATION 3 R 2330H Qualifier ID 2-3 R 1B, 1C, 1D, EI, G2, LU, N5 Other Payer ervice Facility Location econdary Identifier AN 1-30 R 02 OTHER PAYER ERVICE FACILITY LOCATION ECONDARY IDENTIFIER 3 R 2330F Qualifier ID 2-3 R 0B, G2, LU Other Payer ervice Facility Location econdary Identifier AN 1-50 R Description AN Description AN ERENCE IDENTIFIER 04 ERENCE IDENTIFIER NM1 OTHER PAYER RENDERING PROVIDER G 1 NM101 Entity Identifier Code ID 2-3 R 82 NM102 Entity Type Qualifier ID 1-1 R 1 Name Last or Organization NM103 Name AN 1-60 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 Change Code Change Increase from New egment NM109 Other Payer Primary Identifier AN 2-80 NM110 Entity Relationship Code ID 2-2 NM111 Entity Identifier Code ID 2-3 NM112 Name Last or Organization Name AN 1-60 Page 81 of 93

82 OTHER PAYER RENDERING PROVIDER ECONDARY IDENTIFIER 4 R 2330G Qualifier ID 2-3 R 0B, 1G, G2, LU Other Payer Rendering 02 Provider econdary Identifier AN 1-50 R 03 Description AN ERENCE IDENTIFIER NM1 OTHER PAYER ERRING PROVIDER H 1 NM101 Entity Identifier Code ID 2-3 R DN NM102 Entity Type Qualifier ID 1-1 R 1 Name Last or Organization NM103 Name AN 1-60 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 New egment New egment NM109 Other Payer Primary Identifier AN 2-80 NM110 Entity Relationship Code ID 2-2 NM111 Entity Identifier Code ID 2-3 NM112 Name Last or Organization Name AN 1-60 OTHER PAYER ERRING PROVIDER ECONDARY IDENTIFIER 3 R 2330H Qualifier ID 2-3 R 0B, 1G, G2 New egment 02 Other Payer Referring Provider econdary Identifier AN 1-50 R 03 Description AN ERENCE IDENTIFIER NM1 OTHER PAYER BILLING PROVIDER I 1 NM101 Entity Identifier Code ID 2-3 R 85 NM102 Entity Type Qualifier ID 1-1 R 2 Name Last or Organization NM103 Name AN 1-60 NM104 Name First AN 1-35 NM105 Name Middle AN 1-25 NM106 Name Prefix AN 1-10 NM107 Name uffix AN 1-10 New egment Page 82 of 93

83 NM108 Identification Code Qualifier ID 1-2 NM109 Other Payer Primary Identifier AN 2-80 NM110 Entity Relationship Code ID 2-2 NM111 Entity Identifier Code ID 2-3 NM112 Name Last or Organization Name AN 1-60 OTHER PAYER BILLING PROVIDER ECONDARY IDENTIFICATION 2 R 2330I Qualifier ID 2-3 R G2, LU Other Payer Billing Provider 02 econdary Identification AN 1-50 R 03 Description AN ERENCE IDENTIFIER New egment LX ERVICE LINE NUMBER 1 R LX ERVICE LINE 1 R LX01 Assigned Number N0 1-6 R LX01 Assigned Number N0 1-6 R V2 INTITUTIONAL ERVICE LINE 1 R 2400 V2 INTITUTIONAL ERVICE LINE 1 R 2400 V201 Revenue Code AN 1-48 R V201 Revenue Code AN 1-48 R change to Required V202 COMPOITE V202 COMPOITE R Product or ervice ID Product or ervice ID ER, HC, HP, IV, Code Change V202-1 Qualifier ID 2-2 R HC, IV, ZZ V202-1 Qualifier ID 2-2 R WK V202-2 Procedure Code AN 1-48 R V202-2 Procedure Code AN 1-48 R V202-3 Procedure Modifier AN 2-2 V202-3 Procedure Modifier AN 2-2 V202-4 Procedure Modifier AN 2-2 V202-4 Procedure Modifier AN 2-2 V202-5 Procedure Modifier AN 2-2 V202-5 Procedure Modifier