ICRs Contained in 45 CFR Part 162; HIPAA Standards for Electronic Transactions

X098A1

ICRs Contained in 45 CFR Part 162; HIPAA Standards for Electronic Transactions

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ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X098A1 • 837
HEALTH CARE CLAIM: PROFESSIONAL

National Electronic Data Interchange
Transaction Set Implementation Guide

A
D
D
E
N
D
A

Health Care Claim:
Professional
837
ASC X12N 837 (004010X098A1)

October 2002
OCTOBER 2002

1

004010X098A1 • 837
HEALTH CARE CLAIM: PROFESSIONAL

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

$45.00 - Bound Document
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Portable Documents may be downloaded at no charge.
Contact Washington Publishing Company for more Information.

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© 2002 WPC
Copyright for the members of ASC X12N by Washington Publishing Company.
Permission is hereby granted to any organization to copy and distribute this material internally as long as this copyright statement is
included, the contents are not changed, and the copies are not sold.

2

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X098A1 • 837
HEALTH CARE CLAIM: PROFESSIONAL

Table of Contents
Introduction .................................................................................................. 5
Modified pages............................................................................................ 7

OCTOBER 2002

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004010X098A1 • 837
HEALTH CARE CLAIM: PROFESSIONAL

4

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X098A1 • 837
HEALTH CARE CLAIM: PROFESSIONAL

1 Introduction to Modified Pages
This document is addenda to the X12N Health Care Claim: Professional Implementation Guide, originally published May 2000 as 004010X098. As a result of
the post publication review process, items were identified that could be considered impediments to implementation. These items were passed to the X12N
Health Care Work Group that created the original Implementation Guide for their
review.
Modifications based on those comments were reflected in a draft version of the
Addenda to the X12N 004010X098 Implementation Guide. Since the X12N
004010X098 Implementation Guide is named for use under the Health Insurance
Portability and Accountability Act of 1996 (HIPAA), an NPRM Draft Addenda went
through a Notice of Proposed Rule Making (NPRM) comment process that began
on May 31, 2002. The Addenda reflects changes based on comments received
during the NPRM process and X12N’s own review processes. Only the modifications noted in the NPRM Draft Addenda were considered in the NPRM and X12N
review processes. The Addenda was approved for publication by X12N on October 10, 2002. When using the X12N Health Care Claim: Professional Implementation Guide, originally published May 2000 as 004010X098 and incorporating the
changes identified in the Addenda, the value used in GS08 must be
“004010X098A1".
Each of the changes made to the 004010X098 Implementation Guide has been
annotated with a note in red and a line pointing to the location of the change. In
the event that a segment or loop has been deleted, the deletion will be identified
in the Implementation table beginning on Page 7. For convenience, the affected
004010X098 Implementation Guide page number is noted at the bottom of the
page. Please note that as a result of insertion or deletion of material Addenda
pages may not begin or end at the same place as the original referenced page.
Because of this, Addenda pages are not page for page replacements and the
original pages should be retained.
Changes in the Addenda may have caused changes to the Data Element Dictionary and the Data Element Name Index (Appendix E in the original Implementation Guide), but these changes are not identified in the Addenda. Changes in the
Addenda may also have caused changes to the Examples and the EDI Transmission Examples (Section 4 in the original Implementation Guide), again these are
not identified in the Addenda.

OCTOBER 2002

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004010X098A1 • 837
HEALTH CARE CLAIM: PROFESSIONAL

6

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X098A1 • 837

004010X098A1 • 837

IMPLEMENTATION

837

Health Care Claim: Professional

1. The 837 transaction is designed to transmit one or more claims for each billing provider. The hierarchy of
the looping structure is billing provider, subscriber, patient, claim level, and claim service line level. Billing
providers who sort claims using this hierarchy will use the 837 more efficiently because information that applies
to all lower levels in the hierarchy will not have to be repeated within the transaction.
2. This standard is also recommended for the submission of similar data within a pre-paid managed care
context. Referred to as capitated encounters, this data usually does not result in a payment, though it is
possible to submit a “mixed” claim that includes both pre-paid and request for payment services. This standard
will allow for the submission of data from providers of health care products and services to a Managed Care
Organization or other payer. This standard may also be used by payers to share data with plan sponsors,
employers, regulatory entities and Community Health Information Networks.
3. This standard can, also, be used as a transaction set in support of the coordination of benefits claims
process. Additional looped segments can be used within both the claim and service line levels to transfer each
payer’s adjudication information to subsequent payers.

Table 1 - Header
PAGE #

POS. # SEG. ID

NAME

USAGE

REPEAT

61
62
65

005
010
015

ST
BHT
REF

Transaction Set Header
Beginning of Hierarchical Transaction
Transmission Type Identification

R
R
R

1
1
1

66
69

020
045

NM1
PER

LOOP ID - 1000A SUBMITTER NAME
Submitter Name
Submitter EDI Contact Information

R
R

1
2

72

020

NM1

LOOP ID - 1000B RECEIVER NAME
Receiver Name

R

1

LOOP REPEAT

1

N2 Deleted
1

Table 2 - Billing/Pay-to Provider Detail
PAGE #

POS. # SEG. ID

NAME

USAGE

REPEAT

74
76
78

001
003
010

HL
PRV
CUR

LOOP ID - 2000A BILLING/PAY-TO PROVIDER
HIERARCHICAL LEVEL
Billing/Pay-to Provider Hierarchical Level
Billing/Pay-to Provider Specialty Information
Foreign Currency Information

81
84
85
87
90
92

015
025
030
035
035
040

NM1
N3
N4
REF
REF
PER

LOOP ID - 2010AA BILLING PROVIDER NAME
Billing Provider Name
Billing Provider Address
Billing Provider City/State/ZIP Code
Billing Provider Secondary Identification
Credit/Debit Card Billing Information
Billing Provider Contact Information

R
R
R
S
S
S

1
1
1
8
8
2

95
98
99
101

015
025
030
035

NM1
N3
N4
REF

LOOP ID - 2010AB PAY-TO PROVIDER NAME
Pay-to Provider Name
Pay-to Provider Address
Pay-to Provider City/State/ZIP Code
Pay-to-Provider Secondary Identification

S
R
R
S

1
1
1
5

OCTOBER 2002

LOOP REPEAT

>1
R
S
S

1
1
1
1

N2 Deleted

1

Original Page Number 51 dated May 2000

7

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X098A1 • 837

Table 2 - Subscriber Detail
PAGE #

POS. # SEG. ID

NAME

USAGE

REPEAT

103
105
109

001
005
007

HL
SBR
PAT

LOOP ID - 2000B SUBSCRIBER HIERARCHICAL
LEVEL
Subscriber Hierarchical Level
Subscriber Information
Patient Information

112
115
116
118
120
122

015
025
030
032
035
035

NM1
N3
N4
DMG
REF
REF

LOOP ID - 2010BA SUBSCRIBER NAME
Subscriber Name
Subscriber Address
Subscriber City/State/ZIP Code
Subscriber Demographic Information
Subscriber Secondary Identification
Property and Casualty Claim Number

R
S
S
S
S
S

1
1
1
1
4
1

124
127
128
130

015
025
030
035

NM1
N3
N4
REF

LOOP ID - 2010BB PAYER NAME
Payer Name
Payer Address
Payer City/State/ZIP Code
Payer Secondary Identification

R
S
S
S

1
1
1
3

132
135
136

015
025
030

NM1
N3
N4

LOOP ID - 2010BC RESPONSIBLE PARTY NAME
Responsible Party Name
Responsible Party Address
Responsible Party City/State/ZIP Code

S
R
R

1
1
1

NM1
REF

LOOP ID - 2010BD CREDIT/DEBIT CARD HOLDER
NAME
Credit/Debit Card Holder Name
Credit/Debit Card Information

138
141

015
035

LOOP REPEAT

>1
R
R
S

1
1
1
1

1

N2 Deleted

1

1
S
S

1
2

Table 2 - Patient Detail
For purposes of this documentation, the claim detail information is presented only in the dependent level.
Specific claim detail information can be given in either the subscriber or the dependent hierarchical level.
Because of this the claim information is said to “float.” Claim information is positioned in the same hierarchical
level that describes its owner-participant, either the subscriber or the dependent. In other words, the claim
information, loop 2300, is placed following loop 2010BD in the subscriber hierarchical level when the patient is
the subscriber, or it is placed at the patient/dependent hierarchical level when the patient is the dependent of
the subscriber as shown here. When the patient is the subscriber, loops 2000C and 2010CA are not sent. See
2.3.2.1, HL Segment, for details.
PAGE #

POS. # SEG. ID

NAME

USAGE

REPEAT

143
145

001
007

HL
PAT

LOOP ID - 2000C PATIENT HIERARCHICAL LEVEL
Patient Hierarchical Level
Patient Information

S
R

1
1

148
151
152
154
156
158

015
025
030
032
035
035

NM1
N3
N4
DMG
REF
REF

LOOP ID - 2010CA PATIENT NAME
Patient Name
Patient Address
Patient City/State/ZIP Code
Patient Demographic Information
Patient Secondary Identification
Property and Casualty Claim Number

R
R
R
R
S
S

1
1
1
1
5
1

8

Original Page Numbers 52 and 53 dated May 2000

LOOP REPEAT

>1

1

N2 Deleted

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004010X098A1 • 837

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180
182
183
185
186
188
190
191
193
195
197
199
202
204
205
206
208
210
212
214
216
218

130
135
135
135
135
135
135
135
135
135
135
135
135
135
135
135
135
155
160
175
175
175
180
180
180
180
180
180

CLM
DTP
DTP
DTP
DTP
DTP
DTP
DTP
DTP
DTP
DTP
DTP
DTP
DTP
DTP
DTP
DTP
PWK
CN1
AMT
AMT
AMT
REF
REF
REF
REF
REF
REF

220
222
223
225

180
180
180
180

REF
REF
REF
REF

227
228
229
231
233
235
238
241
246
249
251
254
260

180
180
180
185
190
195
200
220
220
220
220
231
241

REF
REF
REF
K3
NTE
CR1
CR2
CRC
CRC
CRC
CRC
HI
HCP

LOOP ID - 2300 CLAIM INFORMATION
Claim Information
Date - Initial Treatment
Date - Date Last Seen
Date - Onset of Current Illness/Symptom
Date - Acute Manifestation
Date - Similar Illness/Symptom Onset
Date - Accident
Date - Last Menstrual Period
Date - Last X-ray
Date - Hearing and Vision Prescription Date
Date - Disability Begin
Date - Disability End
Date - Last Worked
Date - Authorized Return to Work
Date - Admission
Date - Discharge
Date - Assumed and Relinquished Care Dates
Claim Supplemental Information
Contract Information
Credit/Debit Card Maximum Amount
Patient Amount Paid
Total Purchased Service Amount
Service Authorization Exception Code
Mandatory Medicare (Section 4081) Crossover Indicator
Mammography Certification Number
Prior Authorization or Referral Number
Original Reference Number (ICN/DCN)
Clinical Laboratory Improvement Amendment (CLIA)
Number
Repriced Claim Number
Adjusted Repriced Claim Number
Investigational Device Exemption Number
Claim Identification Number for Clearing Houses and
Other Transmission Intermediaries
Ambulatory Patient Group (APG)
Medical Record Number
Demonstration Project Identifier
File Information
Claim Note
Ambulance Transport Information
Spinal Manipulation Service Information
Ambulance Certification
Patient Condition Information: Vision
Homebound Indicator
EPSDT Referral
Health Care Diagnosis Code
Claim Pricing/Repricing Information

S
S

1
3

S
S

1
1

265
267

242
243

CR7
HSD

LOOP ID - 2305 HOME HEALTH CARE PLAN
INFORMATION
Home Health Care Plan Information
Health Care Services Delivery

271
274

250
255

NM1
PRV

LOOP ID - 2310A REFERRING PROVIDER NAME
Referring Provider Name
Referring Provider Specialty Information

OCTOBER 2002

100
R
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S

1
1
1
1
5
10
10
1
1
1
5
5
1
1
1
1
2
10
1
1
1
1
1
1
1
2
1
3

S
S
S
S

1
1
1
1

S
S
S
S
S
S
S
S
S
S
S
S
S

4
1
1
10
1
1
1
3
3
1
1
1
1

DTP
Deleted

New
Segment
Added
6

2

N2 Deleted

Original Page Numbers 53 and 54 dated May 2000

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ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X098A1 • 837
276
278
281
283

271
250
255
271

REF

Referring Provider Secondary Identification

S

5

NM1
PRV
REF

LOOP ID - 2310B RENDERING PROVIDER NAME
Rendering Provider Name
Rendering Provider Specialty Information
Rendering Provider Secondary Identification

S
S
S

1
1
5

S
S

1
5

1

285
288

250
271

NM1
REF

LOOP ID - 2310C PURCHASED SERVICE PROVIDER
NAME
Purchased Service Provider Name
Purchased Service Provider Secondary Identification

290
293
294
296

250
265
270
271

NM1
N3
N4
REF

LOOP ID - 2310D SERVICE FACILITY LOCATION
Service Facility Location
Service Facility Location Address
Service Facility Location City/State/ZIP
Service Facility Location Secondary Identification

S
R
R
S

1
1
1
5

298
301

250
271

NM1
REF

LOOP ID - 2310E SUPERVISING PROVIDER NAME
Supervising Provider Name
Supervising Provider Secondary Identification

S
S

1
5

303
308
317
318
319
320

290
295
300
300
300
300

SBR
CAS
AMT
AMT
AMT
AMT

S
S
S
S
S
S

1
5
1
1
1
1

321
322
323
324
325
326

300
300
300
300
300
300

AMT
AMT
AMT
AMT
AMT
AMT

327
329
332

305
310
320

335
338
339
341
343
346
349
351
353
355

357
359

361

10

1

1

S
S
S
S
S
S

1
1
1
1
1
1

DMG
OI
MOA

S
R
S

1
1
1

325
332
340
355

NM1
N3
N4
REF

LOOP ID - 2330A OTHER SUBSCRIBER NAME
Other Subscriber Name
Other Subscriber Address
Other Subscriber City/State/ZIP Code
Other Subscriber Secondary Identification

R
S
S
S

1
1
1
3

325
345
345
355
355
355

NM1
PER
DTP
REF
REF
REF

LOOP ID - 2330B OTHER PAYER NAME
Other Payer Name
Other Payer Contact Information
Claim Adjudication Date
Other Payer Secondary Identifier
Other Payer Prior Authorization or Referral Number
Other Payer Claim Adjustment Indicator

R
S
S
S
S
S

1
2
1
2
2
2

NM1
REF

LOOP ID - 2330C OTHER PAYER PATIENT
INFORMATION
Other Payer Patient Information
Other Payer Patient Identification

NM1

LOOP ID - 2330D OTHER PAYER REFERRING
PROVIDER
Other Payer Referring Provider

325

Original Page Numbers 54 and 55 dated May
2000

N2 Deleted

1

LOOP ID - 2320 OTHER SUBSCRIBER INFORMATION
Other Subscriber Information
Claim Level Adjustments
Coordination of Benefits (COB) Payer Paid Amount
Coordination of Benefits (COB) Approved Amount
Coordination of Benefits (COB) Allowed Amount
Coordination of Benefits (COB) Patient Responsibility
Amount
Coordination of Benefits (COB) Covered Amount
Coordination of Benefits (COB) Discount Amount
Coordination of Benefits (COB) Per Day Limit Amount
Coordination of Benefits (COB) Patient Paid Amount
Coordination of Benefits (COB) Tax Amount
Coordination of Benefits (COB) Total Claim Before Taxes
Amount
Subscriber Demographic Information
Other Insurance Coverage Information
Medicare Outpatient Adjudication Information

325
355

Usage
Changed
N2 Deleted

N2 Deleted
10

1

N2 Deleted

1

N2 Deleted

1
S
S

1
3
2

S

1

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
363

365
367

369
371

373
375

355

325
355

325
355

325
355

REF

Other Payer Referring Provider Identification

NM1
REF

LOOP ID - 2330E OTHER PAYER RENDERING
PROVIDER
Other Payer Rendering Provider
Other Payer Rendering Provider Secondary Identification

NM1
REF

LOOP ID - 2330F OTHER PAYER PURCHASED
SERVICE PROVIDER
Other Payer Purchased Service Provider
Other Payer Purchased Service Provider Identification

NM1
REF

LOOP ID - 2330G OTHER PAYER SERVICE FACILITY
LOCATION
Other Payer Service Facility Location
Other Payer Service Facility Location Identification
LOOP ID - 2330H OTHER PAYER SUPERVISING
PROVIDER
Other Payer Supervising Provider
Other Payer Supervising Provider Identification

377
379

325
355

NM1
REF

381
383
391
394
396
399
402
404
408
411
413
416
418
420
422
424
426
428
430
431
433
435
437
439
441
444
446
447
448
450
452
454

365
370
400
420
425
430
435
445
450
450
450
455
455
455
455
455
455
455
455
455
455
455
455
455
462
465
470
470
470
470
470
470

LX
SV1
SV5
PWK
CR1
CR2
CR3
CR5
CRC
CRC
CRC
DTP
DTP
DTP
DTP
DTP
DTP
DTP
DTP
DTP
DTP
DTP
DTP
DTP
MEA
CN1
REF
REF
REF
REF
REF
REF

456

470

REF

457
458
459

470
470
470

REF
REF
REF

OCTOBER 2002

004010X098A1 • 837

LOOP ID - 2400 SERVICE LINE
Service Line
Professional Service
Durable Medical Equipment Service
DMERC CMN Indicator
Ambulance Transport Information
Spinal Manipulation Service Information
Durable Medical Equipment Certification
Home Oxygen Therapy Information
Ambulance Certification
Hospice Employee Indicator
DMERC Condition Indicator
Date - Service Date
Date - Certification Revision Date
Date - Begin Therapy Date
Date - Last Certification Date
Date - Date Last Seen
Date - Test
Date - Oxygen Saturation/Arterial Blood Gas Test
Date - Shipped
Date - Onset of Current Symptom/Illness
Date - Last X-ray
Date - Acute Manifestation
Date - Initial Treatment
Date - Similar Illness/Symptom Onset
Test Result
Contract Information
Repriced Line Item Reference Number
Adjusted Repriced Line Item Reference Number
Prior Authorization or Referral Number
Line Item Control Number
Mammography Certification Number
Clinical Laboratory Improvement Amendment (CLIA)
Identification
Referring Clinical Laboratory Improvement Amendment
(CLIA) Facility Identification
Immunization Batch Number
Ambulatory Patient Group (APG)
Oxygen Flow Rate

R

3
1

S
R

1
3
1

S
R

1
3
1

S
R

1
3
1

S
R

1
3

R
R
S
S
S
S
S
S
S
S
S
R
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S

1
1
1
1
1
5
1
1
3
1
2
1
1
1
1
1
2
3
1
1
1
1
1
1
20
1
1
1
2
1
1
1

S

1

S
S
S

1
4
1

50

SV4 Deleted
SV5 Added

DTP Deleted

QTY Deleted

Original Page Numbers 55 and 56 dated May
2000

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461
463
464
465
466
467
468
470
474

470
475
475
475
480
485
488
491
492

REF
AMT
AMT
AMT
K3
NTE
PS1
HSD
HCP

Universal Product Number (UPN)
Sales Tax Amount
Approved Amount
Postage Claimed Amount
File Information
Line Note
Purchased Service Information
Health Care Services Delivery
Line Pricing/Repricing Information

S
S
S
S
S
S
S
S
S

1
1
1
1
10
1
1
1
1

480
483
486

494
495
496

LIN
CTP
REF

LOOP ID - 2410 DRUG IDENTIFICATION
Drug Identification
Drug Pricing
Prescription Number

