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 10-10 R IA02 Authorization Information AN 10-10 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 10-10 R IA04 ecurity Information AN 10-10 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 15-15 R IA06 Interchange ender ID AN 15-15 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 15-15 R IA08 Interchange Receiver ID AN 15-15 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 00501 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 004010X096A1 G08 Version Identifier Code AN 1-12 R 005010X223 Code Change Page 1 of 93
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 30-50 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 87 02 AN 1-30 R 03 Description AN 1-80 04 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 35-60 NM103 NM104 ubmitter First Name AN 1-25 NM104 ubmitter First Name AN 1-35 Increase from 25-35 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
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 1-256 R Increase from 80-256 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 1-256 Increase from 80-256 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 1-256 Increase from 80-256 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 35-60 NM104 Name First AN 1-25 NM104 Name First AN 1-35 Increase from 25-35 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 1 2000A PRV BILLING PROVIDER PECIALTY 1 2000A 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 30-50 PRV04 tate or Province Code ID 2-2 PRV04 tate or Province Code ID 2-2 Page 3 of 93
PRV05 PROVIDER PECIALTY PRV05 PROVIDER PECIALTY PRV06 Provider Organization Code ID 3-3 PRV06 Provider Organization Code ID 3-3 FOREIGN CURRENCY 1 2000A CUR FOREIGN CURRENCY 1 2000A 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 35-60 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 25-35 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
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 02 03 Description AN 1-80 03 Description AN 1-80 04 ERENCE IDENTIFIER 04 ERENCE IDENTIFIER # s change to 1 Code Deleted Increase from 30-50 CREDIT/DEBIT CARD BILLING 8 2010AA Qualifier ID 2-3 R Billing Provider Additional 02 Identifier AN 1-30 R 03 Description AN 1-80 04 ERENCE IDENTIFIER 06, 8U, EM, IJ, LU, RB, T, TT egment Deleted PER BILLING PROVIDER CONTACT 2 2010AA PER BILLING PROVIDER CONTACT 2 2010AA 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 1-256 R Increase from 80-256 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
PER06 Communication Number AN 1-80 PER06 Communication Number AN 1-256 Increase from 80-256 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 1-256 Increase from 80-256 PER09 Contact Inquiry Reference AN 1-20 PER09 Contact Inquiry Reference AN 1-20 NM1 PAY-TO PROVIDER NAME 1 2010AB 1 NM1 PAY-TO ADDRE NAME 1 2010AB 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 35-60 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 25-35 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 1-2 24, 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 5 2010AB 0B, 1A, 1B, 1C, 1D, 1G, 1H, 1J, B3, BQ, EI, FH, G2, G5, LU, Y, X5 egment Deleted Page 6 of 93
Qualifier ID 2-3 R 02 Billing Provider Additional Identifier AN 1-30 R 03 Description AN 1-80 04 ERENCE IDENTIFIER NM1 PAY TO PLAN NAME 1 2010AC 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 1 2010AC Qualifier ID 2-3 R 2U, FY, NF 02 AN 1-50 R 03 Description AN 1-80 04 ERENCE IDENTIFIER New egment New egment PAY-TO PLAN TAX IDENTIFICATION 1 R 2010AC New egment Page 7 of 93
Qualifier ID 2-3 R EI 02 AN 1-50 R 03 Description AN 1-80 04 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 2-2 18 BR02 Individual Relationship Code ID 2-2 18 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 30-50 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 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 11, 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 35-60 NM104 ubscriber First Name AN 1-25 NM104 ubscriber First Name AN 1-35 Increase from 25-35 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