AN 2-2 V202-6 Procedure Modifier AN 2-2 V202-6 Procedure Modifier AN 2-2 V202-7 Description AN 1-80 V202-7 Description AN 1-80 change to ituational V202-8 Product/ervice ID AN 1-48 New V203 Line Item Charge Amount R 1-18 R V203 Line Item Charge Amount R 1-18 R Unit or Basis for Unit or Basis for Code Deleted V204 Measurement Code ID 2-2 R DA, F2, UN V204 Measurement Code ID 2-2 R DA, UN V205 ervice Unit Count R 1-15 R V205 ervice Units/Days R 1-15 R change to Not Used V206 Unit Rate ID 1-10 V206 Unit Rate ID 1-10 V207 Monetary Amount R 1-18 V207 Monetary Amount R 1-18 V208 Y/N ID 1-1 V208 Y/N ID 1-1 V209 NHRC ID 1-1 V209 NHRC ID 1-1 V210 Level of Care V210 Level of Care PWK LINE UPPLEMENTAL PWK LINE UPPLEMENTAL # s change to 10 Page 83 of 93

84 PWK01 Attachment Report Type Code ID 2-2 R Attachment Transmission Code ID 1-2 R A, B2, B3, B4, CT, D2, DA, DG, D, EB, MT, NN, OB, OZ, PN, PO, PZ, RB, RR, RT AA, AB, AD, AF, AG, BM, EL, EM, FX PWK01 Attachment Report Type Code ID 2-2 R Attachment Transmission Code ID 1-2 R PWK02 PWK02 PWK03 Report Copies Needed N0 1-2 PWK03 Report Copies Needed N0 1-2 PWK04 Entity Identifier Code ID 2-3 PWK04 Entity Identifier Code ID 2-3 Code Added 03, 04, 05, 06, 07, 08, 09, 10, 11, 13, 15, 21, A3, A4, AM, A, B2, B3, B4, BR, B, BT, CB, CK, CT, D2, DA, DB, DG, DJ, D, 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, G, V5, XP Code Change AA, BM, EL, EM, FT, FX PWK05 Identification Code Qualifier ID 1-2 AC PWK05 Identification Code Qualifier ID 1-2 AC PWK06 Identification Code AN 2-80 PWK06 Identification Code AN 2-80 PWK07 Description AN 1-80 PWK07 Description AN 1-80 PWK08 ACTION INDICATED PWK08 ACTION INDICATED PWK09 Request Category Code ID 1-2 PWK09 Request Category Code ID 1-2 DTP ERVICE LINE DATE 1 R 2400 DTP DATE - ERVICE DATE 1 R 2400 DTP01 Date Time Qualifier ID 3-3 R 472 DTP01 Date Time Qualifier ID 3-3 R 472 DTP02 Qualifier ID 2-3 R D8, RD8 DTP02 DTP03 ervice Date AN 1-35 R Qualifier ID 2-3 R D8, RD8 CYYMMDD, CCYYMMDD- CCYYMMDD DTP03 ervice Date AN 1-35 R CYYMMDD, CCYYMMDD- CCYYMMDD change to Required DTP AEMENT DATE egment Deleted DTP01 Date Time Qualifier ID 3-3 R 866 DTP02 Qualifier ID 2-3 R D8 DTP03 Assessment Date AN 1-35 R CCYYMMDD LINE ITEM CONTROL NUMBER Qualifier ID 2-3 R 6R 02 Line Item Control Number AN 1-50 R New egment Page 84 of 93

85 03 Description AN ERENCE IDENTIFIER REPRICED LINE ITEM ERENCE NUMBER Qualifier ID 2-3 R 9B Repriced Line Item Reference 02 Number AN 1-50 R 03 Description AN ERENCE IDENTIFIER ITEM ERENCE NUMBER Qualifier ID 2-3 R 9D Adjusted Repriced Line Item 02 Reference Number AN 1-50 R 03 Description AN ERENCE IDENTIFIER New egment New egment AMT ERVICE TAX AMOUNT AMT ERVICE TAX AMOUNT AMT01 Amount Qualifier Code ID 1-3 R GT AMT01 Amount Qualifier Code ID 1-3 R GT AMT02 ervice Tax Amount R 1-18 R AMT02 Tax Amount R 1-18 R AMT03 Credit/Debit Flag AMT03 Credit/Debit Flag AMT FACILITY TAX AMOUNT AMT FACILITY TAX AMOUNT AMT01 Amount Qualifier Code