S
S
S

1
1
1

488
491
493

500
505
525

NM1
PRV
REF

LOOP ID - 2420A RENDERING PROVIDER NAME
Rendering Provider Name
Rendering Provider Specialty Information
Rendering Provider Secondary Identification

S
S
S

1
1
5

S
S

1
5

New Loop
Added
25

1

Usage
Changed
N2 Deleted

495
498

500
525

NM1
REF

LOOP ID - 2420B PURCHASED SERVICE PROVIDER
NAME
Purchased Service Provider Name
Purchased Service Provider Secondary Identification

1

500
503
504
506

500
514
520
525

NM1
N3
N4
REF

LOOP ID - 2420C SERVICE FACILITY LOCATION
Service Facility Location
Service Facility Location Address
Service Facility Location City/State/ZIP
Service Facility Location Secondary Identification

S
R
R
S

1
1
1
5

N2 Deleted

508
511

500
525

NM1
REF

LOOP ID - 2420D SUPERVISING PROVIDER NAME
Supervising Provider Name
Supervising Provider Secondary Identification

S
S

1
5

N2 Deleted

513
516
517
519
521

500
514
520
525
530

NM1
N3
N4
REF
PER

LOOP ID - 2420E ORDERING PROVIDER NAME
Ordering Provider Name
Ordering Provider Address
Ordering Provider City/State/ZIP Code
Ordering Provider Secondary Identification
Ordering Provider Contact Information

S
S
S
S
S

1
1
1
5
1

524
527
529

500
505
525

NM1
PRV
REF

LOOP ID - 2420F REFERRING PROVIDER NAME
Referring Provider Name
Referring Provider Specialty Information
Referring Provider Secondary Identification

S
S
S

1
1
5

S
R

1
2

1

1

1

2

531
534

500
525

NM1
REF

LOOP ID - 2420G OTHER PAYER PRIOR
AUTHORIZATION OR REFERRAL NUMBER
Other Payer Prior Authorization or Referral Number
Other Payer Prior Authorization or Referral Number

536
540
548

540
545
550

SVD
CAS
DTP

LOOP ID - 2430 LINE ADJUDICATION INFORMATION
Line Adjudication Information
Line Adjustment
Line Adjudication Date

S
S
R

1
99
1

549
551
554

551
552
555

LQ
FRM
SE

LOOP ID - 2440 FORM IDENTIFICATION CODE
Form Identification Code
Supporting Documentation
Transaction Set Trailer

S
R
R

1
99
1

12

Original Page Numbers 56 and 57 dated May
2000

N2 Deleted

N2 Deleted
4

25

5

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X098A1 • 837 • REF
TRANSMISSION TYPE IDENTIFICATION

TRANSMISSION• TYPE
004010X098A1
837 • REF
IDENTIFICATION

IMPLEMENTATION

TRANSMISSION TYPE IDENTIFICATION
Usage: REQUIRED
Repeat: 1
Example Changed

Example: REF✽87✽004010X098A1~

2
103
STANDARD

REF Reference Identification
Level: Header
Position: 015
Loop: ____
Requirement: Optional
Max Use: 3
Purpose: To specify identifying information
Syntax:

1. R0203
At least one of REF02 or REF03 is required.

DIAGRAM

REF01

REF

✽

128

Reference
Ident Qual
M

ID

2/3

REF02

127

Reference
Ident

✽
X

REF03

352

REF04

✽ Description ✽

AN 1/30

X

AN 1/80

C040

Reference
Identifier

~

O

ELEMENT SUMMARY

USAGE

REF.
DES.

REQUIRED

REF01

DATA
ELEMENT

128

NAME

ATTRIBUTES

Reference Identification Qualifier

M

ID

2/3

X

AN

1/30

Code qualifying the Reference Identification
CODE

87
REQUIRED

REF02

127

DEFINITION

Functional Category

Reference Identification

Reference information as defined for a particular Transaction Set or as specified
by the Reference Identification Qualifier
INDUSTRY: Transmission
SYNTAX:

Type Code

R0203

When piloting the transaction set, this value is 004010X098DA1.
When sending the transaction set in a production mode, this value
is 004010X098A1.

2352 Note Changed
NOT USED

REF03

352

Description

X

NOT USED

REF04

C040

REFERENCE IDENTIFIER

O

OCTOBER 2002

AN

Original Page Number 56 dated May 2000

1/80

13

004010X098A1 • 837 • 2000A • PRV
BILLING/PAY-TO PROVIDER SPECIALTY INFORMATION

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

BILLING/PAY-TO
004010X098A1 • PROVIDER
837 • 2000ASPECIALTY
INFORMATION
• PRV

IMPLEMENTATION

BILLING/PAY-TO PROVIDER SPECIALTY
INFORMATION
Loop: 2000A — BILLING/PAY-TO PROVIDER HIERARCHICAL LEVEL
Usage: SITUATIONAL
Repeat: 1
Notes:

3
220

1. Required when adjudication is known to be impacted by the provider
taxonomy code, and the Rendering Provider is the same entity as the
Billing and/or Pay-to Provider. In these cases, the Rendering Provider
is being identified at this level for all subsequent claims/encounters in
this HL and Loop ID-2310B is not used.

Note 1. Changed

8
235

2. This PRV is not used when the Billing or Pay-to Provider is a group
and the individual Rendering Provider is in loop 2310B. The PRV
segment is then coded with the Rendering Provider in loop 2310B.

3
279

3. PRV02 qualifies PRV03.
Example: PRV✽BI✽ZZ✽203BA050N~

5
279
STANDARD

PRV Provider Information
Level: Detail
Position: 003
Loop: 2000
Requirement: Optional
Max Use: 1
Purpose: To specify the identifying characteristics of a provider
DIAGRAM

PRV01

PRV

1221

Provider
Code

✽
M

ID

1/3

PRV02

✽

128

Reference
Ident Qual
M

ID

PRV03

✽

2/3

127

Reference
Ident
M

PRV04

AN 1/30

156

State or
Prov Code

✽

O

ID

2/2

PRV05

C035

Provider
Spec. Inf.

✽

PRV06

O

1223

Provider
Org Code

✽
O

ID

~

3/3

ELEMENT SUMMARY

USAGE

REF.
DES.

REQUIRED

PRV01

DATA
ELEMENT

1221

NAME

ATTRIBUTES

Provider Code

M

ID

1/3

Code indentifying the type of provider
CODE

14

DEFINITION

BI

Billing

PT

Pay-To

Original Page Number 79 dated May
2000

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X098A1 • 837 • 2000B • PAT
PATIENT INFORMATION

PATIENT
004010X098A1
INFORMATION
• 837 • 2000B • PAT

SITUATIONAL

PAT05

1250

Date Time Period Format Qualifier

X

ID

2/3

Code indicating the date format, time format, or date and time format
SYNTAX:

Note Changed

P0506

Required if patient is known to be deceased and the date of death
is available to the provider billing system.

1798

CODE

DEFINITION

D8
SITUATIONAL

PAT06

1251

Date Expressed in Format CCYYMMDD

Date Time Period

X

AN

1/35

Expression of a date, a time, or range of dates, times or dates and times
INDUSTRY: Insured
ALIAS: Date
SYNTAX:

of Death

P0506

SEMANTIC:

PAT06 is the date of death.

NSF Reference:

1419
1419

CA0-21.0

Note Changed

Required if patient is known to be deceased and the date of death
is available to the provider billing system.

1000112

SITUATIONAL

Individual Death Date

PAT07

355

Unit or Basis for Measurement Code

X

ID

2/2

Code specifying the units in which a value is being expressed, or manner in which
a measurement has been taken
SYNTAX:

Note Changed

Required when PAT08 is used.

1798

CODE

Code 01 Added
Code GR Deleted
SITUATIONAL

P0708

01
PAT08

81

DEFINITION

Actual Pounds

Weight

X

R

1/10

Numeric value of weight
INDUSTRY: Patient
SYNTAX:

P0708

SEMANTIC:

2403
2403
Note Changed

1000113

OCTOBER 2002

Weight

PAT08 is the patient’s weight.

NSF Reference:
FA0-44.0, GU0-17.0
Required on:
1) claims/encounters involving EPO (epoetin) for patients on
dialysis.
2) Medicare Durable Medical Equipment Regional Carriers
certificate of medical necessity (DMERC CMN) 02.03 and 10.02.

Original Page Number 115 dated May 2000

15

004010X098A1 • 837 • 2000B • PAT
PATIENT INFORMATION

SITUATIONAL

PAT09

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

1073

Yes/No Condition or Response Code

O

ID

1/1

Code indicating a Yes or No condition or response
INDUSTRY: Pregnancy

Indicator

PAT09 indicates whether the patient is pregnant or not pregnant. Code
“Y” indicates the patient is pregnant; code “N” indicates the patient is not pregnant.

SEMANTIC:

Note Changed
1000114

Required when mandated by law. The determination of pregnancy
should be completed in compliance with applicable law. The “Y”
code indicates that the patient is pregnant. If PAT09 is not used it
means the patient is not pregnant.
CODE

Y

16

Original Page Number 116 dated May
2000

DEFINITION

Yes

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X098A1 • 837 • 2010BA • NM1
SUBSCRIBER NAME

004010X098A1NAME
SUBSCRIBER
• 837 • 2010BA • NM1

SITUATIONAL

NM108

66

Identification Code Qualifier

X

ID

1/2

Code designating the system/method of code structure used for Identification
Code (67)
SYNTAX:

P0809

Required if NM102 = 1 (person)

2406

CODE

MI

DEFINITION

Member Identification Number
The code MI is intended to be the subscriber’s
identification number as assigned by the payer.
Payers use different terminology to convey the
same number. Therefore the 837 Professional
Workgroup recommends using MI - Member
Identification Number to convey the following terms:
Insured’s ID, Subscriber’s ID, Health Insurance
Claim Number (HIC), etc.

2407

MI is also intended to be used in claims submitted to
the Indian Health Service/Contract Health Services
(IHS/CHS) Fiscal Intermediary for the purpose of
reporting the Tribe Residency Code (Tribe County
State).
In the event that a Social Security Number is also
available on an IHS/CHS claim, put the SSN in
REF02.
ZZ

Mutually Defined
The value ‘ZZ’, when used in this data element shall
be defined as “HIPAA Individual Identifier” once this
identifier has been adopted. Under the Health
Insurance Portability and Accountability Act of 1996,
the Secretary of the Department of Health and
Human Services must adopt a standard individual
identifier for use in this transaction.

2405

SITUATIONAL

NM109

67

Identification Code

X

AN

2/80

Code identifying a party or other code
INDUSTRY: Subscriber
SYNTAX:

Primary Identifier

P0809

NSF Reference:

2338
2338

DA0-18.0, CA1-05.0, CA1-06.0

Note Changed

Required if the Subscriber is the patient. If the subscriber is not the
patient, use if known. An identifier must be present in either the
subscriber or the patient loop.

1000115
NOT USED

NM110

706

Entity Relationship Code

X

ID

2/2

NOT USED

NM111

98

Entity Identifier Code

O

ID

2/3

OCTOBER 2002

Original Page Number 119 dated May 2000

17

004010X098A1 • 837 • 2010BA • REF
PROPERTY AND CASUALTY CLAIM NUMBER

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X098A1
PROPERTY
AND
CASUALTY
• 837
• 2010BACLAIM
• REFNUMBER

IMPLEMENTATION

PROPERTY AND CASUALTY CLAIM NUMBER
Loop: 2010BA — SUBSCRIBER NAME
Usage: SITUATIONAL
Repeat: 1
Notes:

3
106

1. In the case where the patient is the same person as the subscriber,
the property and casualty claim number is placed in Loop ID-2010BA.
In the case where the patient is a different person than the subscriber,
this number is placed in Loop ID-2010CA. This number should be
transmitted in only one place.

7
185

2. This is a property and casualty payer-assigned claim number. It is
required on property and casualty claims. Providers receive this
number from the property and casualty payer during eligibility
determinations or some other communication with that payer. See
Section 4.2, Property and Casualty, for additional information about
property and casualty claims.

New Note Added
188
3

3. Not required for HIPAA (The statutory definition of a health plan does
not specifically include workers’ compensation programs, property
and casualty programs, or disability insurance programs, and,
consequently, we are not requiring them to comply with the
standards.) but may be required for other uses.

Example: REF✽Y4✽4445555~

5
241
STANDARD

REF Reference Identification
Level: Detail
Position: 035
Loop: 2010
Requirement: Optional
Max Use: 20
Purpose: To specify identifying information
Syntax:

1. R0203
At least one of REF02 or REF03 is required.

DIAGRAM

REF01

REF

✽

M

18

128

Reference
Ident Qual
ID

2/3

REF02

127

Reference
Ident

✽
X

AN 1/30

REF03

352

✽ Description ✽
X

Original Page Number 128 dated May 2000

AN 1/80

REF04

C040

Reference
Identifier

~

O

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X098A1 • 837 • 2000C • PAT
PATIENT INFORMATION

004010X098A1
PATIENT
INFORMATION
• 837 • 2000C • PAT

05

Grandson or Granddaughter

07

Nephew or Niece

09

Adopted Child

10

Foster Child

15

Ward

17

Stepson or Stepdaughter

19

Child

20

Employee

21

Unknown

22

Handicapped Dependent

23

Sponsored Dependent

24

Dependent of a Minor Dependent

29

Significant Other

32

Mother

33

Father

34

Other Adult

36

Emancipated Minor

39

Organ Donor

40

Cadaver Donor

41

Injured Plaintiff

43

Child Where Insured Has No Financial Responsibility

53

Life Partner

G8

Other Relationship

NOT USED

PAT02

1384

Patient Location Code

O

ID

1/1

NOT USED

PAT03

584

Employment Status Code

O

ID

2/2

NOT USED

PAT04

1220

Student Status Code

O

ID

1/1

SITUATIONAL

PAT05

1250

Date Time Period Format Qualifier

X

ID

2/3

Code indicating the date format, time format, or date and time format
SYNTAX:

1798

Note Changed

P0506

Required if patient is known to be deceased and the date of death
is available to the provider billing system.
CODE

D8

OCTOBER 2002

DEFINITION

Date Expressed in Format CCYYMMDD

Original Page Number 155 dated May 2000

19

004010X098A1 • 837 • 2000C • PAT
PATIENT INFORMATION

SITUATIONAL

PAT06

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

1251

Date Time Period

X

AN

1/35

Expression of a date, a time, or range of dates, times or dates and times
INDUSTRY: Patient
ALIAS: Date
SYNTAX:

Death Date

of Death

P0506

SEMANTIC:

PAT06 is the date of death.

1450
1450

NSF Reference:

Note Changed
1000112

Required if patient is known to be deceased and the date of death
is available to the provider billing system.

SITUATIONAL

CA0-21.0

PAT07

355

Unit or Basis for Measurement Code

X

ID

2/2

Code specifying the units in which a value is being expressed, or manner in which
a measurement has been taken
SYNTAX:

Note Changed
1000112

P0708

Required when PAT08 is used.
CODE

Code 01 Added
Code GR Deleted
SITUATIONAL

PAT08

01
81

DEFINITION

Actual Pounds

Weight

X

R

1/10

Numeric value of weight
INDUSTRY: Patient
SYNTAX:

Weight

P0708

SEMANTIC:

PAT08 is the patient’s weight.

2427
2427

NSF Reference:

Note Changed
1000113

Required on:
1) claims/encounters involving EPO (epoetin) for patients on
dialysis.
2) Medicare Durable Medical Equipment Regional Carriers
certificate of medical necessity (DMERC CMN) 02.03 and 10.02.

SITUATIONAL

FA0-44.0, GU0-17.0

PAT09

1073

Yes/No Condition or Response Code

O

ID

1/1

Code indicating a Yes or No condition or response
INDUSTRY: Pregnancy

Indicator

PAT09 indicates whether the patient is pregnant or not pregnant. Code
“Y” indicates the patient is pregnant; code “N” indicates the patient is not pregnant.

SEMANTIC:

Note Changed

1000114

Required when mandated by law. The determination of pregnancy
should be completed in compliance with applicable law. The “Y”
code indicates that the patient is pregnant. If PAT09 is not used it
means the patient is not pregnant.
CODE

Y

20

Original Page Number 156 dated May 2000

DEFINITION

Yes

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X098A1 • 837 • 2010CA • REF
PROPERTY AND CASUALTY CLAIM NUMBER

004010X098A1
PROPERTY
AND
CASUALTY
CLAIM
• 837
• 2010CA
• REFNUMBER

IMPLEMENTATION

PROPERTY AND CASUALTY CLAIM NUMBER
Loop: 2010CA — PATIENT NAME
Usage: SITUATIONAL
Repeat: 1
Notes:

3
106

1. In the case where the patient is the same person as the subscriber,
the property and casualty claim number is placed in Loop ID-2010BA.
In the case where the patient is a different person than the subscriber,
this number is placed in Loop ID-2010CA. This number should be
transmitted in only one place.

7
185

2. This is a property and casualty payer-assigned claim number. It is
required on property and casualty claims. Providers receive this
number from the property and casualty payer during eligibility
determinations or some other communication with that payer. See
Section 4.2, Property and Casualty, for additional information about
property and casualty claims.

New
3 Note Added
188

3. Not required for HIPAA (The statutory definition of a health plan does
not specifically include workers’ compensation programs, property
and casualty programs, or disability insurance programs, and,
consequently, we are not requiring them to comply with the
standards.) but may be required for other uses.

Example: REF✽Y4✽4445555~

5
241
STANDARD

REF Reference Identification
Level: Detail
Position: 035
Loop: 2010
Requirement: Optional
Max Use: 20
Purpose: To specify identifying information
Syntax:

1. R0203
At least one of REF02 or REF03 is required.

DIAGRAM

REF01

REF

✽

M

OCTOBER 2002

128

Reference
Ident Qual
ID

2/3

REF02

127

Reference
Ident

✽
X

AN 1/30

REF03

352

✽ Description ✽
X

AN 1/80

REF04

C040

Reference
Identifier

~

O

Original Page Number 168 dated May 2000

21

004010X098A1 • 837 • 2300 • CLM
CLAIM INFORMATION

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

CLAIM
004010X098A1
INFORMATION
• 837 • 2300 • CLM

REQUIRED

CLM05 - 3

1325

Claim Frequency Type Code

O

ID

1/1

Code specifying the frequency of the claim; this is the third position of
the Uniform Billing Claim Form Bill Type
INDUSTRY: Claim

Note and Codes Deleted

ALIAS: Claim

Frequency Code

Submission Reason Code

CODE SOURCE 235:

REQUIRED

CLM06

1073

Claim Frequency Type Code

Yes/No Condition or Response Code

O

ID

1/1

Code indicating a Yes or No condition or response
INDUSTRY: Provider
ALIAS: Provider

or Supplier Signature Indicator

Signature on File

CLM06 is provider signature on file indicator. A “Y” value indicates the
provider signature is on file; an “N” value indicates the provider signatue is not on
file.

SEMANTIC:

NSF Reference:

1475
1475

EA0-37.0
CODE

REQUIRED

CLM07

1359

DEFINITION

N

No

Y

Yes

Provider Accept Assignment Code

O

ID

1/1

Code indicating whether the provider accepts assignment
INDUSTRY: Medicare

Assignment Code

2438
2438

NSF Reference:

1208

CLM07 indicates whether the provider accepts Medicare
assignment.

2439

The NSF mapping to FA0-59.0 occurs only in payer-to-payer COB
situations.