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 1 2010BA N3 UBCRIBER ADDRE 1 2010BA 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 1 2010BA N4 UBCRIBER CITY/TATE/ZIP CODE 1 2010BA 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 1 2010BA DMG Qualifier ID 2-3 R D8 DMG01 UBCRIBER DEMOGRAPHIC 1 2010BA 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 4 2010BA Qualifier ID 2-3 R 1W, 23, IG, Y ubscriber upplemental Identifier AN 1-30 R 02 UBCRIBER ECONDARY IDENTIFICATION 1 2010BA Qualifier ID 2-3 R Y ubscriber upplemental Identifier AN 1-50 R 02 03 Description AN 1-80 03 Description AN 1-80 04 ERENCE IDENTIFIER 04 ERENCE IDENTIFIER Code Deleted Increase rom 30-50 CAUALTY CLAIM NUMBER 1 2010BA Qualifier ID 2-3 R Y4 CAUALTY CLAIM NUMBER 1 2010BA Qualifier ID 2-3 R Y4 Page 9 of 93
Property Casualty Claim Number AN 1-30 R 02 Property Casualty Claim Number AN 1-50 R 02 03 Description AN 1-80 03 Description AN 1-80 04 ERENCE IDENTIFIER 04 ERENCE IDENTIFIER NM1 CREDIT/DEBIT CARD ACCOUNT HOLDER NAME 1 2010BB 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 30-50 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 2 2010BB Qualifier ID 2-3 R AB, BB Credit or Debt Card 02 Authorization Number AN 1-30 R 03 Description AN 1-80 04 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 35-60 NM104 Name First AN 1-25 NM104 Name First AN 1-35 Increase from 25-35 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 1 2010BC N3 PAYER ADDRE 1 2010BB Change Page 10 of 93
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 3 2010BC Qualifier ID 2-3 R 2U, FY, NF, TJ PAYER ECONDARY IDENTIFICATION 3 2010BB 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 30-50 03 Description AN 1-80 03 Description AN 1-80 04 ERENCE IDENTIFIER 04 ERENCE IDENTIFIER BILLING PROVIDER ECONDARY IDENTIFICATION 1 2010BB Qualifier ID 2-3 R G2, LU 02 Payer Additional Identifier AN 1-50 R 03 Description AN 1-80 04 ERENCE IDENTIFIER egment Added NM1 REPONIBLE PARTY NAME 1 2010BD 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 1 2010BC egment Deleted Page 11 of 93
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 1 2000C >1 HL PATIENT HIERARCHICAL LEVEL 1 2000C >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 1-1 01, 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 35-60 Page 12 of 93
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 25-35 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 5 2010CA egment Deleted Page 13 of 93
Qualifier ID 2-3 R 1W, 23, IG, Y 02 Patient econdary Identifier AN 1-30 R 03 Description AN 1-80 04 ERENCE IDENTIFIER PROPERTY AND CAUALTY CLAIM NUMBER 1 2010CA Qualifier ID 2-3 R Y4 Property Casualty Claim Number AN 1-30 R 02 PROPERTY AND CAUALTY CLAIM NUMBER 1 2010CA Qualifier ID 2-3 R Y4 Property Casualty Claim Number AN 1-50 R 02 03 Description AN 1-80 03 Description AN 1-80 04 ERENCE IDENTIFIER 04 ERENCE IDENTIFIER CLM CLAIM 1 R 2300 100 CLM CLAIM 1 R 2300 100 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 2-3 02, 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 30-50 Code Added Code Added Code Deleted change to ituational Code Added change to ituational Code Added Page 14 of 93
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 1 2300 DTP DATE - DICHARGE HOUR 1 2300 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 1 2300 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 1 2300 DTP DATE - ADMIION DATE/HOUR 1 2300 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 1 2300 CL1 DTP DATE - REPRICER RECEIVED DATE 1 2300 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 1 2300 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 10 2300 PWK CLAIM UPPLEMENTAL 10 2300 Page 15 of 93
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 1 2300 CN1 CONTRACT 1 2300 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 30-50 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 1 2300 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 1 2300 AMT PATIENT ETIMATED AMOUNT DUE 1 2300 AMT01 Amount Qualifier Code ID 1-3 R F3 AMT01 Amount Qualifier Code ID 1-3 R F3 Page 16 of 93