ID 1-3 R N8 AMT01 Amount Qualifier Code ID 1-3 R N8 AMT02 Facility Tax Amount R 1-18 R AMT02 Facility Tax Amount R 1-18 R AMT03 Credit/Debit Flag AMT03 Credit/Debit Flag NTE THIRD PARTY ORGANIZATION NOTE NTE01 Note Reference Code ID 3-3 R TPO NTE02 Claim Note Text AN 1-80 R egment Added HCP LINE PRICING/REPRICING HCP LINE PRICING/REPRICING HCP01 Pricing Methodology ID 2-2 R 00, 01, 02, 03, 04, 05, 06, 07, 08, 09, 10, 11, 12, 13, 14 HCP01 Pricing Methodology ID 2-2 R HCP02 Repriced Allowed Amount R 1-18 R HCP02 Repriced Allowed Amount R 1-18 R HCP03 Repriced aving Amount R 1-18 HCP03 Repriced aving Amount R 1-18 HCP04 HCP05 Repricing Organization Identifier AN 1-30 HCP04 Repricing Per Diem or Flat Rate Amount R 1-9 HCP05 Repricing Organization Identifier AN 1-50 Repricing Per Diem or Flat Rate Amount R , 01, 02, 03, 04, 05, 06, 07, 08, 09, 10, 11, 12, 13, 14 Increase from Page 85 of 93

86 HCP06 HCP07 Ambulatory Patient Group Code AN 1-30 HCP06 Ambulatory Patient Group Amount R 1-18 HCP07 Ambulatory Patient Group Code AN 1-50 Ambulatory Patient Group Amount R 1-18 HCP08 Product/ervice ID AN 1-48 HCP08 Product/ervice ID AN 1-48 Product or ervice ID Qualifier ID 2-2 HC HCP09 Product or ervice ID Qualifier ID 2-2 ER, HC, HP, IV, WK HCP09 HCP10 Procedure Code AN 1-48 HCP10 Procedure Code AN 1-48 HCP11 Measurement Code ID 2-2 DA, UN HCP11 Measurement Code ID 2-2 DA, UN HCP12 Repriced Approved ervice Unit Count "DA" "UN" R 1-15 HCP12 Repriced Approved ervice Unit Count "DA" "UN" R 1-15 T1, T2, T3, T4, T5, T6 HCP13 Reject Reason Code ID 2-2 T1, T2, T3, T4, T5, T6 HCP13 Reject Reason Code ID 2-2 HCP14 Policy Compliance Code ID 1-2 1, 2, 3, 4, 5 HCP14 Policy Compliance Code ID 1-2 1, 2, 3, 4, 5 HCP15 Exception Code ID 1-2 1, 2, 3, 4, 5, 6 HCP15 Exception Code ID 1-2 1, 2, 3, 4, 5, 6 Increase from change to Not Used Code Added LIN DRUG IDENTIFICATION LIN DRUG IDENTIFICATION LIN01 Assigned Identification AN 1-20 LIN01 Assigned Identification AN 1-20 LIN02 Product or ervice ID Qualifier ID 2-2 R N4 LIN02 Product or ervice ID Qualifier ID 2-2 R N4 LIN03 National Drug Code AN 1-48 R LIN03 National Drug Code AN 1-48 R LIN04 Product/ervice ID Qualifier ID 2-2 LIN04 Product/ervice ID Qualifier ID 2-2 LIN05 Product/ervice ID AN 1-48 LIN05 Product/ervice ID AN 1-48 LIN06 Product/ervice ID Qualifier ID 2-2 LIN06 Product/ervice ID Qualifier ID 2-2 LIN07 Product/ervice ID AN 1-48 LIN07 Product/ervice ID AN 1-48 LIN08 Product/ervice ID Qualifier ID 2-2 LIN08 Product/ervice ID Qualifier ID 2-2 LIN09 Product/ervice ID AN 1-48 LIN09 Product/ervice ID AN 1-48 LIN10 Product/ervice ID Qualifier ID 2-2 LIN10 Product/ervice ID Qualifier ID 2-2 LIN11 Product/ervice ID AN 1-48 LIN11 Product/ervice ID AN 1-48 LIN12 Product/ervice ID Qualifier ID 2-2 LIN12 Product/ervice ID Qualifier ID 2-2 LIN13 Product/ervice ID AN 1-48 LIN13 Product/ervice ID AN 1-48 LIN14 Product/ervice ID Qualifier ID 2-2 LIN14 Product/ervice ID Qualifier ID 2-2 LIN15 Product/ervice ID AN 