EA0-36.0, FA0-59.0

CODE

22

DEFINITION

A

Assigned

B

Assignment Accepted on Clinical Lab Services Only

C

Not Assigned

P

Patient Refuses to Assign Benefits

Original Page Number 173 dated May 2000

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

SITUATIONAL

CLM10

1351

004010X098A1 • 837 • 2300 • CLM
CLAIM INFORMATION

Patient Signature Source Code

O

ID

1/1

Code indicating how the patient or subscriber authorization signatures were
obtained and how they are being retained by the provider
ALIAS: Patient

Signature Source Code

1479
1479

NSF Reference:

1209

CLM10 is required except in cases where code ‘‘N’’ is used in
CLM09.

DA0-16.0

CODE

SITUATIONAL

CLM11

C024

DEFINITION

B

Signed signature authorization form or forms for
both HCFA-1500 Claim Form block 12 and block 13
are on file

C

Signed HCFA-1500 Claim Form on file

M

Signed signature authorization form for HCFA-1500
Claim Form block 13 on file

P

Signature generated by provider because the patient
was not physically present for services

S

Signed signature authorization form for HCFA-1500
Claim Form block 12 on file

RELATED CAUSES INFORMATION

O

To identify one or more related causes and associated state or country information

1220

ALIAS: Accident/Employment/Related

1210

CLM11-1, CLM11-2, or CLM11-3 are required when the condition
being reported is accident or employment related. If CLM11-1,
CLM11-2, or CLM11-3 equals AP, then map Yes to EA0-09.0.

2440

If DTP - Date of Accident (DTP01=439) is used, then CLM11 is
required.

REQUIRED

CLM11 - 1

1362

Causes

Related-Causes Code

M

ID

2/3

Code identifying an accompanying cause of an illness, injury or an
accident
INDUSTRY: Related

Causes Code

NSF Reference:

1849
1849

EA0-05.0 - Auto Accident or Other Accident, EA0-04.0 Employment, EA0-09.0 - Responsibility Indicator
CODE

DEFINITION

AA

Auto Accident

AP

Another Party Responsible

EM

Employment

OA

Other Accident

Code AB Deleted

OCTOBER 2002

Original Page Number 176 dated May 2000

23

004010X098A1 • 837 • 2300 • CLM
CLAIM INFORMATION

SITUATIONAL

CLM11 - 2

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

1362

Related-Causes Code

O

ID

2/3

Code identifying an accompanying cause of an illness, injury or an
accident
INDUSTRY: Related

Causes Code

1849
1849

NSF Reference:

2442

Used if more than one code applies.

EA0-05.0 - Auto Accident or Other Accident, EA0-04.0 Employment, EA0-09.0 - Responsibility Indicator

CODE

DEFINITION

AA

Auto Accident

AP

Another Party Responsible

EM

Employment

OA

Other Accident

Code AB Deleted

SITUATIONAL

CLM11 - 3

1362

Related-Causes Code

O

ID

2/3

Code identifying an accompanying cause of an illness, injury or an
accident
INDUSTRY: Related

Causes Code

1849
1849

NSF Reference:

2442

Used if more than one code applies.

EA0-05.0 - Auto Accident or Other Accident, EA0-04.0 Employment, EA0-09.0 - Responsibility Indicator

CODE

DEFINITION

AA

Auto Accident

AP

Another Party Responsible

EM

Employment

OA

Other Accident

Code AB Deleted

SITUATIONAL

CLM11 - 4

156

State or Province Code

O

ID

2/2

Code (Standard State/Province) as defined by appropriate government
agency
INDUSTRY: Auto

Accident State or Province Code

CODE SOURCE 22:

States and Outlying Areas of the U.S.

1482
1482

NSF Reference:

2441

Required if CLM11-1, -2, or -3 = AA to identify the state in
which the automobile accident occurred. Use state postal
code (CA = California, UT = Utah, etc).

24

EA0-10.0

Original Page Number 177 dated May 2000

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

SITUATIONAL

CLM11 - 5

004010X098A1 • 837 • 2300 • CLM
CLAIM INFORMATION

26

Country Code

O

ID

2/3

Code identifying the country
CODE SOURCE 5:

Required if the automobile accident occurred out of the
United States to identify the country in which the accident
occurred.

1006
SITUATIONAL

Countries, Currencies and Funds

CLM12

1366

Special Program Code

O

ID

2/3

Code indicating the Special Program under which the services rendered to the
patient were performed
INDUSTRY: Special
ALIAS: Special

Program Indicator

Program Code

1483
1483

NSF Reference:

2443

Required if the services were rendered under one of the following
circumstances/programs/projects.

EA0-43.0

CODE

DEFINITION

01

Early & Periodic Screening, Diagnosis, and
Treatment (EPSDT) or Child Health Assessment
Program (CHAP)

02

Physically Handicapped Children’s Program

03

Special Federal Funding
This code is used for Medicaid claims only.

2029
05

Disability
This code is used for Medicaid claims only.

2029
Note Added

07

Induced Abortion - Danger to Life
This code is used for Medicaid claims only.

2029
08

Induced Abortion - Rape or Incest
This code is used for Medicaid claims only.

2029
09

Second Opinion or Surgery
This code is used for Medicaid claims only.

2029
NOT USED

CLM13

1073

Yes/No Condition or Response Code

O

ID

1/1

NOT USED

CLM14

1338

Level of Service Code

O

ID

1/3

NOT USED

CLM15

1073

Yes/No Condition or Response Code

O

ID

1/1

OCTOBER 2002

Original Page Number 178 dated May 2000

25

004010X098A1 • 837 • 2300 • DTP
DATE - INITIAL TREATMENT
DATE OR TIME OR PERIOD

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

DATE
004010X098A1
- INITIAL TREATMENT
• 837 • 2300 • DTP

IMPLEMENTATION

DATE - INITIAL TREATMENT
Loop: 2300 — CLAIM INFORMATION
Usage: SITUATIONAL
Repeat: 1
Notes:

7
100

1. Dates in Loop ID-2300 apply to all service lines within Loop ID-2400
unless a DTP segment occurs in Loop ID-2400 with the same value in
DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in
Loop ID-2300 for that service line only.
2. Required on all claims involving spinal manipulation for Medicare Part
B.

Replaced
014
100 Note 2.
8

Example: DTP✽454✽D8✽19970115~

9
124
STANDARD

DTP Date or Time or Period
Level: Detail
Position: 135
Loop: 2300
Requirement: Optional
Max Use: 150
Purpose: To specify any or all of a date, a time, or a time period
DIAGRAM

DTP01

DTP ✽

374

Date/Time
Qualifier
M

ID

3/3

DTP02

✽

1250

Date Time
format Qual
M

ID

DTP03

✽

2/3

1251

Date Time
Period
M

~

AN 1/35

ELEMENT SUMMARY

USAGE

REQUIRED

REF.
DES.

DTP01

DATA
ELEMENT

374

NAME

ATTRIBUTES

Date/Time Qualifier

M

ID

3/3

M

ID

2/3

Code specifying type of date or time, or both date and time
INDUSTRY: Date
CODE

454
REQUIRED

DTP02

1250

Time Qualifier
DEFINITION

Initial Treatment

Date Time Period Format Qualifier

Code indicating the date format, time format, or date and time format
SEMANTIC:

DTP02 is the date or time or period format that will appear in DTP03.

CODE

D8

26

Original Page Number 182 dated May 2000

DEFINITION

Date Expressed in Format CCYYMMDD

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X098A1 • 837 • 2300 • DTP
DATE - DATE LAST SEEN

DATE
004010X098A1
- DATE LAST
• 837SEEN
• 2300 • DTP

IMPLEMENTATION

DATE - DATE LAST SEEN
Loop: 2300 — CLAIM INFORMATION
Usage: SITUATIONAL
Repeat: 1
Notes:

9
186

1. Required when claims involve services from an independent physical
therapist, occupational therapist, or physician services involving
routine foot care and it is known to impact the payer’s adjudication
process.

Note 1. Changed

2. This is the date that the patient was seen by the attending/supervising
physician for the qualifying medical condition related to the services
performed.

5
245

Example: DTP✽304✽D8✽19970115~

0
125
STANDARD

DTP Date or Time or Period
Level: Detail
Position: 135
Loop: 2300
Requirement: Optional
Max Use: 150
Purpose: To specify any or all of a date, a time, or a time period
DIAGRAM

DTP01

DTP ✽

374

Date/Time
Qualifier
M

ID

3/3

DTP02

✽

1250

Date Time
format Qual
M

ID

DTP03

✽

2/3

1251

Date Time
Period
M

~

AN 1/35

ELEMENT SUMMARY

USAGE

REQUIRED

REF.
DES.

DTP01

DATA
ELEMENT

374

NAME

ATTRIBUTES

Date/Time Qualifier

M

ID

3/3

M

ID

2/3

Code specifying type of date or time, or both date and time
INDUSTRY: Date
CODE

304
REQUIRED

DTP02

1250

Time Qualifier
DEFINITION

Latest Visit or Consultation

Date Time Period Format Qualifier

Code indicating the date format, time format, or date and time format
SEMANTIC:

DTP02 is the date or time or period format that will appear in DTP03.

CODE

D8

OCTOBER 2002

DEFINITION

Date Expressed in Format CCYYMMDD

Original Page Number 186 dated May 2000

27

004010X098A1 • 837 • 2300 • DTP
DATE - DISABILITY BEGIN

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

DATE
004010X098A1
- DISABILITY
BEGIN
• 837
• 2300 • DTP

IMPLEMENTATION

DATE - DISABILITY BEGIN
Loop: 2300 — CLAIM INFORMATION
Usage: SITUATIONAL
Repeat: 5
Notes:

1
204

1. Required on claims involving disability where, in the opinion of the
provider, the patient was or will be unable to perform the duties
normally associated with his/her work.

New
5 Note 2. Added
187

2. Not required for HIPAA but may be required for other uses. (The
statutory definition of a health plan does not specifically include
workers compensation programs, property and casualty programs, or
disability insurance programs.)

Example: DTP✽360✽D8✽19970114~

9
125
STANDARD

DTP Date or Time or Period
Level: Detail
Position: 135
Loop: 2300
Requirement: Optional
Max Use: 150
Purpose: To specify any or all of a date, a time, or a time period
DIAGRAM

DTP01

DTP ✽

374

Date/Time
Qualifier
M

ID

3/3

DTP02

✽

1250

Date Time
format Qual
M

ID

DTP03

✽

2/3

1251

Date Time
Period
M

~

AN 1/35

ELEMENT SUMMARY

USAGE

REQUIRED

REF.
DES.

DTP01

DATA
ELEMENT

374

NAME

ATTRIBUTES

Date/Time Qualifier

M

ID

3/3

M

ID

2/3

Code specifying type of date or time, or both date and time
INDUSTRY: Date
CODE

360
REQUIRED

DTP02

1250

Time Qualifier
DEFINITION

Disability Begin

Date Time Period Format Qualifier

Code indicating the date format, time format, or date and time format
SEMANTIC:

DTP02 is the date or time or period format that will appear in DTP03.

CODE

D8

28

Original Page Number 201 dated May 2000

DEFINITION

Date Expressed in Format CCYYMMDD

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X098A1 • 837 • 2300 • DTP
DATE - DISABILITY END

DATE
004010X098A1
- DISABILITY
END
• 837
• 2300 • DTP

IMPLEMENTATION

DATE - DISABILITY END
Loop: 2300 — CLAIM INFORMATION
Usage: SITUATIONAL
Repeat: 5
Notes:

8
245

1. Required on claims/encounters involving disability where, in the
opinion of the provider, the patient, after having been absent from
work for reasons related to the disability, was or will be able to
perform the duties normally associated with his/her work.

New
5 Note 2. Added
187

2. Not required for HIPAA but may be required for other uses. (The
statutory definition of a health plan does not specifically include
workers compensation programs, property and casualty programs, or
disability insurance programs.)

Example: DTP✽361✽D8✽19970613~

0
126
STANDARD

DTP Date or Time or Period
Level: Detail
Position: 135
Loop: 2300
Requirement: Optional
Max Use: 150
Purpose: To specify any or all of a date, a time, or a time period
DIAGRAM

DTP01

DTP ✽

374

Date/Time
Qualifier
M

ID

3/3

DTP02

✽

1250

Date Time
format Qual
M

ID

DTP03

✽

2/3

1251

Date Time
Period
M

~

AN 1/35

ELEMENT SUMMARY

USAGE

REQUIRED

REF.
DES.

DTP01

DATA
ELEMENT

374

NAME

ATTRIBUTES

Date/Time Qualifier

M

ID

3/3

Code specifying type of date or time, or both date and time
INDUSTRY: Date
CODE

361

OCTOBER 2002

Time Qualifier
DEFINITION

Disability End

Original Page Number 203 dated May 2000

29

004010X098A1 • 837 • 2300 • AMT
PATIENT AMOUNT PAID

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

PATIENT
004010X098A1
AMOUNT
PAID
• 837
• 2300 • AMT

IMPLEMENTATION

PATIENT AMOUNT PAID
Loop: 2300 — CLAIM INFORMATION
Usage: SITUATIONAL
Repeat: 1

3
122

Notes:
Note Changed

1. Required when patient has made payment specifically toward this
claim.

2
130

2. Patient Amount Paid refers to the sum of all amounts paid on the
claim by the patient or his/her representative(s).

Note 3. Deleted
Example: AMT✽F5✽152.45~
5
126
STANDARD

AMT Monetary Amount
Level: Detail
Position: 175
Loop: 2300
Requirement: Optional
Max Use: 40
Purpose: To indicate the total monetary amount
DIAGRAM

AMT01

AMT

522

AMT02

✽ Amount Qual ✽
Code

M

ID

1/3

782

Monetary
Amount
M

R

AMT03

✽

1/18

478

Cred/Debit
Flag Code
O

ID

~

1/1

ELEMENT SUMMARY

USAGE

REF.
DES.

REQUIRED

AMT01

DATA
ELEMENT

522

NAME

ATTRIBUTES

Amount Qualifier Code

M

ID

1/3

M

R

1/18

O

ID

1/1

Code to qualify amount
CODE

F5
REQUIRED

AMT02

782

DEFINITION

Patient Amount Paid

Monetary Amount
Monetary amount
INDUSTRY: Patient

NSF Reference:

1500
1500
NOT USED

30

Amount Paid

XA0-19.0
AMT03

478

Credit/Debit Flag Code

Original Page Number 220 dated May 2000

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X098A1 • 837 • 2300 • AMT
TOTAL PURCHASED SERVICE AMOUNT

TOTAL
004010X098A1
PURCHASED
2300 • AMT
AMOUNT
• 837 •SERVICE

IMPLEMENTATION

TOTAL PURCHASED SERVICE AMOUNT
Loop: 2300 — CLAIM INFORMATION
Usage: SITUATIONAL
Repeat: 1
Notes:

1
121

1. Required if there are purchased service components to this claim.

New Note Added
189
0

2. Use this segment on vision claims when the acquisition cost of lenses
is known to impact adjudication or reimbursement.

0
203

3. Required on service lines when the purchased service charge amount
is necessary for processing.
Example: AMT✽NE✽57.35~

6
126
STANDARD

AMT Monetary Amount
Level: Detail
Position: 175
Loop: 2300
Requirement: Optional
Max Use: 40
Purpose: To indicate the total monetary amount
DIAGRAM

AMT01

AMT

522

AMT02

✽ Amount Qual ✽
Code
M

ID

1/3

782

Monetary
Amount
M

R

AMT03

✽

1/18

478

Cred/Debit
Flag Code
O

ID

~

1/1

ELEMENT SUMMARY

USAGE

REF.
DES.

REQUIRED

AMT01

DATA
ELEMENT

522

NAME

ATTRIBUTES

Amount Qualifier Code

M

ID

1/3

Code to qualify amount
CODE

DEFINITION

NE

Net Billed
Use this code to indicate Total Purchased Service
Charges.

1267
REQUIRED

AMT02

782

Monetary Amount

M

R

1/18

Monetary amount
INDUSTRY: Total

1501
1501
OCTOBER 2002

Purchased Service Amount

NSF Reference:
EA0-31.0

Original Page Number 221 dated May 2000

31

004010X098A1 • 837 • 2300 • REF
MAMMOGRAPHY CERTIFICATION NUMBER

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

MAMMOGRAPHY
004010X098A1 • 837
CERTIFICATION
• 2300 • REF NUMBER

IMPLEMENTATION

MAMMOGRAPHY CERTIFICATION NUMBER
Loop: 2300 — CLAIM INFORMATION
Usage: SITUATIONAL
Repeat: 1
Notes:

4
268

1. Required when mammography services are rendered by a certified
mammography provider.

Note Changed

Example: REF✽EW✽T554~

8
136
STANDARD

REF Reference Identification
Level: Detail
Position: 180
Loop: 2300
Requirement: Optional
Max Use: 30
Purpose: To specify identifying information
Syntax:

1. R0203
At least one of REF02 or REF03 is required.

DIAGRAM

REF01

REF

✽

128

Reference
Ident Qual
M

ID

2/3

REF02

127

Reference
Ident

✽
X

REF03

352

REF04

✽ Description ✽

AN 1/30

X

AN 1/80

C040

Reference
Identifier

~

O

ELEMENT SUMMARY

USAGE

REF.
DES.

REQUIRED

REF01

DATA
ELEMENT

128

NAME

ATTRIBUTES

Reference Identification Qualifier

M

ID

2/3

AN

1/30

Code qualifying the Reference Identification
CODE

EW
REQUIRED

REF02

127

DEFINITION

Mammography Certification Number

Reference Identification

X

Reference information as defined for a particular Transaction Set or as specified
by the Reference Identification Qualifier
INDUSTRY: Mammography
SYNTAX:

Certification Number

R0203

NSF Reference:

1614
1614

FA0-31.0

NOT USED

REF03

352

Description

X

NOT USED

REF04

C040

REFERENCE IDENTIFIER

O

32

Original Page Number 226 dated May 2000

AN

1/80

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X098A1 • 837 • 2300 • CR2
SPINAL MANIPULATION SERVICE INFORMATION

SPINAL
004010X098A1
MANIPULATION
SERVICE
• 837 • 2300
• CR2 INFORMATION

IMPLEMENTATION

SPINAL MANIPULATION SERVICE
INFORMATION
Loop: 2300 — CLAIM INFORMATION
Usage: SITUATIONAL
Repeat: 1
Notes:

5
101

1. The CR2 segment in Loop ID-2300 applies to the entire claim unless
overridden by the presence of a CR2 segment in Loop ID-2400.
2. Required on chiropractic claims involving spinal manipulation and
known to impact payer’s adjudication process.

2Note 2. Changed
203

Example Changed

Example: CR2✽✽✽✽✽✽✽✽M✽✽✽✽Y~

7
244
STANDARD

CR2 Chiropractic Certification
Level: Detail
Position: 200
Loop: 2300
Requirement: Optional
Max Use: 1
Purpose: To supply information related to the chiropractic service rendered to a patient
Syntax:

1. P0102
If either CR201 or CR202 is present, then the other is required.
2. C0403
If CR204 is present, then CR203 is required.
3. P0506
If either CR205 or CR206 is present, then the other is required.
Usage Changed

DIAGRAM

CR201

609

Count

CR2 ✽
X

N0

CR207

✽
X

380

CR208

O

R

1/15

✽

380

Quantity

1/9

Quantity

✽

CR202

R

ID

1367

CR204

1367

CR205

✽ Subluxation ✽ Subluxation ✽
Level Code
Level Code

1/15

X

1342

Nature of
Cond Code
O

CR203

ID

CR209

2/3

1073

✽ Yes/No Cond ✽
Resp Code

1/1

O

ID

1/1

O

ID

CR210

2/3

X

352

CR211

Description
O

AN 1/80

✽

355

Unit/Basis
Meas Code
ID

X

352

380

Quantity

✽

2/2

Description
O

CR206

R

CR212

1/15

1073

✽ Yes/No Cond ~
Resp Code

AN 1/80

O

ID

1/1

ELEMENT SUMMARY

Usage Changed
USAGE

REF.
DES.