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 1 2300 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 1 2300 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 1 2300 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 1 2300 Qualifier ID 2-3 R 4N ervice Authorization Exception Code AN 1-50 R 1, 2, 3, 4, 5, 6, 7 02 03 Description AN 1-80 03 Description AN 1-80 04 ERENCE IDENTIFIER 04 ERENCE IDENTIFIER Increase from 30-50 ERRAL NUMBER 1 2300 New egment Qualifier ID 2-3 R 9F Prior Authorization or 02 Referral Number AN 1-50 R 03 Description AN 1-80 04 ERENCE IDENTIFIER PRIOR AUTHORIZATION 2 2300 PRIOR AUTHORIZATION 1 2300 # 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 30-50 03 Description AN 1-80 03 Description AN 1-80 04 ERENCE IDENTIFIER 04 ERENCE IDENTIFIER ORIGINAL ERENCE NUMBER (ICN/DCN) 1 2300 Qualifier ID 2-3 R F8 Claim Original Reference Number AN 1-30 R 02 PAYER CLAIM CONTROL NUMBER 1 2300 Qualifier ID 2-3 R F8 Claim Original Reference Number AN 1-50 R 02 03 Description AN 1-80 03 Description AN 1-80 Increase from 30-50 Page 17 of 93
04 ERENCE IDENTIFIER 04 ERENCE IDENTIFIER REPRICED CLAIM NUMBER 1 2300 REPRICED CLAIM NUMBER 1 2300 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 02 03 Description AN 1-80 03 Description AN 1-80 04 ERENCE IDENTIFIER 04 ERENCE IDENTIFIER ADJUTED REPRICED CLAIM NUMBER 1 2300 Qualifier ID 2-3 R 9C Adjusted Repriced Claim Reference Number AN 1-30 R 02 ADJUTED REPRICED CLAIM NUMBER 1 2300 Qualifier ID 2-3 R 9C Adjusted Repriced Claim Reference Number AN 1-50 R 02 03 Description AN 1-80 03 Description AN 1-80 04 ERENCE IDENTIFIER 04 ERENCE IDENTIFIER INVETIGATIONAL DEVICE EXEMPTION NUMBER 1 2300 Qualifier ID 2-3 R LX Investigational Device Exemption Number AN 1-30 R 02 INVETIGATIONAL DEVICE EXEMPTION NUMBER 5 2300 Qualifier ID 2-3 R LX Investigational Device Exemption Number AN 1-50 R 02 03 Description AN 1-80 03 Description AN 1-80 04 ERENCE IDENTIFIER 04 ERENCE IDENTIFIER CLAIM IDENTIFIER FOR TRANMIION INTERMEDIARIE 1 2300 Qualifier ID 2-3 R D9 CLAIM IDENTIFIER FOR TRANMIION INTERMEDIARIE 1 2300 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 1-80 03 Description AN 1-80 04 ERENCE IDENTIFIER 04 ERENCE IDENTIFIER DOCUMENT IDENTIFICATION CODE 2 2300 Qualifier ID 2-3 R DD 02 Document ControlIdentifier AN 1-30 R 03 Description AN 1-80 04 ERENCE IDENTIFIER Increase from 30-50 Increase from 30-50 Increase from 30-50 Increase from 30-50 egment Deleted AUTO ACCIDENT TATE 1 2300 New egment Page 18 of 93
MEDICAL RECORD NUMBER 1 2300 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 1-80 04 ERENCE IDENTIFIER MEDICAL RECORD NUMBER 1 2300 Qualifier ID 2-3 R EA 02 Medical Record Number AN 1-30 R 02 Medical Record Number AN 1-50 R Increase from 30-50 03 Description AN 1-80 03 Description AN 1-80 04 ERENCE IDENTIFIER 04 ERENCE IDENTIFIER DEMONTRATION PROJECT IDENTIFIER 1 2300 Qualifier ID 2-3 R P4 Demonstration Project Identifier AN 1-30 R 02 DEMONTRATION PROJECT IDENTIFIER 1 2300 Qualifier ID 2-3 R P4 Demonstration Project Identifier AN 1-50 R 02 03 Description AN 1-80 03 Description AN 1-80 04 ERENCE IDENTIFIER 04 ERENCE IDENTIFIER Increase from 30-50 PEER REVIEW ORGANIZARION (PRO) APPROVAL NUMBER 1 2300 Qualifier ID 2-3 R G4 PEER REVIEW ORGANIZARION (PRO) APPROVAL NUMBER 1 2300 Qualifier ID 2-3 R G4 02 PRO Number AN 1-30 R 02 PRO Number AN 1-50 R Increase from 30-50 03 Description AN 1-80 03 Description AN 1-80 04 ERENCE IDENTIFIER 04 ERENCE IDENTIFIER K3 FILE 10 2300 K3 FILE 10 2300 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 10 2300 NTE CLAIM NOTE 10 2300 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 1 2300 NTE BILLING NOTE 1 2300 NTE01 Note Reference Code ID 3-3 R ADD NTE01 Note Reference Code ID 3-3 R ADD Page 19 of 93
NTE02 Billing Note Text AN 1-80 R NTE02 Billing Note Text AN 1-80 R CR6 HOME HEALTH CARE 1 2300 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 3 2300 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