1-48 LIN15 Product/ervice ID AN 1-48 LIN16 Product/ervice ID Qualifier ID 2-2 LIN16 Product/ervice ID Qualifier ID 2-2 LIN17 Product/ervice ID AN 1-48 LIN17 Product/ervice ID AN 1-48 LIN18 Product/ervice ID Qualifier ID 2-2 LIN18 Product/ervice ID Qualifier ID 2-2 LIN19 Product/ervice ID AN 1-48 LIN19 Product/ervice ID AN 1-48 LIN20 Product/ervice ID Qualifier ID 2-2 LIN20 Product/ervice ID Qualifier ID 2-2 LIN21 Product/ervice ID AN 1-48 LIN21 Product/ervice ID AN 1-48 LIN22 Product/ervice ID Qualifier ID 2-2 LIN22 Product/ervice ID Qualifier ID 2-2 LIN23 Product/ervice ID AN 1-48 LIN23 Product/ervice ID AN 1-48 LIN24 Product/ervice ID Qualifier ID 2-2 LIN24 Product/ervice ID Qualifier ID 2-2 LIN25 Product/ervice ID AN 1-48 LIN25 Product/ervice ID AN 1-48 LIN26 Product/ervice ID Qualifier ID 2-2 LIN26 Product/ervice ID Qualifier ID 2-2 LIN27 Product/ervice ID AN 1-48 LIN27 Product/ervice ID AN 1-48 LIN28 Product/ervice ID Qualifier ID 2-2 LIN28 Product/ervice ID Qualifier ID 2-2 LIN29 Product/ervice ID AN 1-48 LIN29 Product/ervice ID AN 1-48 LIN30 Product/ervice ID Qualifier ID 2-2 LIN30 Product/ervice ID Qualifier ID 2-2 # s change to 1 Page 86 of 93

87 LIN31 Product/ervice ID AN 1-48 LIN31 Product/ervice ID AN 1-48 CTP DRUG QUANTITY CTP DRUG QUANTITY 1 R 2410 CTP01 Class of Trade Code ID 2-2 CTP01 Class of Trade Code ID 2-2 CTP02 Price Identifier Code ID 3-3 CTP02 Price Identifier Code ID 3-3 CTP03 Unit Price R 1-17 R CTP03 Unit Price R 1-17 CTP04 National Drug Unit Count R 1-15 R CTP04 National Drug Unit Count R 1-15 R CTP05 COMPOITE UNIT OF MEAURE R CTP05 Unit or Basis For Measurement Code ID 2-2 R F2, GR, ML, UN CTP05-1 COMPOITE UNIT OF MEAURE R Unit or Basis For Measurement Code ID 2-2 R CTP05-1 CTP05-2 Exponent R 1-15 CTP05-2 Exponent R 1-15 CTP05-3 Multiplier R 1-10 CTP05-3 Multiplier R 1-10 Unit or Basis For Measurement Code ID 2-2 CTP05-4 Unit or Basis For Measurement Code ID 2-2 CTP05-4 CTP05-5 Exponent R 1-15 CTP05-5 Exponent R 1-15 CTP05-6 Multiplier R 1-10 CTP05-6 Multiplier R 1-10 Unit or Basis For Measurement Code ID 2-2 CTP05-7 Unit or Basis For Measurement Code ID 2-2 CTP05-7 CTP05-8 Exponent R 1-15 CTP05-8 Exponent R 1-15 CTP05-9 Multiplier R 1-10 CTP05-9 Multiplier R 1-10 Unit or Basis For Measurement Code ID 2-2 CTP05-10 Unit or Basis For Measurement Code ID 2-2 CTP05-10 CTP05-11 Exponent R 1-15 CTP05-11 Exponent R 1-15 CTP05-12 Multiplier R 1-10 CTP05-12 Multiplier R 1-10 Unit or Basis For Measurement Code ID 2-2 CTP05-13 Unit or Basis For Measurement Code ID 2-2 CTP05-13 CTP05-14 Exponent R 1-15 CTP05-14 Exponent R 1-15 CTP05-15 Multiplier R 1-10 CTP05-15 Multiplier R 1-10 CTP06 Price Multiplier Qualifier ID 3-3 CTP06 Price Multiplier Qualifier ID 3-3 CTP07 Multiplier R 1-10 CTP07 Multiplier R 1-10 CTP08 Monetary Amount R 1-18 CTP08 Monetary Amount R 1-18 CTP09 Basis of Unit Price Code ID 2-2 CTP09 Basis of Unit Price Code ID 2-2 CTP10 Condition Value AN 1-10 CTP10 Condition Value AN 1-10 CTP11 