DATA
ELEMENT

NAME

ATTRIBUTES

NOT USED

CR201

609

Count

X

N0

1/9

NOT USED

CR202

380

Quantity

X

R

1/15

Usage Changed
OCTOBER 2002

Original Page Numbers 251 to 252 dated May 2000

33

004010X098A1 • 837 • 2300 • CR2
SPINAL MANIPULATION SERVICE INFORMATION

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

NOT USED

CR203

1367

Subluxation Level Code

X

ID

2/3

NOT USED

CR204

1367

Subluxation Level Code

O

ID

2/3

NOT USED

CR205

355

Unit or Basis for Measurement Code

X

ID

2/2

NOT USED

CR206

380

Quantity

X

R

1/15

NOT USED

CR207

380

Quantity

O

R

1/15

REQUIRED

CR208

1342

Nature of Condition Code

O

ID

1/1

Code indicating the nature of a patient’s condition
INDUSTRY: Patient

Usage Changed

ALIAS: Nature

Condition Code

of Condition Code. Spinal Manipulation

NSF Reference:

1514
1514

GC0-11.0
CODE

NOT USED

CR209

1073

SITUATIONAL

CR210

352

DEFINITION

A

Acute Condition

C

Chronic Condition

D

Non-acute

E

Non-Life Threatening

F

Routine

G

Symptomatic

M

Acute Manifestation of a Chronic Condition

Yes/No Condition or Response Code

O

ID

1/1

Description

O

AN

1/80

A free-form description to clarify the related data elements and their content
INDUSTRY: Patient
ALIAS: Patient
SEMANTIC:

Condition Description

Condition Description. Spinal Manipulation

CR210 is a description of the patient’s condition.

1516
1516

NSF Reference:

2225

Used at discretion of submitter.

SITUATIONAL

GC0-14.0

CR211

352

Description

O

AN

1/80

A free-form description to clarify the related data elements and their content
INDUSTRY: Patient
ALIAS: Patient
SEMANTIC:

Condition Description

Condition Description. Spinal Manipulation

CR211 is an additional description of the patient’s condition.

1516
1516

NSF Reference:

2225

Used at discretion of submitter.

34

GC0-14.0

Original Page Numbers 252 to 256 dated May 2000

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

SITUATIONAL

CR212

1073

004010X098A1 • 837 • 2300 • CR2
SPINAL MANIPULATION SERVICE INFORMATION

Yes/No Condition or Response Code

O

ID

1/1

Code indicating a Yes or No condition or response

Usage Changed

INDUSTRY: X-ray
ALIAS: X-ray

Availability Indicator

Availability Indicator. Spinal Manipulation

CR212 is X-rays availability indicator. A “Y” value indicates X-rays are
maintained and available for carrier review; an “N” value indicates X-rays are not
maintained and available for carrier review.

SEMANTIC:

1692
1692

NSF Reference:

New Note Added
2610

Required for service dates prior to January 1, 2000.

GC0-15.0

CODE

OCTOBER 2002

DEFINITION

N

No

Y

Yes

Original Page Number 256 dated May 2000

35

004010X098A1 • 837 • 2300 • CRC
PATIENT CONDITION INFORMATION: VISION

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

PATIENT
004010X098A1
CONDITION
2300 • CRC VISION
• 837 •INFORMATION:

IMPLEMENTATION

PATIENT CONDITION INFORMATION: VISION
Loop: 2300 — CLAIM INFORMATION
Usage: SITUATIONAL
Repeat: 3
Notes:

7
248

1. Required on vision claims/encounters involving replacement lenses
or frames when this information is known to impact reimbursement.

Note Changed

Example: CRC✽E1✽Y✽L1~

6
248
STANDARD

CRC Conditions Indicator
Level: Detail
Position: 220
Loop: 2300
Requirement: Optional
Max Use: 100
Purpose: To supply information on conditions
DIAGRAM

CRC01

CRC ✽
M

ID

CRC07

✽

1136

Code
Category
2/2

ID

1073

M

ID

1/1

CRC03

1321

Certificate
Cond Code
M

ID

2/2

CRC04

✽

1321

Certificate
Cond Code
O

ID

2/2

CRC05

✽

1321

Certificate
Cond Code
O

ID

CRC06

✽

2/2

1321

Certificate
Cond Code
O

ID

2/2

1321

Certificate
Cond Code
O

CRC02

✽ Yes/No Cond ✽
Resp Code

~

2/2

ELEMENT SUMMARY

USAGE

REF.
DES.

REQUIRED

CRC01

DATA
ELEMENT

1136

NAME

ATTRIBUTES

Code Category

M

ID

2/2

Specifies the situation or category to which the code applies
SEMANTIC:

CRC01 qualifies CRC03 through CRC07.

CODE

36

DEFINITION

E1

Spectacle Lenses

E2

Contact Lenses

E3

Spectacle Frames

Original Page Number 260 dated May 2000

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X098A1 • 837 • 2300 • CRC
EPSDT REFERRAL

New Segment Added

EPSDT
004010X098A1
REFERRAL
• 837 • 2300 • CRC

IMPLEMENTATION

EPSDT REFERRAL
Loop: 2300 — CLAIM INFORMATION
Usage: SITUATIONAL
Repeat: 1
Notes:

011
100
7

1. Required on Early & Periodic Screening, Diagnosis, and Treatment
(EPSDT) claims/encounters.

Example: CRC✽ZZ✽Y✽ST~

0
245
STANDARD

CRC Conditions Indicator
Level: Detail
Position: 220
Loop: 2300
Requirement: Optional
Max Use: 100
Purpose: To supply information on conditions
DIAGRAM

CRC01

CRC ✽
M

ID

CRC07

✽

1136

Code
Category
2/2

ID

1073

M

ID

1/1

CRC03

1321

Certificate
Cond Code
M

ID

2/2

CRC04

✽

1321

Certificate
Cond Code
O

ID

2/2

CRC05

✽

1321

Certificate
Cond Code
O

ID

CRC06

✽

2/2

1321

Certificate
Cond Code
O

ID

2/2

1321

Certificate
Cond Code
O

CRC02

✽ Yes/No Cond ✽
Resp Code

~

2/2

ELEMENT SUMMARY

USAGE

REF.
DES.

REQUIRED

CRC01

DATA
ELEMENT

1136

NAME

ATTRIBUTES

Code Category

M

ID

2/2

Specifies the situation or category to which the code applies
SEMANTIC:

CRC01 qualifies CRC03 through CRC07.

CODE

ZZ

1000118

OCTOBER 2002

DEFINITION

Mutually Defined
EPSDT Screening referral information.

New Page inserted after page 264 dated May 2000

37

004010X098A1 • 837 • 2300 • CRC
EPSDT REFERRAL

REQUIRED

CRC02

New Segment Added
1073

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

Yes/No Condition or Response Code

M

ID

1/1

Code indicating a Yes or No condition or response
INDUSTRY: Certification
ALIAS: Certification

Condition Indicator

Condition Code Applies Indicator

CRC02 is a Certification Condition Code applies indicator. A “Y” value
indicates the condition codes in CRC03 through CRC07 apply; an “N” value
indicates the condition codes in CRC03 through CRC07 do not apply.

SEMANTIC:

Was an EPSDT referral given to the patient?

1000119

CODE

N

No
If no, then choose “NU” in CRC03 indicating no
referral given.

1000120
Y
REQUIRED

DEFINITION

CRC03

1321

Yes

Condition Indicator

M

ID

2/2

Code indicating a condition
INDUSTRY: Condition
ALIAS: Condition

Indicator

The codes for CRC03 also can be used for CRC04 through CRC07.

1029

CODE

AV

DEFINITION

Available - Not Used
Patient refused referral.

1000121
NU

Not Used
This conditioner indicator must be used when the
submitter answers “N” in CRC02.

1000122
S2

Under Treatment
Patient is currently under treatment for referred
diagnostic or corrective health problem.

1000123
ST

New Services Requested
Referral to another provider for diagnostic or
corrective treatment/scheduled for another
appointment with screening provider for diagnostic
or corrective treatment for at least one health
problem identified during an initial or periodic
screening service (not including dental referrals).

2453

SITUATIONAL

Code

CRC04

1321

Condition Indicator

O

ID

2/2

Code indicating a condition
INDUSTRY: Condition

Code

2488

Use codes listed in CRC03.

1782

Required if additional condition codes are needed.

38 New Page inserted after page 264 dated May 2000

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

New Segment Added

SITUATIONAL

Condition Indicator

CRC05

1321

004010X098A1 • 837 • 2300 • CRC
EPSDT REFERRAL

O

ID

2/2

Code indicating a condition
INDUSTRY: Condition

Code

2488

Use codes listed in CRC03.

1782

Required if additional condition codes are needed.

NOT USED

CRC06

1321

Condition Indicator

O

ID

2/2

NOT USED

CRC07

1321

Condition Indicator

O

ID

2/2

OCTOBER 2002

New Page inserted after page 264 dated May 2000

39

004010X098A1 • 837 • 2310A • PRV
REFERRING PROVIDER SPECIALTY INFORMATION

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

REFERRING
004010X098A1
PROVIDER
SPECIALTY
• 837 • 2310A
• PRV INFORMATION

IMPLEMENTATION

REFERRING PROVIDER SPECIALTY
INFORMATION
Loop: 2310A — REFERRING PROVIDER NAME
Usage: SITUATIONAL
Repeat: 1
Notes:

3
102

1. The PRV segment in Loop ID-2310 applies to the entire claim unless
overridden on the service line level by the presence of a PRV segment
with the same value in PRV01.

Note
3 2. Changed
194

2. Required when adjudication is known to be impacted by provider
taxonomy code.

3
279

3. PRV02 qualifies PRV03.

4
102

Example: PRV✽RF✽ZZ✽363LP0200N~

STANDARD

PRV Provider Information
Level: Detail
Position: 255
Loop: 2310
Requirement: Optional
Max Use: 1
Purpose: To specify the identifying characteristics of a provider
DIAGRAM

PRV01

1221

Provider
Code

PRV ✽
M

ID

1/3

PRV02

✽

128

Reference
Ident Qual
M

ID

PRV03

✽

2/3

127

Reference
Ident
M

AN 1/30

PRV04

156

State or
Prov Code

✽

O

ID

2/2

PRV05

C035

Provider
Spec. Inf.

✽

PRV06

✽

O

1223

Provider
Org Code
O

ID

~

3/3

ELEMENT SUMMARY

USAGE

REF.
DES.

REQUIRED

PRV01

DATA
ELEMENT

1221

NAME

ATTRIBUTES

Provider Code

M

ID

1/3

Code indentifying the type of provider
CODE

RF

40

Original Page Number 285 dated May 2000

DEFINITION

Referring

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X098A1 • 837 • 2310B • PRV
RENDERING PROVIDER SPECIALTY INFORMATION

RENDERING
004010X098A1
PROVIDER
SPECIALTY
• 837 • 2310B
• PRV INFORMATION

IMPLEMENTATION

RENDERING PROVIDER SPECIALTY
INFORMATION
Loop: 2310B — RENDERING PROVIDER NAME
Usage Changed
Usage: SITUATIONAL
Repeat: 1
Notes:

3
102

1. The PRV segment in Loop ID-2310 applies to the entire claim unless
overridden on the service line level by the presence of a PRV segment
with the same value in PRV01.

3
279

2. PRV02 qualifies PRV03.

New Note Added
194
3

3. Required when adjudication is known to be impacted by provider
taxonomy code.

Example: PRV✽PE✽ZZ✽203BA0200N~

8
123
STANDARD

PRV Provider Information
Level: Detail
Position: 255
Loop: 2310
Requirement: Optional
Max Use: 1
Purpose: To specify the identifying characteristics of a provider
DIAGRAM

PRV01

1221

Provider
Code

PRV ✽
M

ID

1/3

PRV02

✽

128

Reference
Ident Qual
M

ID

PRV03

✽

2/3

127

Reference
Ident
M

AN 1/30

PRV04

156

State or
Prov Code

✽

O

ID

2/2

PRV05

C035

Provider
Spec. Inf.

✽

PRV06

✽

O

1223

Provider
Org Code
O

ID

~

3/3

ELEMENT SUMMARY

USAGE

REF.
DES.

REQUIRED

PRV01

DATA
ELEMENT

1221

NAME

ATTRIBUTES

Provider Code

M

ID

1/3

Code indentifying the type of provider
CODE

PE

OCTOBER 2002

DEFINITION

Performing

Original Page Number 293 dated May 2000

41

004010X098A1 • 837 • 2310C • NM1
PURCHASED SERVICE PROVIDER NAME

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

Usage Changed

004010X098A1SERVICE
PURCHASED
PROVIDER
• 837 • 2310C
• NM1NAME

DIAGRAM

NM101

98

Entity ID
Code

NM1 ✽
M

ID

NM107

O

✽

2/3

ID

ID

1035

Name Last/
Org Name

✽

O

66

NM109

ID Code
Qualifier
X

NM103

1/1

NM108

✽

AN 1/10

1065

Entity Type
Qualifier
M

1039

Name
Suffix

✽

NM102

✽
X

O

67

X

ID

O

706

1037

Name
Middle

✽

Entity
Relat Code

✽

NM105

AN 1/25

NM110

AN 2/80

1036

Name
First

✽

AN 1/35

ID
Code

1/2

NM104

O

ID

O

AN 1/10

98

Entity ID
Code

✽

1038

Name
Prefix

✽

AN 1/25

NM111

2/2

NM106

~

2/3

ELEMENT SUMMARY

USAGE

REF.
DES.

REQUIRED

NM101

DATA
ELEMENT

98

NAME

ATTRIBUTES

Entity Identifier Code

M

ID

2/3

Code identifying an organizational entity, a physical location, property or an
individual
CODE

QB
REQUIRED

NM102

1065

DEFINITION

Purchase Service Provider

Entity Type Qualifier

M

ID

1/1

O

AN

1/35

O

AN

1/25

O

AN

1/25

Code qualifying the type of entity
SEMANTIC:

NM102 qualifies NM103.

CODE

REQUIRED

NM103

1035

DEFINITION

1

Person

2

Non-Person Entity

Name Last or Organization Name
Individual last name or organizational name

SITUATIONAL

NM104

1036

Name First
Individual first name

Usage Changed

Required if NM102 = 1.

1000152
SITUATIONAL

NM105

1037

Name Middle
Individual middle name or initial

New Notes Added

Required if NM102=1 and the middle name/initial of the person is
known.

1000153
NOT USED

NM106

1038

Name Prefix

O

AN

1/10

NOT USED

NM107

1039

Name Suffix

O

AN

1/10

SITUATIONAL

NM108

66

Identification Code Qualifier

X

ID

1/2

Code designating the system/method of code structure used for Identification
Code (67)
SYNTAX:

2506

P0809

Required if either Employer’s Identification/Social Security Number
or National Provider Identifier is known.
CODE

24

42

Original Page Number 299 dated May 2000

DEFINITION

Employer’s Identification Number

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X098A1 • 837 • 2330C • NM1
OTHER PAYER PATIENT INFORMATION

004010X098A1
OTHER
PAYER•PATIENT
837 • 2330C
INFORMATION
• NM1

IMPLEMENTATION

OTHER PAYER PATIENT INFORMATION
Loop: 2330C — OTHER PAYER PATIENT INFORMATION Repeat: 1
Usage: SITUATIONAL
Repeat: 1
Notes:

0
256

1. Required when it is necessary, in COB situations, to send one or more
payer-specific patient identification numbers. The patient
identification number(s) carried in this iteration of the 2330 loop are
those patient ID’s which belong to non-destination (COB) payers. The
patient ID(s) forr the destination payer are carried in the 2010CA loop
NM1 and REF segments. See Section 1.4.5 Crosswalking COB Data
Elements for more information on handling non-destination payer
patient identifiers and other COB elements.
2. Because the usage of this segment is “Situational” this is not a
syntactically required loop. If this loop is used, then this segment is a
“Required” segment. See Appendix A for further details on ASC X12
syntax rules.

7
221

Example: NM1✽QC✽1✽✽✽✽✽✽MI✽6677U801~

9
255
STANDARD

NM1 Individual or Organizational Name
Level: Detail
Position: 325
Loop: 2330 Repeat: 10
Requirement: Optional
Max Use: 1
Purpose: To supply the full name of an individual or organizational entity
Set Notes:

1. Segments NM1-N4 contain name and address information of the insurance
carriers referenced in loop 2320.

Syntax:

1. P0809
If either NM108 or NM109 is present, then the other is required.
2. C1110
If NM111 is present, then NM110 is required.

Usage Changed

DIAGRAM

NM101

NM1

M

ID

NM107

O

NM102

✽

2/3

AN 1/10

1065

Entity Type
Qualifier
M

1039

Name
Suffix

✽

OCTOBER 2002

98

Entity ID
Code

✽

ID

O

66

NM109

ID Code
Qualifier
X

ID

1/2

1035

Name Last/
Org Name

1/1

NM108

✽

NM103

✽

AN 1/35

X

ID

2/2

1037

Name
Middle
O

706

Entity
Relat Code
X

NM105

✽

AN 1/25

NM110

✽

AN 2/80

1036

Name
First
O

67

ID
Code

✽

NM104

✽

AN 1/25

NM111

O

ID

1038

Name
Prefix
O

AN 1/10

98

Entity ID
Code

✽

NM106

✽

~

2/3

Original Page Number 374 dated May 2000

43

004010X098A1 • 837 • 2330C • NM1
OTHER PAYER PATIENT INFORMATION

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

ELEMENT SUMMARY

USAGE

REF.
DES.

REQUIRED

NM101

DATA
ELEMENT

98

NAME

ATTRIBUTES

Entity Identifier Code

M

ID

2/3

Code identifying an organizational entity, a physical location, property or an
individual
CODE

QC
REQUIRED

NM102

1065

DEFINITION

Patient

Entity Type Qualifier

M

ID

1/1

Code qualifying the type of entity
SEMANTIC:

NM102 qualifies NM103.

CODE

Usage Changed

1

DEFINITION

Person

NOT USED

NM103

1035

Name Last or Organization Name

O

AN

1/35

NOT USED

NM104

1036

Name First

O

AN

1/25

NOT USED

NM105

1037

Name Middle

O

AN

1/25

NOT USED

NM106

1038

Name Prefix

O

AN

1/10

NOT USED

NM107

1039

Name Suffix

O

AN

1/10

REQUIRED

NM108

66

Identification Code Qualifier

X

ID

1/2

Code designating the system/method of code structure used for Identification
Code (67)
SYNTAX:

P0809

CODE

MI

Member Identification Number
The code MI is intended to be the subscriber’s
identification number as assigned by the payer.
Payers use different terminology to convey the
same number. Therefore the 837 Professional
Workgroup recommends using MI - Member
Identification Number to convey the following terms:
Insured’s ID, Subscriber’s ID, Health Insurance
Claim Number (HIC), etc.

1000102

REQUIRED

DEFINITION

NM109

67

Identification Code

X

AN

2/80

Code identifying a party or other code
INDUSTRY: Other

Payer Patient Primary Identifier

ALIAS: Patient’s

Other Payer Primary Identification Number

SYNTAX:

P0809

NOT USED

NM110

706

Entity Relationship Code

X

ID

2/2

NOT USED

NM111

98

Entity Identifier Code

O

ID

2/3

44

Original Page Number 375 dated May 2000

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X098A1 • 837 • 2330D • NM1
OTHER PAYER REFERRING PROVIDER

004010X098A1
OTHER
PAYER•REFERRING
837 • 2330DPROVIDER
• NM1

IMPLEMENTATION

OTHER PAYER REFERRING PROVIDER
Loop: 2330D — OTHER PAYER REFERRING PROVIDER Repeat: 2
Usage: SITUATIONAL
Repeat: 1
Notes:

3
276

1. Used when it is necessary to send an additional payer-specific
provider identification number for non-destination (COB) payers.

7
221

2. Because the usage of this segment is “Situational” this is not a
syntactically required loop. If this loop is used, then this segment is a
“Required” segment. See Appendix A for further details on ASC X12
syntax rules.

0
280

3. See Section 1.4.5 Crosswalking COB Data Elements for more
information on handling COB in the 837.
Example: NM1✽DN✽1~

2
276
STANDARD

NM1 Individual or Organizational Name
Level: Detail
Position: 325
Loop: 2330 Repeat: 10
Requirement: Optional
Max Use: 1
Purpose: To supply the full name of an individual or organizational entity
Set Notes:

1. Segments NM1-N4 contain name and address information of the insurance
carriers referenced in loop 2320.

Syntax:

1. P0809
If either NM108 or NM109 is present, then the other is required.
2. C1110
If NM111 is present, then NM110 is required.
Usage Changed

DIAGRAM

NM101

98

Entity ID
Code

NM1 ✽
M

ID

NM107

O

✽

2/3

AN 1/10

1065

Entity Type
Qualifier
M

1039

Name
Suffix

✽

NM102

ID

O

66

NM109

ID Code
Qualifier
X

ID

✽

1/2

1035

Name Last/
Org Name

1/1

NM108

✽

NM103

X

O

67

ID

O

706

2/2

1037

Name
Middle

✽

Entity
Relat Code
X

NM105

AN 1/25

NM110

✽

AN 2/80

1036

Name
First

✽

AN 1/35

ID
Code

✽

NM104

ID

O

AN 1/10

98

Entity ID
Code
O

1038

Name
Prefix

✽

AN 1/25

NM111

✽

NM106

~

2/3

004010X098A1
OTHER
PAYER•REFERRING
837 • 2330DPROVIDER
• NM1

OCTOBER 2002

Original Page Number 378 dated May 2000

45

004010X098A1 • 837 • 2330D • NM1
OTHER PAYER REFERRING PROVIDER

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

ELEMENT SUMMARY

USAGE

REF.
DES.

REQUIRED

NM101

DATA
ELEMENT

98

NAME

ATTRIBUTES

Entity Identifier Code

M

ID

2/3

Code identifying an organizational entity, a physical location, property or an
individual
CODE

DN

Referring Provider
Use on first iteration of this loop. Use if loop is used
only once.

2764
P3

Primary Care Provider
Use only if loop is used twice. Use only on second
iteration of this loop.

2765
REQUIRED

DEFINITION

NM102

1065

Entity Type Qualifier

M

ID

1/1

Code qualifying the type of entity
SEMANTIC:

NM102 qualifies NM103.

CODE

DEFINITION

1

Person

2

Non-Person Entity

Usage Changed
NOT USED

NM103

1035

Name Last or Organization Name

O

AN

1/35

NOT USED

NM104

1036

Name First

O

AN

1/25

NOT USED

NM105

1037

Name Middle

O

AN

1/25

NOT USED

NM106

1038

Name Prefix

O

AN

1/10

NOT USED

NM107

1039

Name Suffix

O

AN

1/10

NOT USED

NM108

66

Identification Code Qualifier

X

ID

1/2

NOT USED

NM109

67

Identification Code

X

AN

2/80

NOT USED

NM110

706

Entity Relationship Code

X

ID

2/2

NOT USED

NM111

98

Entity Identifier Code

O

ID

2/3

46

Original Page Number 379 dated May 2000

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X098A1 • 837 • 2330E • NM1
OTHER PAYER RENDERING PROVIDER

OTHER
004010X098A1
PAYER•RENDERING
837 • 2330E PROVIDER
• NM1

IMPLEMENTATION

OTHER PAYER RENDERING PROVIDER
Loop: 2330E — OTHER PAYER RENDERING PROVIDER Repeat: 1
Usage: SITUATIONAL
Repeat: 1
Notes:

3
276

1. Used when it is necessary to send an additional payer-specific
provider identification number for non-destination (COB) payers.

7
221

2. Because the usage of this segment is “Situational” this is not a
syntactically required loop. If this loop is used, then this segment is a
“Required” segment. See Appendix A for further details on ASC X12
syntax rules.

0
280

3. See Section 1.4.5 Crosswalking COB Data Elements for more
information on handling COB in the 837.
Example: NM1✽82✽1~

8
276
STANDARD

NM1 Individual or Organizational Name
Level: Detail
Position: 325
Loop: 2330 Repeat: 10
Requirement: Optional
Max Use: 1
Purpose: To supply the full name of an individual or organizational entity
Set Notes:

1. Segments NM1-N4 contain name and address information of the insurance
carriers referenced in loop 2320.

Syntax:

1. P0809
If either NM108 or NM109 is present, then the other is required.
2. C1110
If NM111 is present, then NM110 is required.
Usage Changed

DIAGRAM

NM101

98

Entity ID
Code

NM1 ✽
M

ID

NM107

O

✽

2/3

AN 1/10

1065

Entity Type
Qualifier
M

1039

Name
Suffix

✽

NM102

ID

O

66

NM109

ID Code
Qualifier
X

ID

✽

1/2

1035

Name Last/
Org Name

1/1

NM108

✽

NM103

X

O

67

ID

O

706

2/2

1037

Name
Middle

✽

Entity
Relat Code
X

NM105

AN 1/25

NM110

✽

AN 2/80

1036

Name
First

✽

AN 1/35

ID
Code

✽

NM104

ID

O

AN 1/10

98

Entity ID
Code
O

1038

Name
Prefix

✽

AN 1/25

NM111

✽

NM106

~

2/3

OTHER
004010X098A1
PAYER•RENDERING
837 • 2330E PROVIDER
• NM1

OCTOBER 2002

Original Page Number 382 dated May 2000

47

004010X098A1 • 837 • 2330E • NM1
OTHER PAYER RENDERING PROVIDER

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

ELEMENT SUMMARY

USAGE

REF.
DES.

REQUIRED

NM101

DATA
ELEMENT

98

NAME

ATTRIBUTES

Entity Identifier Code

M

ID

2/3

Code identifying an organizational entity, a physical location, property or an
individual
CODE

82
REQUIRED

NM102

1065

DEFINITION

Rendering Provider

Entity Type Qualifier

M

ID

1/1

Code qualifying the type of entity
SEMANTIC:

NM102 qualifies NM103.

CODE

DEFINITION

1

Person

2

Non-Person Entity

Usage Changed
NOT USED

NM103

1035

Name Last or Organization Name

O

AN

1/35

NOT USED

NM104

1036

Name First

O

AN

1/25

NOT USED

NM105

1037

Name Middle

O

AN

1/25

NOT USED

NM106

1038

Name Prefix

O

AN

1/10

NOT USED

NM107

1039

Name Suffix

O

AN

1/10

NOT USED

NM108

66

Identification Code Qualifier

X

ID

1/2

NOT USED

NM109

67

Identification Code

X

AN

2/80

NOT USED

NM110

706

Entity Relationship Code

X

ID

2/2

NOT USED

NM111

98

Entity Identifier Code

O

ID

2/3

48

Original Page Number 383 dated May 2000

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X098A1 • 837 • 2330F • NM1
OTHER PAYER PURCHASED SERVICE PROVIDER

004010X098A1
OTHER PAYER•PURCHASED
837 • 2330F •SERVICE
NM1
PROVIDER

IMPLEMENTATION

OTHER PAYER PURCHASED SERVICE
PROVIDER
Loop: 2330F — OTHER PAYER PURCHASED SERVICE PROVIDER Repeat: 1
Usage: SITUATIONAL
Repeat: 1
Notes:

7
221

1. Because the usage of this segment is “Situational” this is not a
syntactically required loop. If this loop is used, then this segment is a
“Required” segment. See Appendix A for further details on ASC X12
syntax rules.

3
276

2. Used when it is necessary to send an additional payer-specific
provider identification number for non-destination (COB) payers.

0
280

3. See Section 1.4.5 Crosswalking COB Data Elements for more
information on handling COB in the 837.
Example: NM1✽QB✽2~

2
277
STANDARD

NM1 Individual or Organizational Name
Level: Detail
Position: 325
Loop: 2330 Repeat: 10
Requirement: Optional
Max Use: 1
Purpose: To supply the full name of an individual or organizational entity
Set Notes:

1. Segments NM1-N4 contain name and address information of the insurance
carriers referenced in loop 2320.

Syntax:

1. P0809
If either NM108 or NM109 is present, then the other is required.
2. C1110
If NM111 is present, then NM110 is required.
Usage Changed

DIAGRAM

NM101

98

Entity ID
Code

NM1 ✽
M

ID

NM107

O

✽

2/3

AN 1/10

1065

Entity Type
Qualifier
M

1039

Name
Suffix

✽

NM102

ID

O

66

NM109

ID Code
Qualifier
X

ID

✽

1/2

1035

Name Last/
Org Name

1/1

NM108

✽

NM103

X

O

67

ID

O

706

2/2

1037

Name
Middle

✽

Entity
Relat Code
X

NM105

AN 1/25

NM110

✽

AN 2/80

1036

Name
First

✽

AN 1/35

ID
Code

✽

NM104

ID

O

AN 1/10

98

Entity ID
Code
O

1038

Name
Prefix

✽

AN 1/25

NM111

✽

NM106

~

2/3

004010X098A1
OTHER PAYER•PURCHASED
837 • 2330F •SERVICE
NM1
PROVIDER

OCTOBER 2002

Original Page Number 386 dated May 2000

49

004010X098A1 • 837 • 2330F • NM1
OTHER PAYER PURCHASED SERVICE PROVIDER

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

ELEMENT SUMMARY

USAGE

REF.
DES.

REQUIRED

NM101

DATA
ELEMENT

98

NAME

ATTRIBUTES

Entity Identifier Code

M

ID

2/3

Code identifying an organizational entity, a physical location, property or an
individual
CODE

QB
REQUIRED

NM102

1065

DEFINITION

Purchase Service Provider

Entity Type Qualifier

M

ID

1/1

Code qualifying the type of entity
SEMANTIC:

NM102 qualifies NM103.

CODE

Usage Changed

DEFINITION

1

Person

2

Non-Person Entity

NOT USED

NM103

1035

Name Last or Organization Name

O

AN

1/35

NOT USED

NM104

1036

Name First

O

AN

1/25

NOT USED

NM105

1037

Name Middle

O

AN

1/25

NOT USED

NM106

1038

Name Prefix

O

AN

1/10

NOT USED

NM107

1039

Name Suffix

O

AN

1/10

NOT USED

NM108

66

Identification Code Qualifier

X

ID

1/2

NOT USED

NM109

67

Identification Code

X

AN

2/80

NOT USED

NM110

706

Entity Relationship Code

X

ID

2/2

NOT USED

NM111

98

Entity Identifier Code

O

ID

2/3

50

Original Page Number 387 dated May 2000

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X098A1 • 837 • 2330G • NM1
OTHER PAYER SERVICE FACILITY LOCATION

004010X098A1
OTHER
PAYER•SERVICE
837 • 2330G
FACILITY
• NM1LOCATION

IMPLEMENTATION

OTHER PAYER SERVICE FACILITY LOCATION
Loop: 2330G — OTHER PAYER SERVICE FACILITY LOCATION Repeat: 1
Usage: SITUATIONAL
Repeat: 1
Notes:

7
221

1. Because the usage of this segment is “Situational” this is not a
syntactically required loop. If this loop is used, then this segment is a
“Required” segment. See Appendix A for further details on ASC X12
syntax rules.

3
276

2. Used when it is necessary to send an additional payer-specific
provider identification number for non-destination (COB) payers.

0
280

3. See Section 1.4.5 Crosswalking COB Data Elements for more
information on handling COB in the 837.
Example: NM1✽TL✽2~

6
277
STANDARD

NM1 Individual or Organizational Name
Level: Detail
Position: 325
Loop: 2330 Repeat: 10
Requirement: Optional
Max Use: 1
Purpose: To supply the full name of an individual or organizational entity
Set Notes:

1. Segments NM1-N4 contain name and address information of the insurance
carriers referenced in loop 2320.

Syntax:

1. P0809
If either NM108 or NM109 is present, then the other is required.
2. C1110
If NM111 is present, then NM110 is required.
Usage Changed

DIAGRAM

NM101

98

Entity ID
Code

NM1 ✽
M

ID

NM107

O

✽

2/3

AN 1/10

1065

Entity Type
Qualifier
M

1039

Name
Suffix

✽

NM102

ID

O

66

NM109

ID Code
Qualifier
X

ID

✽

1/2

1035

Name Last/
Org Name

1/1

NM108

✽

NM103

X

O

67

ID

O

706

2/2

1037

Name
Middle

✽

Entity
Relat Code
X

NM105

AN 1/25

NM110

✽

AN 2/80

1036

Name
First

✽

AN 1/35

ID
Code

✽

NM104

ID

O

AN 1/10

98

Entity ID
Code
O

1038

Name
Prefix

✽

AN 1/25

NM111

✽

NM106

~

2/3

004010X098A1
OTHER
PAYER•SERVICE
837 • 2330G
FACILITY
• NM1LOCATION

OCTOBER 2002

Original Page Number 390 dated May 2000

51

004010X098A1 • 837 • 2330G • NM1
OTHER PAYER SERVICE FACILITY LOCATION

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

ELEMENT SUMMARY

USAGE

REF.
DES.

REQUIRED

NM101

DATA
ELEMENT

98

NAME

ATTRIBUTES

Entity Identifier Code

M

ID

2/3

Code identifying an organizational entity, a physical location, property or an
individual
CODE

77

Service Location
Use when other codes in this element do not apply.

2777

REQUIRED

DEFINITION

NM102

1065

FA

Facility

LI

Independent Lab

TL

Testing Laboratory

Entity Type Qualifier

M

ID

1/1

Code qualifying the type of entity
SEMANTIC:

NM102 qualifies NM103.

CODE

Usage Changed

2

DEFINITION

Non-Person Entity

NOT USED

NM103

1035

Name Last or Organization Name

O

AN

1/35

NOT USED

NM104

1036

Name First

O

AN

1/25

NOT USED

NM105

1037

Name Middle

O

AN

1/25

NOT USED

NM106

1038

Name Prefix

O

AN

1/10

NOT USED

NM107

1039

Name Suffix

O

AN

1/10

NOT USED

NM108

66

Identification Code Qualifier

X

ID

1/2

NOT USED

NM109

67

Identification Code

X

AN

2/80

NOT USED

NM110

706

Entity Relationship Code

X

ID

2/2

NOT USED

NM111

98

Entity Identifier Code

O

ID

2/3

52

Original Page Number 391 dated May 2000

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X098A1 • 837 • 2330H • NM1
OTHER PAYER SUPERVISING PROVIDER

004010X098A1
OTHER
PAYER•SUPERVISING
837 • 2330H • PROVIDER
NM1

IMPLEMENTATION

OTHER PAYER SUPERVISING PROVIDER
Loop: 2330H — OTHER PAYER SUPERVISING PROVIDER Repeat: 1
Usage: SITUATIONAL
Repeat: 1
Notes:

7
221

1. Because the usage of this segment is “Situational” this is not a
syntactically required loop. If this loop is used, then this segment is a
“Required” segment. See Appendix A for further details on ASC X12
syntax rules.

3
276

2. Used when it is necessary to send an additional payer-specific
provider identification number for non-destination (COB) payers.

0
280

3. See Section 1.4.5 Crosswalking COB Data Elements for more
information on handling COB in the 837.
Example: NM1✽DQ✽1~

1
278
STANDARD

NM1 Individual or Organizational Name
Level: Detail
Position: 325
Loop: 2330 Repeat: 10
Requirement: Optional
Max Use: 1
Purpose: To supply the full name of an individual or organizational entity
Set Notes:

1. Segments NM1-N4 contain name and address information of the insurance
carriers referenced in loop 2320.

Syntax:

1. P0809
If either NM108 or NM109 is present, then the other is required.
2. C1110
If NM111 is present, then NM110 is required.
Usage Changed

DIAGRAM

NM101

98

Entity ID
Code

NM1 ✽
M

ID

NM107

O

✽

2/3

AN 1/10

1065

Entity Type
Qualifier
M

1039

Name
Suffix

✽

NM102

ID

O

66

NM109

ID Code
Qualifier
X

ID

✽

1/2

1035

Name Last/
Org Name

1/1

NM108

✽

NM103

X

O

67

ID

O

706

2/2

1037

Name
Middle

✽

Entity
Relat Code
X

NM105

AN 1/25

NM110

✽

AN 2/80

1036

Name
First

✽

AN 1/35

ID
Code

✽

NM104

ID

O

AN 1/10

98

Entity ID
Code
O

1038

Name
Prefix

✽

AN 1/25

NM111

✽

NM106

~

2/3

004010X098A1
OTHER
PAYER•SUPERVISING
837 • 2330H • PROVIDER
NM1

OCTOBER 2002

Original Page Number 394 dated May 2000

53

004010X098A1 • 837 • 2330H • NM1
OTHER PAYER SUPERVISING PROVIDER

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

ELEMENT SUMMARY

USAGE

REF.
DES.

REQUIRED

NM101

DATA
ELEMENT

98

NAME

ATTRIBUTES

Entity Identifier Code

M

ID

2/3

Code identifying an organizational entity, a physical location, property or an
individual
CODE

DQ
REQUIRED

NM102

1065

DEFINITION

Supervising Physician

Entity Type Qualifier

M

ID

1/1

Code qualifying the type of entity
SEMANTIC:

NM102 qualifies NM103.

CODE

Usage Changed
1

DEFINITION

Person

NOT USED

NM103

1035

Name Last or Organization Name

O

AN

1/35

NOT USED

NM104

1036

Name First

O

AN

1/25

NOT USED

NM105

1037

Name Middle

O

AN

1/25

NOT USED

NM106

1038

Name Prefix

O

AN

1/10

NOT USED

NM107

1039

Name Suffix

O

AN

1/10

NOT USED

NM108

66

Identification Code Qualifier

X

ID

1/2

NOT USED

NM109

67

Identification Code

X

AN

2/80

NOT USED

NM110

706

Entity Relationship Code

X

ID

2/2

NOT USED

NM111

98

Entity Identifier Code

O

ID

2/3

54

Original Page Number 395 dated May 2000

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X098A1 • 837 • 2400 • SV1
PROFESSIONAL SERVICE

PROFESSIONAL
004010X098A1 • 837
SERVICE
• 2400 • SV1

IMPLEMENTATION

PROFESSIONAL SERVICE
Loop: 2400 — SERVICE LINE
Usage: REQUIRED
Repeat: 1
Example: SV1✽HC:99211:25✽12.25✽UN✽1✽11✽✽1:2:3✽✽N~

7
102
STANDARD

SV1 Professional Service
Level: Detail
Position: 370
Loop: 2400
Requirement: Optional
Max Use: 1
Purpose: To specify the claim service detail for a Health Care professional
Syntax:

1. P0304
If either SV103 or SV104 is present, then the other is required.

DIAGRAM

SV101

SV1 ✽

C003

Comp. Med.
Proced. ID

SV102

✽

M

O

SV107

C004

O

1364

O

ID

SV119

782

SV120

O

R

1/18

✽

AN

O

X

SV109

1341

SV115

X

1073

ID

1/2

O

✽

1/1

O

O

ID

O

SV111

O

1334

ID

AN

SV106

✽
1/2

O

1073

1365

Service
Type Code
ID

SV112

1/2

1073

✽ Yes/No Cond ✽ Yes/No Cond
Resp Code
Resp Code

1/2

Healthcare
Short Code

ID

SV117

✽

1/1

1/1

O

127

SV118

Reference
Ident
O

1/1

116

Postal
Code

✽

AN 1/30

ID

O

ID

3/15

Usage Changed

1360

Provider
Agree Code

ID

1331

Facility
Code

✽

1340

SV116

1/1

SV105

1/15

Multiple
Proc Code
O

1327

SV121

R

SV110

1/1

ID

380

Quantity

✽

2/2

Copay
✽
✽
Status Code

1337

ID

ID

SV104

✽ Yes/No Cond ✽
Resp Code
O

Level of
Care Code

355

Unit/Basis
Meas Code

1/18

Natl/Local
Rev Value
O

Monetary
Amount

✽

R

1/2

✽

782

SV114

✽

SV103

1/18

Monetary
Amount
O

Review
Code

✽

R

SV108

✽ Comp. Diag. ✽
Code Point.