Multiple Price Quantity N0 1-2 CTP11 Multiple Price Quantity N0 1-2 F2, GR, ME, ML, UN Change to Required change to Not Used Code Added PRECRIPTION OR PRECRIPTION NUMBER COMPOUND DRUG AOCIATION NUMBER Code Added Qualifier ID 2-3 R XZ Qualifier ID 2-3 R VY, XZ 02 Prescription Number AN 1-30 R 02 Prescription Number AN 1-50 R Increase from Desciption AN Desciption AN ERENCE IDENTIFIER 04 ERENCE IDENTIFIER NM1 ATTENDING PHYICIAN NAME A 1 egment Deleted Page 87 of 93

88 NM101 Entity Identifier Code ID 2-3 R 71 NM102 Entity Type Qualifier ID 1-1 R 1, 2 NM103 Last Name AN 1-35 R NM104 First Name AN 1-25 NM105 Middle Name AN 1-25 NM106 Name Prefix AN 1-10 NM107 Name uffix AN 1-10 NM108 Identification Code Qualifier ID , 34, XX NM109 Identifier AN 2-80 NM110 Entity Relationship Code ID 2-2 NM111 Entity Identifier Code ID 2-3 ATTENDING PHYICIAN ECONDARY IDENTIFICATION A Qualifier ID 2-3 R 02 econdary Identifier AN 1-30 R 03 Description AN ERENCE IDENTIFIER OB, 1A, 1B, 1C, 1D, 1G, 1H, EI, G2, LU, N5, Y, X5 egment Deleted OPERATING PHYICIAN NAME B 1 NM1 OPERATING PHYICIAN NAME A 1 NM1 NM101 Entity Identifier Code ID 2-3 R 72 NM101 Entity Identifier Code ID 2-3 R 72 NM102 Entity Type Qualifier ID 1-1 R 1 NM102 Entity Type Qualifier ID 1-1 R 1 NM103 Last Name AN 1-35 R NM103 Last Name AN 1-60 R Increase from NM104 First Name AN 1-25 NM104 First Name AN 1-35 Increase from NM105 Middle Name AN 1-25 NM105 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 , 34, XX NM108 Identification Code Qualifier ID 1-2 XX Code Deleted NM109 Identifier AN 2-80 NM109 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 OPERATING PHYICIAN ECONDARY IDENTIFICATION B Name Last or Organization Name AN 1-60 OPERATING PHYICIAN ECONDARY IDENTIFICATION A New # Reeats change to 20 OB, 1A, 1B, 1C, Code Change Qualifier ID 2-3 R 1D, 1G, 1H, EI, G2, LU, N5, Y, X5 Qualifier ID 2-3 R OB, 1G, G2, LU 02 econdary Identifier AN 1-30 R 02 econdary Identifier AN 1-50 R Increase from Description AN Description AN 1-80 change to iuational 04 ERENCE IDENTIFIER 04 ERENCE IDENTIFIER Page 88 of 93

89 New 04-1 Reference Identifier Qualifier ID 2-3 R 2U 04-2 Idenitifer AN 1-50 R New New AN 1-50 New New AN 1-50 New NM1 OTHER OPERATING PHYICIAN NAME B 1 NM101 Entity Identifier Code ID 2-3 R ZZ NM102 Entity Type Qualifier ID 1-1 R 1 NM103 Last Name AN 1-60 R NM104 First Name AN 1-35 NM105 Middle Name AN 1-25 NM106 Name Prefix AN 1-10 NM107 Name uffix AN 1-10 NM108 Identification Code Qualifier ID 1-2 XX NM109 Identifier AN 2-80 NM110 Entity Relationship Code ID 2-2 NM111 Entity Identifier Code ID 2-3 Name Last or Organization NM112 Name AN 1-60 New egment OTHER OPERATING PHYICIAN ECONDARY IDENTIFICATION B Qualifier ID 2-3 R OB, 1G, G2, LU 02 econdary Identifier AN 1-50 R 03 Description AN ERENCE IDENTIFIER 04-1 Reference Identifier Qualifier ID 2-3 R 2U 04-2 Idenitifer AN 1-50 R AN AN 1-50 New egment NM1 OTHER PROVIDER NAME C 1 egment Deleted NM101 Entity Identifier Code ID 2-3 R 73 NM102 Entity Type Qualifier ID 1-1 R 1, 2 NM103 Other Physician Last Name AN 1-35 R NM104 Other Physician First Name AN 1-25 Page 89 of 93