SV113

782

Monetary
Amount

~

1/1

ELEMENT SUMMARY

USAGE

REQUIRED

REF.
DES.

SV101

DATA
ELEMENT

C003

NAME

ATTRIBUTES

COMPOSITE MEDICAL PROCEDURE
IDENTIFIER

M

To identify a medical procedure by its standardized codes and applicable
modifiers

1801

ALIAS: Procedure

identifier

PROFESSIONAL
004010X098A1 • 837
SERVICE
• 2400 • SV1

OCTOBER 2002

Original Page Number 400 dated May 2000

55

004010X098A1 • 837 • 2400 • SV1
PROFESSIONAL SERVICE

REQUIRED

SV101 - 1

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

235

Product/Service ID Qualifier

M

ID

2/2

Code identifying the type/source of the descriptive number used in
Product/Service ID (234)
INDUSTRY: Product

or Service ID Qualifier

The NDC number is used for reporting prescribed drugs
and biologics when required by government regulation, or
as deemed by the provider to enhance claim
reporting/adjudication processes. The NDC number is
reported in the LIN segment of Loop ID-2410 only.

New Note Added

CODE

HC

DEFINITION

Health Care Financing Administration Common
Procedural Coding System (HCPCS) Codes
Because the AMA’s CPT codes are also level 1
HCPCS codes, they are reported under HC.

1297

CODE SOURCE 130: Health Care Financing Administration
Common Procedural Coding System

IV

1947

Home Infusion EDI Coalition (HIEC) Product/Service
Code
This code set is not allowed for use under HIPAA at
the time of this writing. The qualifier can only be
used:
1) If a new rule names HIEC as an allowable code set
under HIPAA.
2) For Property & Casualty claims/encounters that
are not covered under HIPAA.

New Note Added

CODE SOURCE 513: Home Infusion EDI Coalition (HIEC)
Product/Service Code List

Codes N1, N2, N3 and N4 Deleted
ZZ

Mutually Defined
Jurisdictionally Defined Procedure and Supply
Codes. (Used for Worker’s Compensation claims).
Contact your local (State) Jurisdiction for a list of
these codes.

1843

REQUIRED

SV101 - 2

234

Product/Service ID

M

AN

1/48

O

AN

2/2

Identifying number for a product or service
INDUSTRY: Procedure

NSF Reference:

2257
2257
SITUATIONAL

Code

FA0-09.0, FB0-15.0, GU0-07.0
SV101 - 3

1339

Procedure Modifier

This identifies special circumstances related to the performance of the
service, as defined by trading partners
ALIAS: Procedure

Modifier 1

2258
2258

NSF Reference:

1091

Use this modifier for the first procedure code modifier.

2578

Required when a modifier clarifies/improves the reporting
accuracy of the associated procedure code.

56

FA0-10.0, GU0-08.0

Original Page Number 401 dated May 2000

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

SITUATIONAL

SV109

1073

004010X098A1 • 837 • 2400 • SV1
PROFESSIONAL SERVICE

Yes/No Condition or Response Code

O

ID

1/1

Code indicating a Yes or No condition or response

Usage Changed

INDUSTRY: Emergency

Indicator

SV109 is the emergency-related indicator; a “Y” value indicates service
provided was emergency related; an “N” value indicates service provided was not
emergency related.

SEMANTIC:

1584
1584

NSF Reference:

New Note Added

Required when the service is known to be an emergency by the
provider.

FA0-20.0

1971

Emergency definition: The patient requires immediate medical
intervention as a result of severe, life threatening, or potentially
disabling conditions.
CODE

DEFINITION

Code N Deleted
Y

Yes

NOT USED

SV110

1340

Multiple Procedure Code

O

ID

1/2

SITUATIONAL

SV111

1073

Yes/No Condition or Response Code

O

ID

1/1

Code indicating a Yes or No condition or response
INDUSTRY: EPSDT

Indicator

SV111 is early and periodic screen for diagnosis and treatment of
children (EPSDT) involvement; a “Y” value indicates EPSDT involvement; an “N”
value indicates no EPSDT involvement.

SEMANTIC:

1585
1585

NSF Reference:

2583

Required if Medicaid services are the result of a screening referral.

FB0-22.0

CODE

Y
SITUATIONAL

SV112

1073

DEFINITION

Yes

Yes/No Condition or Response Code

O

ID

1/1

Code indicating a Yes or No condition or response
INDUSTRY: Family

Planning Indicator

SV112 is the family planning involvement indicator. A “Y” value
indicates family planning services involvement; an “N” value indicates no family
planning services involvement.

SEMANTIC:

1294
1294

NSF Reference:

2584

Required if applicable for Medicaid claims.

FB0-23.0

CODE

Y

DEFINITION

Yes

NOT USED

SV113

1364

Review Code

O

ID

1/2

NOT USED

SV114

1341

National or Local Assigned Review Value

O

AN

1/2

OCTOBER 2002

Original Page Number 406 dated May 2000

57

004010X098A1 • 837 • 2400 • SV5
DURABLE MEDICAL EQUIPMENT SERVICE
DURABLE MEDICAL EQUIPMENT SERVICE
SV5

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

New Segment Added

004010X098A1
DURABLE MEDICAL
• 837 EQUIPMENT
• 2400 • SV5SERVICE

IMPLEMENTATION

DURABLE MEDICAL EQUIPMENT SERVICE
Loop: 2400 — SERVICE LINE
Usage: SITUATIONAL
Repeat: 1
Notes:

012
100
5

1. Required when reporting rental and purchase price information for
durable medical equipment.

Example: SV5✽HC:A4631✽DA✽30✽50✽5000✽4~

6
197
STANDARD

SV5 Durable Medical Equipment Service
Level: Detail
Position: 400
Loop: 2400
Requirement: Optional
Max Use: 1
Purpose: To specify the claim service detail for durable medical equipment
Syntax:

1. R0405
At least one of SV504 or SV505 is required.
2. C0604
If SV506 is present, then SV504 is required.

DIAGRAM

SV501

SV5 ✽

C003

Comp. Med.
Proced. ID

SV502

✽

M

M

SV507

✽

ID

SV503

✽

2/2

380

Quantity
M

R

1/15

SV504

782

Monetary
Amount

✽
X

R

SV505

✽

1/18

782

Monetary
Amount
X

R

SV506

✽

1/18

594

Frequency
Code
O

ID

1/1

923

Prognosis
Code
O

355

Unit/Basis
Meas Code

ID

~

1/1

ELEMENT SUMMARY

USAGE

REQUIRED

REF.
DES.

SV501

DATA
ELEMENT

C003

NAME

COMPOSITE MEDICAL PROCEDURE
IDENTIFIER

ATTRIBUTES

M

To identify a medical procedure by its standardized codes and applicable
modifiers

58 New Page inserted after page 407 dated May 2000

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

New Segment Added

REQUIRED

235

SV501 - 1

004010X098A1 • 837 • 2400 • SV5
DURABLE MEDICAL EQUIPMENT SERVICE

Product/Service ID Qualifier

M

ID

2/2

Code identifying the type/source of the descriptive number used in
Product/Service ID (234)
INDUSTRY: Procedure
CODE

Identifier

DEFINITION

HC

Health Care Financing Administration Common
Procedural Coding System (HCPCS) Codes
CODE SOURCE 130: Health Care Financing Administration
Common Procedural Coding System

REQUIRED

SV501 - 2

234

Product/Service ID

M

AN

1/48

Identifying number for a product or service
INDUSTRY: Procedure

Code

This value must be the same as that reported in SV101-2.

1000126
NOT USED

SV501 - 3

1339

Procedure Modifier

O

AN

2/2

NOT USED

SV501 - 4

1339

Procedure Modifier

O

AN

2/2

NOT USED

SV501 - 5

1339

Procedure Modifier

O

AN

2/2

NOT USED

SV501 - 6

1339

Procedure Modifier

O

AN

2/2

NOT USED

SV501 - 7

352

Description

O

AN

1/80

REQUIRED

SV502

M

ID

2/2

355

Unit or Basis for Measurement Code

Code specifying the units in which a value is being expressed, or manner in which
a measurement has been taken
CODE

DEFINITION

DA
REQUIRED

SV503

380

Days

Quantity

M

R

1/15

X

R

1/18

X

R

1/18

O

ID

1/1

Numeric value of quantity
INDUSTRY: Length
SEMANTIC:

SITUATIONAL

SV504

782

of Medical Necessity

SV503 is the length of medical treatment required.

Monetary Amount
Monetary amount
INDUSTRY: DME
SYNTAX:

R0405, C0604

SEMANTIC:

SITUATIONAL

SV505

782

Rental Price

SV504 is the rental price.

Monetary Amount
Monetary amount
INDUSTRY: DME
SYNTAX:

R0405

SEMANTIC:

SITUATIONAL

SV506

594

Purchase Price

SV505 is the purchase price.

Frequency Code
Code indicating frequency or type of payment
INDUSTRY: Rental
SYNTAX:

C0604

SEMANTIC:

SV506 is the frequency at which the rental equipment is billed.

CODE

1

OCTOBER 2002

Unit Price Indicator

DEFINITION

Weekly

New Page inserted after page 407 dated May 2000

59

004010X098A1 • 837 • 2400 • SV5
DURABLE MEDICAL EQUIPMENT SERVICE

NOT USED

SV507

923

New Segment Added
4

Monthly

6

Daily

Prognosis Code

60 New Page inserted after page 407 dated May 2000

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

O

ID

1/1

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X098A1 • 837 • 2400 • CR2
SPINAL MANIPULATION SERVICE INFORMATION

SPINAL
004010X098A1
MANIPULATION
SERVICE
• 837 • 2400
• CR2 INFORMATION

IMPLEMENTATION

SPINAL MANIPULATION SERVICE
INFORMATION
Loop: 2400 — SERVICE LINE
Usage: SITUATIONAL
Repeat: 5
Notes:

2
203

1. Required on chiropractic claims involving spinal manipulation and
known to impact payer’s adjudication process.

Note
Changed Example: CR2✽✽✽✽✽✽✽✽M✽✽✽✽Y~
7
244

Example Changed

STANDARD

CR2 Chiropractic Certification
Level: Detail
Position: 430
Loop: 2400
Requirement: Optional
Max Use: 5
Purpose: To supply information related to the chiropractic service rendered to a patient
Syntax:

1. P0102
If either CR201 or CR202 is present, then the other is required.
2. C0403
If CR204 is present, then CR203 is required.
3. P0506
If either CR205 or CR206 is present, then the other is required.
Usage Changed

DIAGRAM

CR201

609

Count

CR2 ✽
X

N0

CR202

✽
1/9

380

Quantity
X

R

CR203

1367

CR204

1367

✽ Subluxation ✽ Subluxation ✽
Level Code
Level Code

1/15

X

ID

2/3

O

ID

CR205

355

Unit/Basis
Meas Code

2/3

X

ID

352

CR211

CR206

380

Quantity

✽

2/2

X

R

352

CR212

1/15

Usage Changed
CR207

380

Quantity

✽
O

R

1/15

CR208

✽

1342

Nature of
Cond Code
O

ID

CR209

1073

CR210

1073

✽ Yes/No Cond ✽ Description ✽ Description ✽ Yes/No Cond ~
Resp Code
Resp Code

1/1

O

ID

1/1

O

AN 1/80

O

AN 1/80

O

ID

1/1

ELEMENT SUMMARY

USAGE

REF.
DES.

DATA
ELEMENT

NAME

ATTRIBUTES

NOT USED

CR201

609

Count

X

N0

1/9

NOT USED

CR202

380

Quantity

X

R

1/15

NOT USED

CR203

1367

Subluxation Level Code

X

ID

2/3

NOT USED

CR204

1367

Subluxation Level Code

O

ID

2/3

Usage Changed
OCTOBER 2002

Original Page Numbers 415 to 418 dated May 2000

61

004010X098A1 • 837 • 2400 • CR2
SPINAL MANIPULATION SERVICE INFORMATION

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

NOT USED

CR205

355

Unit or Basis for Measurement Code

X

ID

2/2

NOT USED

CR206

380

Quantity

X

R

1/15

NOT USED

CR207

380

Quantity

O

R

1/15

REQUIRED

CR208

1342

Nature of Condition Code

O

ID

1/1

Usage Changed

Code indicating the nature of a patient’s condition
INDUSTRY: Patient
ALIAS: Nature

Condition Code

of Condition Code. Spinal Manipulation

NSF Reference:

1599
1599

GC0-11.0
CODE

NOT USED

CR209

1073

SITUATIONAL

CR210

352

DEFINITION

A

Acute Condition

C

Chronic Condition

D

Non-acute

E

Non-Life Threatening

F

Routine

G

Symptomatic

M

Acute Manifestation of a Chronic Condition

Yes/No Condition or Response Code

O

ID

1/1

Description

O

AN

1/80

A free-form description to clarify the related data elements and their content
INDUSTRY: Patient
ALIAS: Patient
SEMANTIC:

Condition Description

Condition Description, Chiropractic

CR210 is a description of the patient’s condition.

1601
1601

NSF Reference:

2225

Used at discretion of submitter.

SITUATIONAL

GC0-14.0

CR211

352

Description

O

AN

1/80

A free-form description to clarify the related data elements and their content
INDUSTRY: Patient
ALIAS: Patient
SEMANTIC:

Condition Description

Condition Description, Chiropractic

CR211 is an additional description of the patient’s condition.

1602
1602

NSF Reference:

2225

Used at discretion of submitter.

62

GC0-14.0

Original Page Numbers 418 to 420 dated May 2000

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

SITUATIONAL

CR212

1073

Usage Changed

004010X098A1 • 837 • 2400 • CR2
SPINAL MANIPULATION SERVICE INFORMATION

Yes/No Condition or Response Code

O

ID

1/1

Code indicating a Yes or No condition or response
INDUSTRY: X-ray
ALIAS: X-ray

Availability Indicator

Availability Indicator, Chiropractic

CR212 is X-rays availability indicator. A “Y” value indicates X-rays are
maintained and available for carrier review; an “N” value indicates X-rays are not
maintained and available for carrier review.

SEMANTIC:

1692
1692

NSF Reference:

New
2610Note Added

Required for service dates prior to January 1, 2000.

GC0-15.0

CODE

OCTOBER 2002

DEFINITION

N

No

Y

Yes

Original Page Number 420 dated May 2000

63

004010X098A1 • 837 • 2400 • DTP
DATE - DATE LAST SEEN

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

DATE
004010X098A1
- DATE LAST
• 837SEEN
• 2400 • DTP

IMPLEMENTATION

DATE - DATE LAST SEEN
Loop: 2400 — SERVICE LINE
Usage: SITUATIONAL
Repeat: 1
Notes:

Note 1. Changed

1. Required when a claim involves services from an independent
physical therapist, occupational therapist, or physician service
involving routine foot care and is different than the date listed at the
claim level and is known to impact the payer’s adjudication process.

5
259

2. The total number of DTP segments in the 2400 loop cannot exceed 15.

0
234

Example: DTP✽304✽D8✽19970813~

2
128
STANDARD

DTP Date or Time or Period
Level: Detail
Position: 455
Loop: 2400
Requirement: Optional
Max Use: 15
Purpose: To specify any or all of a date, a time, or a time period
DIAGRAM

DTP01

DTP

✽

374

Date/Time
Qualifier
M

ID

3/3

DTP02

✽

1250

Date Time
format Qual
M

ID

DTP03

✽

2/3

1251

Date Time
Period
M

~

AN 1/35

ELEMENT SUMMARY

USAGE

REQUIRED

REF.
DES.

DTP01

DATA
ELEMENT

374

NAME

ATTRIBUTES

Date/Time Qualifier

M

ID

3/3

M

ID

2/3

Code specifying type of date or time, or both date and time
INDUSTRY: Date
CODE

304
REQUIRED

DTP02

1250

Time Qualifier
DEFINITION

Latest Visit or Consultation

Date Time Period Format Qualifier

Code indicating the date format, time format, or date and time format
SEMANTIC:

DTP02 is the date or time or period format that will appear in DTP03.

CODE

D8

64

Original Page Number 445 dated May 2000

DEFINITION

Date Expressed in Format CCYYMMDD

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X098A1 • 837 • 2400 • DTP
DATE - TEST

DATE
004010X098A1
- TEST • 837 • 2400 • DTP

IMPLEMENTATION

DATE - TEST
Loop: 2400 — SERVICE LINE
Usage: SITUATIONAL
Repeat: 2
Notes:

015
100
8

1. Required on initial EPO claims service lines for dialysis patients
where test results are being billed/reported.

Replaced Note 1.
259
5

2. The total number of DTP segments in the 2400 loop cannot exceed 15.

Example: DTP✽738✽D8✽19970615~

2
261
STANDARD

DTP Date or Time or Period
Level: Detail
Position: 455
Loop: 2400
Requirement: Optional
Max Use: 15
Purpose: To specify any or all of a date, a time, or a time period
DIAGRAM

DTP01

DTP

✽

374

Date/Time
Qualifier
M

ID

3/3

DTP02

✽

1250

Date Time
format Qual
M

ID

DTP03

✽

2/3

1251

Date Time
Period
M

~

AN 1/35

ELEMENT SUMMARY

USAGE

REQUIRED

REF.
DES.

DTP01

DATA
ELEMENT

374

NAME

ATTRIBUTES

Date/Time Qualifier

M

ID

3/3

Code specifying type of date or time, or both date and time
INDUSTRY: Date
CODE

REQUIRED

DTP02

1250

Time Qualifier
DEFINITION

738

Most Recent Hemoglobin or Hematocrit or Both

739

Most Recent Serum Creatine

Date Time Period Format Qualifier

M

ID

2/3

Code indicating the date format, time format, or date and time format
SEMANTIC:

DTP02 is the date or time or period format that will appear in DTP03.

CODE

D8

OCTOBER 2002

DEFINITION

Date Expressed in Format CCYYMMDD

Original Page Number 447 dated May 2000

65

004010X098A1 • 837 • 2400 • DTP
DATE - INITIAL TREATMENT

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

DATE
004010X098A1
- INITIAL TREATMENT
• 837 • 2400 • DTP

IMPLEMENTATION

DATE - INITIAL TREATMENT
Loop: 2400 — SERVICE LINE
Usage: SITUATIONAL
Repeat: 1
Notes:

015
100
5

1. Required on all claims involving spinal manipulation for Medicare Part
B if different than information at the claim level (Loop ID-2300).

Changed Note 1.
259
5

2. The total number of DTP segments in the 2400 loop cannot exceed 15.

Example: DTP✽454✽D8✽19970112~

4
139
STANDARD

DTP Date or Time or Period
Level: Detail
Position: 455
Loop: 2400
Requirement: Optional
Max Use: 15
Purpose: To specify any or all of a date, a time, or a time period
DIAGRAM

DTP01

DTP

✽

374

Date/Time
Qualifier
M

ID

3/3

DTP02

✽

1250

Date Time
format Qual
M

ID

DTP03

✽

2/3

1251

Date Time
Period
M

~

AN 1/35

ELEMENT SUMMARY

USAGE

REQUIRED

REF.
DES.

DTP01

DATA
ELEMENT

374

NAME

ATTRIBUTES

Date/Time Qualifier

M

ID

3/3

M

ID

2/3

Code specifying type of date or time, or both date and time
INDUSTRY: Date
CODE

454
REQUIRED

DTP02

1250

Time Qualifier
DEFINITION

Initial Treatment

Date Time Period Format Qualifier

Code indicating the date format, time format, or date and time format
SEMANTIC:

DTP02 is the date or time or period format that will appear in DTP03.

CODE

D8

66

Original Page Number 458 dated May 2000

DEFINITION

Date Expressed in Format CCYYMMDD

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X098A1 • 837 • 2400 • MEA
TEST RESULT

TEST
004010X098A1
RESULT • 837 • 2400 • MEA

IMPLEMENTATION

TEST RESULT
Loop: 2400 — SERVICE LINE
Usage: SITUATIONAL
Repeat: 20
Notes:

7
258

Note 1. Changed

1. Required on service lines for Dialysis for ESRD. Use R1, R2, R3, or R4
to qualify the Hemoglobin, Hematocrit, Epoetin Starting Dosage and
Creatinine test results.

0
223

2. Required on Oxygen Therapy service lines to report the Oxygen
Saturation measurement from the Certificate of Medical Necessity
(CMN). Use ZO qualifier.

New Notes Added
012
100
7

3. Required on Oxygen Therapy service lines to report the Arterial Blood
Gas measurement from the Certificate of Medical Necessity (CMN).
Use GRA qualifier.

012
100
8

4. Required on DMERC service lines to report the Patient’s Height from
the Certificate of Medical Necessity (CMN). Use HT qualifier.
Example: MEA✽TR✽R1✽113.4~

1
114
STANDARD

MEA Measurements
Level: Detail
Position: 462
Loop: 2400
Requirement: Optional
Max Use: 20
Purpose: To specify physical measurements or counts, including dimensions, tolerances,
variances, and weights
Syntax:

1. R03050608
At least one of MEA03, MEA05, MEA06 or MEA08 is required.
2. C0504
If MEA05 is present, then MEA04 is required.
3. C0604
If MEA06 is present, then MEA04 is required.
4. L07030506
If MEA07 is present, then at least one of MEA03, MEA05 or MEA06 are
required.
5. E0803
Only one of MEA08 or MEA03 may be present.

OCTOBER 2002

Original Page Number 464 dated May 2000

67

004010X098A1 • 837 • 2400 • MEA
TEST RESULT

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

DIAGRAM

MEA01

MEA

737

MEA02

738

MEA03

739

MEA04

✽ Measurement ✽ Measurement ✽ Measurement ✽
Ref ID Code
Qualifier
Value
O

ID

MEA07

2/2

O

ID

935

MEA08

1/3

X

936

MEA09

✽ Measurement ✽ Measurement ✽
Sig Code
Attrib Code
O

ID

2/2

X

ID

R

1/20

2/2

O

ID

MEA05

X

MEA10

740

Range
Minimum

✽

X

752

Layer/Posit
Code

C001

Composite
Unit of Mea

R

MEA06

✽

1/20

741

Range
Maximum
X

R

1/20

1373

✽ Measurement ~
Method

2/2

O

ID

2/4

ELEMENT SUMMARY

USAGE

REF.
DES.

REQUIRED

MEA01

DATA
ELEMENT

737

NAME

ATTRIBUTES

Measurement Reference ID Code

O

ID

2/2

Code identifying the broad category to which a measurement applies
INDUSTRY: Measurement
ALIAS: Measurement
CODE

OG

identifier

DEFINITION

Original
Starting dosage

1705
TR
REQUIRED

Reference Identification Code

MEA02

738

Test Results

Measurement Qualifier

O

ID

1/3

Code identifying a specific product or process characteristic to which a
measurement applies
CODE

DEFINITION

Code CON Deleted

REQUIRED

MEA03

739

GRA

Gas Test Rate

HT

Height

R1

Hemoglobin

R2

Hematocrit

R3

Epoetin Starting Dosage

R4

Creatin

ZO

Oxygen

Measurement Value

X

R

1/20

The value of the measurement
INDUSTRY: Test
SYNTAX:

2616
2616

Note Changed

68

Results

R03050608, L07030506, E0803

NSF Reference:
FA0-42.0 - Hemoglobin, FA0-43.0 - Hematocrit, FA0-45.0 - Epoetin
Starting Dosage, FA0-47.0 - Creatin, GX0-17.0 - Arterial Blood Gas
on 4 liters/minute, GX0-18.0 - Oxygen Saturation on 4 liters/minute,
GU0-16.0 - Patient Height

Original Page Number 465 dated May 2000

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X098A1 • 837 • 2400 • REF
MAMMOGRAPHY CERTIFICATION NUMBER

MAMMOGRAPHY
004010X098A1 • 837
CERTIFICATION
• 2400 • REF NUMBER

IMPLEMENTATION

MAMMOGRAPHY CERTIFICATION NUMBER
Loop: 2400 — SERVICE LINE
Usage: SITUATIONAL
Repeat: 1
Notes:

1
203

1. Required when mammography services are rendered by a certified
mammography provider.

Note Changed

Example: REF✽EW✽T554~

8
136
STANDARD

REF Reference Identification
Level: Detail
Position: 470
Loop: 2400
Requirement: Optional
Max Use: 30
Purpose: To specify identifying information
Syntax:

1. R0203
At least one of REF02 or REF03 is required.

DIAGRAM

REF01

REF

✽

128

Reference
Ident Qual
M

ID

2/3

REF02

127

Reference
Ident

✽
X

REF03

352

REF04

✽ Description ✽

AN 1/30

X

AN 1/80

C040

Reference
Identifier

~

O

ELEMENT SUMMARY

USAGE

REF.
DES.

REQUIRED

REF01

DATA
ELEMENT

128

NAME

ATTRIBUTES

Reference Identification Qualifier

M

ID

2/3

AN

1/30

Code qualifying the Reference Identification
CODE

EW
REQUIRED

REF02

127

DEFINITION

Mammography Certification Number

Reference Identification

X

Reference information as defined for a particular Transaction Set or as specified
by the Reference Identification Qualifier
INDUSTRY: Mammography
SYNTAX:

Certification Number

R0203

NSF Reference:

1614
1614

FA0-31.0

NOT USED

REF03

352

Description

X

NOT USED

REF04

C040

REFERENCE IDENTIFIER

O

OCTOBER 2002

AN

1/80

Original Page Number 474 dated May 2000

69

004010X098A1 • 837 • 2400 • PS1
PURCHASED SERVICE INFORMATION

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

PURCHASED
004010X098A1SERVICE
INFORMATION
• 837 • 2400
• PS1

IMPLEMENTATION

PURCHASED SERVICE INFORMATION
Loop: 2400 — SERVICE LINE
Usage: SITUATIONAL
Repeat: 1
Notes:

8
110

1. Using the PS1 segment indicates that services were purchased from
another source.

Note Changed
203
0

2. Required on service lines when the purchased service charge amount
is necessary for processing.

New Note Added
189
0

3. Use this segment on vision claims when the acquisition cost of lenses
is known to impact adjudication or reimbursement.

Example: PS1✽PN222222✽110~

4
105
STANDARD

PS1 Purchase Service
Level: Detail
Position: 488
Loop: 2400
Requirement: Optional
Max Use: 1
Purpose: To specify the information about services that are purchased
DIAGRAM

PS101

PS1 ✽

127

Reference
Ident
M

AN 1/30

PS102

782

Monetary
Amount

✽
M

R

PS103

✽

1/18

156

State or
Prov Code
O

ID

~

2/2

ELEMENT SUMMARY

USAGE

REQUIRED

REF.
DES.

PS101

DATA
ELEMENT

127

NAME

ATTRIBUTES

Reference Identification

M

AN

1/30

Reference information as defined for a particular Transaction Set or as specified
by the Reference Identification Qualifier
INDUSTRY: Purchased
SEMANTIC:

1295
1295

Service Provider Identifier

PS101 is provider identification number.

NSF Reference:
FB0-11.0

70 Original Page Number 489 dated May 2000

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

New Loop and Segment Added

004010X098A1 • 837 • 2410 • LIN
DRUG IDENTIFICATION

DRUG
004010X098A1
IDENTIFICATION
• 837 • 2410 • LIN

IMPLEMENTATION

DRUG IDENTIFICATION
Loop: 2410 — DRUG IDENTIFICATION Repeat: 25
Usage: SITUATIONAL
Repeat: 1
Notes:

013
100
0

1. The NDC number is used for reporting prescribed drugs and biologics
when required by government regulation, or as deemed by the
provider to enhance claim reporting/adjudication processes. The NDC
number is reported in the LIN segment of Loop ID-2410.
2. Use Loop ID 2410 to specify billing/reporting for drugs provided that
may be part of the service(s) described in SV1.

013
100
1

Example: LIN✽✽N4✽01234567891~

012
100
9
STANDARD

LIN Item Identification
Level: Detail
Position: 494
Loop: 2410 Repeat: >1
Requirement: Optional
Max Use: 1
Purpose: To specify basic item identification data
Set Notes:
Syntax:

1. Loop 2410 contains compound drug components, quantities and prices.
1. P0405
If either LIN04 or LIN05 is present, then the other is required.
2. P0607
If either LIN06 or LIN07 is present, then the other is required.
3. P0809
If either LIN08 or LIN09 is present, then the other is required.
4. P1011
If either LIN10 or LIN11 is present, then the other is required.
5. P1213
If either LIN12 or LIN13 is present, then the other is required.
6. P1415
If either LIN14 or LIN15 is present, then the other is required.
7. P1617
If either LIN16 or LIN17 is present, then the other is required.
8. P1819
If either LIN18 or LIN19 is present, then the other is required.
9. P2021
If either LIN20 or LIN21 is present, then the other is required.

OCTOBER 2002

New Page inserted after page 500 dated May 2000

71

004010X098A1 • 837 • 2410 • LIN
DRUG IDENTIFICATION

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

New Segment Added

10. P2223
If either LIN22 or LIN23 is present, then the other is required.
11. P2425
If either LIN24 or LIN25 is present, then the other is required.
12. P2627
If either LIN26 or LIN27 is present, then the other is required.
13. P2829
If either LIN28 or LIN29 is present, then the other is required.
14. P3031
If either LIN30 or LIN31 is present, then the other is required.
DIAGRAM

LIN01

350

Assigned
ID

LIN ✽
O

X

X

X

AN 1/48

LIN25

✽
X

X

235

ID

X

X

2/2

X

ID

235

LIN27

X

AN 1/48

ID

LIN11

ID

ID

LIN23

X

235

LIN29

2/2

X

235

ID

LIN18

X

235

ID

LIN24

X

235

ID

LIN30

2/2

235

Prod/Serv
ID Qual

✽

AN 1/48

2/2

Prod/Serv
ID Qual

✽

234

2/2

Prod/Serv
ID Qual

✽

AN 1/48

Product/
Service ID

✽

X

234

Product/
Service ID

2/2

Prod/Serv
ID Qual

✽

AN 1/48

2/2

Prod/Serv
ID Qual
X

X

ID

LIN12

234

Product/
Service ID

✽

X

234

235

Prod/Serv
ID Qual

✽

AN 1/48

LIN17

235

LIN28

✽

X

✽

LIN06

AN 1/48

Product/
Service ID

✽

2/2

Prod/Serv
ID Qual
X

234

Product/
Service ID

✽

2/2

AN 1/48

235

235

LIN22

✽

✽

2/2

234

Product/
Service ID
X

Prod/Serv
ID Qual
X

234

Product/
Service ID

ID

LIN16

✽

AN 1/48

LIN21

✽

X

LIN05

2/2

Prod/Serv
ID Qual

✽

234

Product/
Service ID

ID

LIN10

AN 1/48

LIN15

✽

2/2

Prod/Serv
ID Qual

✽

X

X

234

235

Prod/Serv
ID Qual

✽

AN 1/48

Product/
Service ID

✽

LIN04

X

ID

2/2

234

Product/
Service ID

✽

LIN09

Prod/Serv
ID Qual

LIN26

AN 1/48

LIN31

ID

X

234

Product/
Service ID

235

235

LIN20

✽

✽

2/2

234

Product/
Service ID
M

Prod/Serv
ID Qual
X

234

Product/
Service ID

ID

LIN14

✽

AN 1/48

LIN19

✽

X

LIN03

2/2

Prod/Serv
ID Qual

✽

234

Product/
Service ID

ID

LIN08

AN 1/48

LIN13

✽

M

234

Product/
Service ID

235

Prod/Serv
ID Qual

✽

AN 1/20

LIN07

✽

LIN02

~

AN 1/48

ELEMENT SUMMARY

USAGE

NOT USED

REF.
DES.

LIN01

DATA
ELEMENT

350

NAME

Assigned Identification

72 New Page inserted after page 500 dated May 2000

ATTRIBUTES

O

AN

1/20

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

REQUIRED

LIN02

235

004010X098A1 • 837 • 2410 • LIN
DRUG IDENTIFICATION

New Segment Added
Product/Service ID Qualifier

M

ID

2/2

Code identifying the type/source of the descriptive number used in
Product/Service ID (234)
COMMENT: LIN02 through LIN31 provide for fifteen different product/service IDs for
each item. For example: Case, Color, Drawing No., U.P.C. No., ISBN No., Model
No., or SKU.

INDUSTRY: Product
CODE

or Service ID Qualifier

DEFINITION

N4

National Drug Code in 5-4-2 Format
CODE SOURCE 240:

REQUIRED

LIN03

234

National Drug Code by Format

Product/Service ID

M

AN

1/48

Identifying number for a product or service
INDUSTRY: National
ALIAS: National

Drug Code

Drug Code

NOT USED

LIN04

235

Product/Service ID Qualifier

X

ID

2/2

NOT USED

LIN05

234

Product/Service ID

X

AN

1/48

NOT USED

LIN06

235

Product/Service ID Qualifier

X

ID

2/2

NOT USED

LIN07

234

Product/Service ID

X

AN

1/48

NOT USED

LIN08

235

Product/Service ID Qualifier

X

ID

2/2

NOT USED

LIN09

234

Product/Service ID

X

AN

1/48

NOT USED

LIN10

235

Product/Service ID Qualifier

X

ID

2/2

NOT USED

LIN11

234

Product/Service ID

X

AN

1/48

NOT USED

LIN12

235

Product/Service ID Qualifier

X

ID

2/2

NOT USED

LIN13

234

Product/Service ID

X

AN

1/48

NOT USED

LIN14

235

Product/Service ID Qualifier

X

ID

2/2

NOT USED

LIN15

234

Product/Service ID

X

AN

1/48

NOT USED

LIN16

235

Product/Service ID Qualifier

X

ID

2/2

NOT USED

LIN17

234

Product/Service ID

X

AN

1/48

NOT USED

LIN18

235

Product/Service ID Qualifier

X

ID

2/2

NOT USED

LIN19

234

Product/Service ID

X

AN

1/48

NOT USED

LIN20

235

Product/Service ID Qualifier

X

ID

2/2

NOT USED

LIN21

234

Product/Service ID

X

AN

1/48

NOT USED

LIN22

235

Product/Service ID Qualifier

X

ID

2/2

NOT USED

LIN23

234

Product/Service ID

X

AN

1/48

NOT USED

LIN24

235

Product/Service ID Qualifier

X

ID

2/2

NOT USED

LIN25

234

Product/Service ID

X

AN

1/48

NOT USED

LIN26

235

Product/Service ID Qualifier

X

ID

2/2

NOT USED

LIN27

234

Product/Service ID

X

AN

1/48

NOT USED

LIN28

235

Product/Service ID Qualifier

X

ID

2/2

NOT USED

LIN29

234

Product/Service ID

X

AN

1/48

NOT USED

LIN30

235

Product/Service ID Qualifier

X

ID

2/2

NOT USED

LIN31

234

Product/Service ID

X

AN

1/48

OCTOBER 2002

New Page inserted after page 500 dated May 2000

73

004010X098A1 • 837 • 2410 • CTP
DRUG PRICING
PRICING INFORMATION
CTP

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

New Segment Added

DRUG
004010X098A1
PRICING• 837 • 2410 • CTP

IMPLEMENTATION

DRUG PRICING
Loop: 2410 — DRUG IDENTIFICATION
Usage: SITUATIONAL
Repeat: 1
Notes:

013
100
2

1. Required when it is necessary to provide a price specific to the NDC
provided in LIN03 that is different than the price reported in SV102.

Example: CTP✽✽✽1.15✽2✽UN~

012
100
9
STANDARD

CTP Pricing Information
Level: Detail
Position: 495
Loop: 2410
Requirement: Optional
Max Use: 1
Purpose: To specify pricing information
Syntax:

1. P0405
If either CTP04 or CTP05 is present, then the other is required.
2. C0607
If CTP06 is present, then CTP07 is required.
3. C0902
If CTP09 is present, then CTP02 is required.
4. C1002
If CTP10 is present, then CTP02 is required.
5. C1103
If CTP11 is present, then CTP03 is required.

DIAGRAM

CTP01

CTP ✽

687

Class of
Trade Code
O

ID

CTP07

X

X

649

R

1/10

236

Price ID
Code

✽

2/2

Multiplier

✽

CTP02

ID

CTP08

3/3

O

X

782

R

212

Unit
Price

✽

Monetary
Amount

✽

CTP03

R

CTP09

✽

1/18

1/17

ID

X

639

R

CTP10

O

CTP05

✽

1/15

AN 1/10

C001

Composite
Unit of Mea

CTP06

✽

X

499

Condition
Value

✽

2/2

380

Quantity

✽

Basis Unit
Price Code
O

CTP04

O

CTP11

✽

N0

ID

3/3

289

Mult Price
Quantity
O

648

Price Mult
Qualifier

~

1/2

ELEMENT SUMMARY

USAGE

NOT USED

REF.
DES.