90 NM105 Middle Name AN 1-25 NM106 Name Prefix AN 1-10 NM107 Name uffix AN 1-10 NM108 Identification Code Qualifier ID 1-2 R 24, 34, XX NM109 Identifier AN 2-80 R NM110 Entity Relationship Code ID 2-2 NM111 Entity Identifier Code ID 2-3 OTHER PROVIDER ECONDARY IDENTIFICATION B Qualifier ID 2-3 R 02 econdary Identifier AN 1-30 R 03 Description AN ERENCE IDENTIFIER OB, 1A, 1B, 1C, 1D, 1G, 1H, EI, G2, LU, N5, Y, X5 egment Deleted NM1 RENDERING PROVIDER NAME C 1 NM101 Entity Identifier Code ID 2-3 R 82 NM102 Entity Type Qualifier ID 1-1 R 1 Rendering Provider Last or NM103 Organization Name AN 1-60 R Rendering Provider First NM104 Name AN 1-35 Rendering Provider Middle NM105 Name AN 1-25 NM106 Name Prefix AN 1-10 Rendering Provider Name NM107 uffix AN 1-10 NM108 Identification Code Qualifier ID 1-2 XX New egment NM109 Rendering Provider Identifier AN 2-80 NM110 Entity Relationship Code ID 2-2 NM111 Entity Identifier Code ID 2-3 NM112 Name Last or Organization Name AN 1-60 RENDERING PROVIDER ECONDARY IDENTIFICATION C Qualifier ID 2-3 R OB, 1G, G2, LU Rendering Provider 02 econdary Identifier AN 1-50 R 03 Description AN ERENCE IDENTIFIER New egment Page 90 of 93

91 04-1 Reference Identifier Qualifier ID 2-3 R 2U 04-2 Other Payer Primary Idenitifer AN 1-50 R AN AN 1-50 NM1 ERRING PROVIDER NAME D 1 NM101 Entity Identifier Code ID 2-3 R DN NM102 Entity Type Qualifier ID 1-1 R 1 New egment NM103 Referring Provider Last Name AN 1-60 R NM104 Referring Provider First Name AN 1-35 NM105 Referring Provider Middle Name or Initial AN 1-25 NM106 Name Prefix AN 1-10 NM107 Referring Provider Name uffix AN 1-10 NM108 Identification Code Qualifier ID 1-2 XX NM109 Other Payer Primary Identifier AN 2-80 NM110 Entity Relationship Code ID 2-2 NM111 Entity Identifier Code ID 2-3 NM112 Name Last or Organization Name AN 1-60 ERRING PROVIDER ECONDARY IDENTIFICATION D Qualifier ID 2-3 R OB, 1G, G2 Referring Provider econdary 02 Identifier AN 1-50 R 03 Description AN ERENCE IDENTIFIER New egment 04-1 Reference Identifier Qualifier ID 2-3 R 2U 04-2 Other Payer Primary Idenitifer AN 1-50 R AN Page 91 of 93

92 04-6 AN 1-50 VD LINE ADJUDICATION VD LINE ADJUDICATION VD01 Payer Identifier AN 2-80 R VD01 Other Payer Primary Identifier AN 2-80 R VD02 ervice Line Paid Amount R 1-18 R VD02 ervice Line Paid Amount R 1-18 R VD03 VD03-1 COMPOITE MEDICAL PROCEDURE IDENTIFIER R VD03 Product or ervice ID Qualifier ID 2-2 R HC, IV, ZZ VD03-1 COMPOITE MEDICAL PROCEDURE IDENTIFIER R Product or ervice ID Qualifier ID 2-2 R VD03-2 Procedure Code AN 1-48 R VD03-2 Procedure Code AN 1-48 R VD03-3 Procedure Modifier AN 2-2 VD03-3 Procedure Modifier AN 2-2 VD03-4 Procedure Modifier AN 2-2 VD03-4 Procedure Modifier AN 2-2 VD03-5 Procedure Modifier AN 2-2 VD03-5 Procedure Modifier AN 2-2 VD03-6 Procedure Modifier AN 2-2 VD03-6 Procedure Modifier AN 2-2 ER, HC, HP, IV, WK Code Change VD03-7 Procedure Code Description AN 1-80 VD03-7 Procedure Code Description AN 1-80 VD03-8 Product/ervice ID AN 1-48 New change to Not Used VD04 Product or ervice ID AN 1-48 R VD04 Product or ervice ID AN 1-48 VD05 Paid ervice Unit Count R 1-15 R VD05 Paid ervice Unit Count R 1-15 R VD06 Bundled or Unbundled Line Number N0 1-6 VD06 Bundled or Unbundled Line Number N0 1-6 CA LINE ADJUTMENT CA LINE ADJUTMENT Claim Adjustment Group Code ID 1-2 R CO, CR, OA, PI, PR Claim Adjustment Group Code ID 1-2 R CA01 CA01 CA02 Adjustment Reason Code ID 1-5 R CA02 Adjustment Reason Code ID 1-5 R CA03 Adjustment Amount R 1-18 R CA03 Adjustment Amount R 1-18 R CA04 Adjustment Quantity R 1-15 CA04 Adjustment Quantity R 1-15 CA05 Adjustment Reason Code ID 1-5 CA05 Adjustment Reason Code ID 1-5 CA06 Adjustment Amount R 1-18 CA06 Adjustment Amount R 1-18 CA07 Adjustment Quantity R 1-15 CA07 Adjustment Quantity R 1-15 CA08 Adjustment Reason Code ID 1-5 CA08 Adjustment Reason Code ID 1-5 CA09 Adjustment Amount R 1-18 CA09 Adjustment Amount R 1-18 CA10 Adjustment Quantity R 1-15 CA10 Adjustment Quantity R 1-15 CA11 Adjustment Reason Code ID 1-5 CA11 Adjustment Reason Code ID 1-5 CA12 Adjustment Amount R 1-18 CA12 Adjustment Amount R 1-18 CA13 Adjustment Quantity R 1-15 CA13 Adjustment Quantity R 1-15 CA14 Adjustment Reason Code ID 1-5 CA14 Adjustment Reason Code ID 1-5 CA15 Adjustment Amount R 1-18 CA15 Adjustment Amount R 1-18 CA16 Adjustment Quantity R 1-15 CA16 Adjustment Quantity R 1-15 CA17 Adjustment Reason Code ID 1-5 CA17 Adjustment Reason Code ID 1-5 CA18 Adjustment Amount R 1-18 CA18 Adjustment Amount R 1-18 CA19 Adjustment Quantity R 1-15 CA19 Adjustment Quantity R 1-15 CO, CR, OA, PI, PR DTP ERVICE ADJUDICATION DATE DTP LINE CHECK OR REMITTANCE DATE 1 R 2430 change to Required Page 92 of 93

93 DTP01 Date Time Qualifier ID 3-3 R 573 DTP01 Date Time Qualifier ID 3-3 R 573 DTP02 Qualifier ID 2-3 R D8 DTP02 Qualifier ID 2-3 R D8 DTP03 Adjudication or Payment Date AN 1-35 R CCYYMMDD DTP03 Adjudication or Payment Date AN 1-35 R CCYYMMDD AMT REMAINING PATIENT LIABILITY AMT01 Amount Qualifier Code ID 1-3 R EAF Remaining Patient Liability AMT02 Amount R 1-18 R AMT03 Credit/Debit Flag New egment E TRANACTION ET TRAILER 1 R >1 E TRANACTION ET TRAILER 1 R >1 E01 Transaction egment Count N R E01 Transaction egment Count N R E02 GE Transaction et Control Number AN 4-9 R E02 FUNCTION GROUP TRAILER 1 R 1 GE Number of Transaction ets Included N0 1-6 R GE01 Transaction et Control Number AN 4-9 R FUNCTION GROUP TRAILER 1 R 1 Number of Transaction ets Included N0 1-6 R GE01 GE02 Group Control Number N0 1-9 R GE02 Group Control Number N0 1-9 R IEA IEA01 INTERCHANGE CONTROL TRAILER 1 R 1 IEA Number of Included Functional Groups N0 1-5 R IEA01 INTERCHANGE CONTROL TRAILER 1 R 1 Number of Included Functional Groups N0 1-5 R IEA02 Interchange Control Number N0 9-9 R IEA02 Interchange Control Number N0 9-9 R Page 93 of 93