CTP01

DATA
ELEMENT

687

NAME

Class of Trade Code

74 New Page inserted after page 500 dated May 2000

ATTRIBUTES

O

ID

2/2

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

New Segment Added

004010X098A1 • 837 • 2410 • CTP
DRUG PRICING

NOT USED

CTP02

236

Price Identifier Code

X

ID

3/3

REQUIRED

CTP03

212

Unit Price

X

R

1/17

X

R

1/15

ID

2/2

Price per unit of product, service, commodity, etc.
INDUSTRY: Drug
ALIAS: Drug
SYNTAX:

REQUIRED

CTP04

380

Unit Price

Unit Price

C1103

Quantity
Numeric value of quantity
INDUSTRY: National
ALIAS: National
SYNTAX:

REQUIRED

CTP05

C001

Drug Unit Count

Drug Unit Count

P0405

COMPOSITE UNIT OF MEASURE

X

To identify a composite unit of measure
INDUSTRY: Unit

1000134
1000134
REQUIRED

or Basis of Measurement

ALIAS: Unit/Basis

CTP05 - 1

355

of Measurement

Unit or Basis for Measurement Code

M

Code specifying the units in which a value is being expressed, or
manner in which a measurement has been taken
ALIAS: Code
CODE

qualifier

DEFINITION

F2

International Unit

GR

Gram

ML

Milliliter

UN

Unit

NOT USED

CTP05 - 2

1018

Exponent

O

R

1/15

NOT USED

CTP05 - 3

649

Multiplier

O

R

1/10

NOT USED

CTP05 - 4

355

Unit or Basis for Measurement Code

O

ID

2/2

NOT USED

CTP05 - 5

1018

Exponent

O

R

1/15

NOT USED

CTP05 - 6

649

Multiplier

O

R

1/10

NOT USED

CTP05 - 7

355

Unit or Basis for Measurement Code

O

ID

2/2

NOT USED

CTP05 - 8

1018

Exponent

O

R

1/15

NOT USED

CTP05 - 9

649

Multiplier

O

R

1/10

NOT USED

CTP05 - 10

355

Unit or Basis for Measurement Code

O

ID

2/2

NOT USED

CTP05 - 11

1018

Exponent

O

R

1/15

NOT USED

CTP05 - 12

649

Multiplier

O

R

1/10

NOT USED

CTP05 - 13

355

Unit or Basis for Measurement Code

O

ID

2/2

NOT USED

CTP05 - 14

1018

Exponent

O

R

1/15

NOT USED

CTP05 - 15

649

Multiplier

O

R

1/10

NOT USED

CTP06

648

Price Multiplier Qualifier

O

ID

3/3

NOT USED

CTP07

649

Multiplier

X

R

1/10

NOT USED

CTP08

782

Monetary Amount

O

R

1/18

OCTOBER 2002

New Page inserted after page 500 dated May 2000

75

004010X098A1 • 837 • 2410 • CTP
DRUG PRICING

New Segment Added

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

NOT USED

CTP09

639

Basis of Unit Price Code

O

ID

2/2

NOT USED

CTP10

499

Condition Value

O

AN

1/10

NOT USED

CTP11

289

Multiple Price Quantity

O

N0

1/2

76 New Page inserted after page 500 dated May 2000

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
REFERENCE IDENTIFICATION
REF

004010X098A1 • 837 • 2410 • REF
PRESCRIPTION NUMBER

New Segment Added

PRESCRIPTION
004010X098A1 • NUMBER
837 • 2410 • REF

IMPLEMENTATION

PRESCRIPTION NUMBER
Loop: 2410 — DRUG IDENTIFICATION
Usage: SITUATIONAL
Repeat: 1
Notes:

013
100
6

1. Required if dispensing of the drug has been done with an assigned Rx
number.
2. In cases where a compound drug is being billed, the components of
the compound will all have the same prescription number. Payers
receiving the claim can relate all the components by matching the
prescription number.

8
258

Example: REF✽XZ✽123456~

013
100
7
STANDARD

REF Reference Identification
Level: Detail
Position: 496
Loop: 2410
Requirement: Optional
Max Use: 1
Purpose: To specify identifying information
Syntax:

1. R0203
At least one of REF02 or REF03 is required.

DIAGRAM

REF01

REF ✽

128

Reference
Ident Qual
M

ID

2/3

REF02

127

Reference
Ident

✽
X

REF03

✽

AN 1/30

352

Description
X

AN 1/80

REF04

C040

Reference
Identifier

✽

~

O

ELEMENT SUMMARY

USAGE

REF.
DES.

REQUIRED

REF01

DATA
ELEMENT

128

NAME

ATTRIBUTES

Reference Identification Qualifier

M

ID

2/3

Code qualifying the Reference Identification
ALIAS: Code
CODE

XZ

OCTOBER 2002

qualifier
DEFINITION

Pharmacy Prescription Number

New Page inserted after page 500 dated May 2000

77

004010X098A1 • 837 • 2410 • REF
PRESCRIPTION NUMBER

REQUIRED

REF02

New Segment Added
127

Reference Identification

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

X

AN

1/30

Reference information as defined for a particular Transaction Set or as specified
by the Reference Identification Qualifier
INDUSTRY: Prescription
ALIAS: Prescription
SYNTAX:

Number

Number

R0203

NOT USED

REF03

352

Description

X

NOT USED

REF04

C040

REFERENCE IDENTIFIER

O

78 New Page inserted after page 500 dated May 2000

AN

1/80

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X098A1 • 837 • 2420A • PRV
RENDERING PROVIDER SPECIALTY INFORMATION

RENDERING
004010X098A1
PROVIDER
SPECIALTY
• 837 • 2420A
• PRV INFORMATION

IMPLEMENTATION

RENDERING PROVIDER SPECIALTY
INFORMATION
Loop: 2420A — RENDERING PROVIDER NAME
Usage: SITUATIONAL

Usage Changed

Repeat: 1
Notes:

3
279

1. PRV02 qualifies PRV03.

New Note Added
194
3

2. Required when adjudication is known to be impacted by provider
taxonomy code.

Example: PRV✽PE✽ZZ✽203BA050N~

7
235
STANDARD

PRV Provider Information
Level: Detail
Position: 505
Loop: 2420
Requirement: Optional
Max Use: 1
Purpose: To specify the identifying characteristics of a provider
DIAGRAM

PRV01

PRV

1221

Provider
Code

✽
M

ID

1/3

PRV02

✽

128

Reference
Ident Qual
M

ID

PRV03

✽

2/3

127

Reference
Ident
M

AN 1/30

PRV04

156

State or
Prov Code

✽

O

ID

2/2

PRV05

C035

Provider
Spec. Inf.

✽

PRV06

O

1223

Provider
Org Code

✽
O

ID

~

3/3

ELEMENT SUMMARY

USAGE

REF.
DES.

REQUIRED

PRV01

DATA
ELEMENT

1221

NAME

ATTRIBUTES

Provider Code

M

ID

1/3

Code indentifying the type of provider
CODE

PE

OCTOBER 2002

DEFINITION

Performing

Original Page Number 504 dated May 2000

79

004010X098A1 • 837 • 2430 • SVD
LINE ADJUDICATION INFORMATION

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

LINE
004010X098A1
ADJUDICATION
2430 • SVD
• 837 •INFORMATION

ELEMENT SUMMARY

USAGE

REF.
DES.

REQUIRED

SVD01

DATA
ELEMENT

67

NAME

ATTRIBUTES

Identification Code

M

AN

2/80

Code identifying a party or other code
INDUSTRY: Other
ALIAS: Other
SEMANTIC:

Payer identification code

SVD01 is the payer identification code.

This number should match NM109 in Loop ID-2330B identifying
Other Payer.

1306
REQUIRED

Payer Primary Identifier

SVD02

782

Monetary Amount

M

R

1/18

Monetary amount
INDUSTRY: Service
ALIAS: Paid
SEMANTIC:

Line Paid Amount

Amount

SVD02 is the amount paid for this service line.

2645
2645

NSF Reference:

2244

Zero “0" is an acceptable value for this element.

2646

The FA0-52.0 NSF crosswalk is only used in payer-to-payer COB
situations.

REQUIRED

FA0-52.0

SVD03

C003

COMPOSITE MEDICAL PROCEDURE
IDENTIFIER

O

To identify a medical procedure by its standardized codes and applicable
modifiers

1801

ALIAS: Procedure

2245

This element contains the procedure code that was used to pay this
service line. It crosswalks from SVC01 in the 835 transmission.

REQUIRED

SVD03 - 1

235

identifier

Product/Service ID Qualifier

M

ID

2/2

Code identifying the type/source of the descriptive number used in
Product/Service ID (234)
INDUSTRY: Product

or Service ID Qualifier

The NDC number is used for reporting prescribed drugs
and biologics when required by government regulation, or
as deemed by the provider to enhance claim
reporting/adjudication processes. The NDC number is
reported in the LIN segment of Loop ID-2410 only.

Added New Note

CODE

HC

1297

DEFINITION

Health Care Financing Administration Common
Procedural Coding System (HCPCS) Codes
Because the AMA’s CPT codes are also level 1
HCPCS codes, they are reported under HC.
CODE SOURCE 130: Health Care Financing Administration
Common Procedural Coding System

80

Original Page Number 555 dated May 2000

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X098A1 • 837 • 2430 • SVD
LINE ADJUDICATION INFORMATION

IV

2343

This code set is not allowed for use under HIPAA at
the time of this writing. The qualifier can only be
used: 1) If a new rule names HIEC as an allowable
code set under HIPAA. 2) For Property & Casualty
claims/encounters that are not covered under
HIPAA.

New Note Added

CODE SOURCE 513: Home Infusion EDI Coalition (HIEC)
Product/Service Code List

Codes N1, N2, N3 and N4 Deleted
ZZ

Mutually Defined
Jurisdictionally Defined Procedure and Supply
Codes. (Used for Worker’s Compensation claims).
Contact your local (State) Jurisdiction for a list of
these codes.

1843

REQUIRED

Home Infusion EDI Coalition (HIEC) Product/Service
Code

SVD03 - 2

234

Product/Service ID

M

AN

1/48

O

AN

2/2

Identifying number for a product or service
INDUSTRY: Procedure

SITUATIONAL

SVD03 - 3

1339

Code

Procedure Modifier

This identifies special circumstances related to the performance of the
service, as defined by trading partners
ALIAS: Procedure

Modifier 1

1091

Use this modifier for the first procedure code modifier.

2578

Required when a modifier clarifies/improves the reporting
accuracy of the associated procedure code.

SITUATIONAL

SVD03 - 4

1339

Procedure Modifier

O

AN

2/2

This identifies special circumstances related to the performance of the
service, as defined by trading partners
ALIAS: Procedure

Modifier 2

1092

Use this modifier for the second procedure code modifier.

2578

Required when a modifier clarifies/improves the reporting
accuracy of the associated procedure code.

SITUATIONAL

SVD03 - 5

1339

Procedure Modifier

O

AN

2/2

This identifies special circumstances related to the performance of the
service, as defined by trading partners
ALIAS: Procedure

Modifier 3

1093

Use this modifier for the third procedure code modifier.

2578

Required when a modifier clarifies/improves the reporting
accuracy of the associated procedure code.

SITUATIONAL

SVD03 - 6

1339

Procedure Modifier

O

AN

2/2

This identifies special circumstances related to the performance of the
service, as defined by trading partners
ALIAS: Procedure

Modifier 4

1094

Use this modifier for the fourth procedure code modifier.

2578

Required when a modifier clarifies/improves the reporting
accuracy of the associated procedure code.

OCTOBER 2002

Original Page Numbers 555 to 556 dated May 2000

81

004010X098A1 • 837 • 2430 • SVD
LINE ADJUDICATION INFORMATION

SITUATIONAL

SVD03 - 7

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

352

Description

O

AN

1/80

A free-form description to clarify the related data elements and their
content
INDUSTRY: Procedure

Code Description

Required if SVC01-7 was returned in the 835 transaction.

2246
NOT USED

SVD04

234

REQUIRED

SVD05

380

Product/Service ID

O

AN

1/48

Quantity

O

R

1/15

Numeric value of quantity

Industry and Alias
Names Changed

INDUSTRY: Paid
ALIAS: Paid
SEMANTIC:

units of service

SVD05 is the paid units of service.

Crosswalk from SVC05 in 835 or, if not present in 835, use original
billed units.

2247
SITUATIONAL

Service Unit Count

SVD06

554

Assigned Number

O

N0

1/6

Number assigned for differentiation within a transaction set

Notes Changed

INDUSTRY: Bundled
ALIAS: Bundled

Line Number

Line Number

COMMENT: SVD06 is only used for bundling of service lines. It references the LX
Assigned Number of the service line into which this service line was bundled.

2153

Use the LX from this transaction which points to the bundled line.

1000139

Required if payer bundled this service line.

82

Original Page Number 557 dated May 2000

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X098A1 • 837
HEALTH CARE CLAIM: PROFESSIONAL

Data elements are assigned a unique reference number. Each data element has
a name, description, type, minimum length, and maximum length. For ID type
data elements, this guide provides the applicable ASC X12 code values and their
descriptions or references where the valid code list can be obtained.
Each data element is assigned a minimum and maximum length. The length of
the data element value is the number of character positions used except as
noted for numeric, decimal, and binary elements.
The data element types shown in matrix A4, Data Element Types, appear in this
implementation guide.
SYMBOL
TYPE
Nn
Numeric
R
Decimal
ID
Identifier
AN
String
DT
Date
TM
Time
B
Binary
Matrix A4. Data Element Types

A.1.3.1.1

Numeric
A numeric data element is represented by one or more digits with an optional
leading sign representing a value in the normal base of 10. The value of a numeric data element includes an implied decimal point. It is used when the position of the decimal point within the data is permanently fixed and is not to be
transmitted with the data.
This set of guides denotes the number of implied decimal positions. The representation for this data element type is “Nn” where N indicates that it is numeric
and n indicates the number of decimal positions to the right of the implied decimal point.
If n is 0, it need not appear in the specification; N is equivalent to N0. For negative values, the leading minus sign (-) is used. Absence of a sign indicates a positive value. The plus sign (+) should not be transmitted.
EXAMPLE
A transmitted value of 1234, when specified as numeric type N2, represents a
value of 12.34.
Leading zeros should be suppressed unless necessary to satisfy a minimum
length requirement. The length of a numeric type data element does not include
the optional sign.

A.1.3.1.2

Decimal
A decimal data element may contain an explicit decimal point and is used for numeric values that have a varying number of decimal positions. This data element
type is represented as “R.”
The decimal point always appears in the character stream if the decimal point is
at any place other than the right end. If the value is an integer (decimal point at
the right end) the decimal point should be omitted. For negative values, the leading minus sign (-) is used. Absence of a sign indicates a positive value. The plus
sign (+) should not be transmitted.

OCTOBER 2002

Original Page Number A.5 dated May 2000

83

004010X098A1 • 837
HEALTH CARE CLAIM: PROFESSIONAL

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

Leading zeros should be suppressed unless necessary to satisfy a minimum
length requirement. Trailing zeros following the decimal point should be suppressed unless necessary to indicate precision. The use of triad separators (for
example, the commas in 1,000,000) is expressly prohibited. The length of a decimal type data element does not include the optional leading sign or decimal point.
EXAMPLE
A transmitted value of 12.34 represents a decimal value of 12.34.
New note

A.1.3.1.3

For implementation of this guide under the rules promulgated under the Health Insurance Portability and Accountability Act (HIPAA), decimal data elements in
Data Element 782 (Monetary Amount) will be limited to a maximum length of 10
characters including reported or implied places for cents (implied value of 00 after
the decimal point). Note the statement in the preceding paragraph that the decimal point and leading sign, if sent, are not part of the character count.

Identifier
An identifier data element always contains a value from a predefined list of codes
that is maintained by the ASC X12 Committee or some other body recognized by
the Committee. Trailing spaces should be suppressed unless they are necessary
to satisfy a minimum length. An identifier is always left justified. The representation for this data element type is “ID.”

A.1.3.1.4

String
A string data element is a sequence of any characters from the basic or extended
character sets. The significant characters shall be left justified. Leading spaces,
when they occur, are presumed to be significant characters. Trailing spaces
should be suppressed unless they are necessary to satisfy a minimum length.
The representation for this data element type is “AN.”

A.1.3.1.5

Date
A date data element is used to express the standard date in either YYMMDD or
CCYYMMDD format in which CC is the first two digits of the calendar year, YY is
the last two digits of the calendar year, MM is the month (01 to 12), and DD is the
day in the month (01 to 31). The representation for this data element type is “DT.”
Users of this guide should note that all dates within transactions are 8-character
dates (millennium compliant) in the format CCYYMMDD. The only date data element that is in format YYMMDD is the Interchange Date data element in the ISA
segment, and also used in the TA1 Interchange Acknowledgment, where the century can be readily interpolated because of the nature of an interchange header.

A.1.3.1.6

Time
A time data element is used to express the ISO standard time HHMMSSd..d format in which HH is the hour for a 24 hour clock (00 to 23), MM is the minute (00
to 59), SS is the second (00 to 59) and d..d is decimal seconds. The representation for this data element type is “TM.” The length of the data element determines the format of the transmitted time.
EXAMPLE
Transmitted data elements of four characters denote HHMM. Transmitted data
elements of six characters denote HHMMSS.

84

Original Page Number A.6 dated May 2000

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X098A1 • 837 • GS
FUNCTIONAL GROUP HEADER

004010X098A1GROUP
FUNCTIONAL
GS
• 002 • HEADER

IMPLEMENTATION

FUNCTIONAL GROUP HEADER
Example: GS✽HC✽SENDER CODE✽RECEIVER
CODE✽19940331✽0802✽1✽X✽004010X098A1~

005
100
4

Example Changed

STANDARD

GS Functional Group Header
Purpose: To indicate the beginning of a functional group and to provide control information
DIAGRAM

GS01

GS ✽

479

Functional
ID Code
M

ID

GS07

GS02

2/2

M

455

GS08

✽ Responsible ✽
Agency Code
M

ID

1/2

142

GS03

✽ Application ✽
Send’s Code
AN 2/15

M

AN 2/15

GS04

373

Date

✽
M

DT

GS05

✽
8/8

337

Time
M

TM

GS06

✽
4/8

28

Group Ctrl
Number
M

N0

1/9

480

Ver/Release
ID Code
M

124

Application
Rec’s Code

~

AN 1/12

ELEMENT SUMMARY

USAGE

REQUIRED

REF.
DES.

GS01

DATA
ELEMENT

479

NAME

ATTRIBUTES

Functional Identifier Code

M

ID

2/2

AN

2/15

Code identifying a group of application related transaction sets
CODE

HC
REQUIRED

GS02

142

DEFINITION

Health Care Claim (837)

Application Sender’s Code

M

Code identifying party sending transmission; codes agreed to by trading partners

Use this code to identify the unit sending the information.

1000009
REQUIRED

GS03

124

Application Receiver’s Code

M

AN

2/15

Code identifying party receiving transmission. Codes agreed to by trading partners

Use this code to identify the unit receiving the information.

1000010
REQUIRED

GS04

373

Date

M

DT

8/8

TM

4/8

Date expressed as CCYYMMDD
SEMANTIC:

Use this date for the functional group creation date.

1000011
REQUIRED

GS04 is the group date.

GS05

337

Time

M

Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or
HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S =
integer seconds (00-59) and DD = decimal seconds; decimal seconds are
expressed as follows: D = tenths (0-9) and DD = hundredths (00-99)
SEMANTIC:

1000012

OCTOBER 2002

GS05 is the group time.

Use this time for the creation time. The recommended format is
HHMM.

Original Page Number B.8 dated May 2000

85

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X098A1 • 837

REQUIRED

GS06

28

Group Control Number

M

N0

1/9

Assigned number originated and maintained by the sender
The data interchange control number GS06 in this header must be
identical to the same data element in the associated functional group trailer,
GE02.

SEMANTIC:

REQUIRED

GS07

455

Responsible Agency Code

M

ID

1/2

Code used in conjunction with Data Element 480 to identify the issuer of the
standard
CODE

X
REQUIRED

GS08

480

DEFINITION

Accredited Standards Committee X12

Version / Release / Industry Identifier Code

M

AN

1/12

Code indicating the version, release, subrelease, and industry identifier of the EDI
standard being used, including the GS and GE segments; if code in DE455 in GS
segment is X, then in DE 480 positions 1-3 are the version number; positions 4-6
are the release and subrelease, level of the version; and positions 7-12 are the
industry or trade association identifiers (optionally assigned by user); if code in
DE455 in GS segment is T, then other formats are allowed
CODE

New Code Value Added

DEFINITION

004010X098A1 Draft Standards Approved for Publication by ASC
X12 Procedures Review Board through October
1997, as published in this implementation guide.

1091

When using the X12N Health Care Claim:
Professional Implementation Guide, originally
published May 2000 as 004010X098 and
incorporating the changes identified in the Addenda,
the value used in GS08 must be “004010X098A1”.

004010X098A1 • 837

86

Original Page Number B.9 dated May 2000

OCTOBER 2002
File Type	application/pdf
File Modified	2002-10-31
File Created	2001-08-31