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pdfASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X097A1 • 837
HEALTH CARE CLAIM: DENTAL
National Electronic Data Interchange
Transaction Set Implementation Guide
A
D
D
E
N
D
A
Health Care Claim:
Dental
837
ASC X12N 837 (004010X097A1)
October 2002
OCTOBER 2002
1
004010X097A1 • 837
HEALTH CARE CLAIM: DENTAL
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
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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
004010X097A1 • 837
HEALTH CARE CLAIM: DENTAL
Table of Contents
Introduction .................................................................................................. 5
Modified pages............................................................................................ 7
OCTOBER 2002
3
004010X097A1 • 837
HEALTH CARE CLAIM: DENTAL
4
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X097A1 • 837
HEALTH CARE CLAIM: DENTAL
1 Introduction to Modified Pages
This document is addenda to the X12N Health Care Claim: Dental Implementation Guide, originally published May 2000 as 004010X097. 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 004010X097 Implementation Guide. Since the X12N
004010X097 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: Dental Implementation
Guide, originally published May 2000 as 004010X097 and incorporating the
changes identified in the Addenda, the value used in GS08 must be
“004010X097A1".
Each of the changes made to the 004010X097 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
004010X097 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
5
004010X097A1 • 837
HEALTH CARE CLAIM: DENTAL
1.1.2
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
HIPAA Role in Implementation Guides
The Health Insurance Portability and Accountability Act of 1996 (P.L. 104-191 known as HIPAA) includes provisions for Administrative Simplification, which require the Secretary of Department of Health and Human Services to adopt standards to support the electronic exchange of administrative and financial health
care transactions primarily between health care providers and plans. HIPAA directs the Secretary to adopt standards for transactions to enable health information to be exchanged electronically and to adopt specifications for implementing
each standard.
Detailed Implementation Guides for each standard must be available at the time
of the adoption of HIPAA standards so that health plans, providers, clearinghouses, and software vendors can ready their information systems and application software for compliance with the standards. Consistent usage of the standards, including loops, segments, data elements, etc., across all guides is mandatory to support the Secretary’s commitment to standardization.
This Implementation Guide has been developed for use as a HIPAA Implementation Guide for Health Care Claim: Dental. Should the Secretary adopt the X12
837 Health Care Claim: Dental transaction as an industry standard, this Implementation Guide describes the consistent industry usage called for by HIPAA. If
adopted under HIPAA, the X12N 837 Health Care Claim: Dental transaction cannot be implemented except as described in this Implementation Guide.
1.2
Version and Release
This implementation guide is based on the October 1997 ASC X12 standards, referred to as Version 4, Release 1, Sub-release 0 (004010).
1.3
Business Use and Definition
The ASC X12 standards are formulated to minimize the need for users to reprogram their data processing systems for multiple formats by allowing data interchange through the use of a common interchange structure. These standards do
not define the method in which interchange partners should establish the required electronic media communication link, nor the hardware and translation software requirements to exchange EDI data. Each trading partner must provide
these specific requirements separately.
First sentence replaced.
6
This implementation guide is intended to provide assistance in developing and
executing the electronic transfer of health encounter data, health claim data and
health care predetermination of dental benefits data. With a few exceptions, this
implementation guide does not contain payer-specific instructions. Trading partners agreements are not allowed to set data specifications that conflict with the
HIPAA implementations. Payers are required by law to have the capability to
send/receive all HIPAA transactions. For example, a payer who does not pay
claims with certain home health information must still be able to electronically accept on their front end an 837 with all the home health data. The payer cannot upfront reject such a claim. However, that does not mean that the payer is required
to bring that data into their adjudication system. The payer, acting in accordance
with policy and contractual agreements, can ignore data within the 837 data set.
In light of this, it is permissible for trading partners to specify a subset of an
Original Page Number 10 Dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X097A1 • 837
004010X097A1 • 837
IMPLEMENTATION
837
Health Care Claim: Dental
1. The 837 transaction is designed to transmit one or more claims for each billing provider. The hierarchy of
the looping structure is as follows: billing provider, subscriber, patient, claim level, and claim service line level.
Billing providers who sort claims using this hierarchy use the 837 more efficiently because information that
applies to all lower levels in the hierarchy does not have to be repeated within the transaction.
2. The developers of this implementation guide also recommend this standard for submitting similar data
within a prepaid 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 prepaid and request for payment
services. This standard allows for the submission of data from providers of health care products and services to
a Managed Care Organization or other payer. This standard may be used by payers to share data with plan
sponsors, employers, regulatory entities, and Community Health Information Networks.
3. This standard also can be used as a transaction set in support of the Coordination of Benefits (COB) 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
53
54
57
005
010
015
ST
BHT
REF
Transaction Set Header
Beginning of Hierarchical Transaction
Transmission Type Identification
R
R
R
1
1
1
59
62
020
045
NM1
PER
LOOP ID - 1000A SUBMITTER NAME
Submitter Name
Submitter Contact Information
R
R
1
2
65
020
NM1
LOOP ID - 1000B RECEIVER NAME
Receiver Name
R
1
LOOP REPEAT
1
1
N2 Segment Deleted
Table 2 - Billing/Pay-to Provider Detail
PAGE #
POS. # SEG. ID
NAME
USAGE
REPEAT
67
69
71
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
74
77
78
80
82
015
025
030
035
035
NM1
N3
N4
REF
REF
LOOP ID - 2010AA BILLING PROVIDER NAME
Billing Provider Name
Billing Provider Address
Billing Provider City/State/ZIP Code
Billing Provider Secondary Identification Number
Claim Submitter Credit/Debit Card Information
R
R
R
S
S
1
1
1
5
8
84
87
88
90
015
025
030
035
NM1
N3
N4
REF
LOOP ID - 2010AB PAY-TO PROVIDER’S NAME
Pay-to Provider’s Name
Pay-to Provider’s Address
Pay-to Provider City/State/Zip
Pay-to Provider Secondary Identification Number
S
R
R
S
1
1
1
5
OCTOBER 2002
LOOP REPEAT
>1
R
S
S
1
1
1
1
1
Original Page Number 45 Dated May 2000
7
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X097A1 • 837
Table 2 - Subscriber Detail
PAGE #
POS. # SEG. ID
NAME
USAGE
REPEAT
92
95
001
005
HL
SBR
LOOP ID - 2000B SUBSCRIBER HIERARCHICAL
LEVEL
Subscriber Hierarchical Level
Subscriber Information
99
103
104
106
108
110
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
112
115
116
118
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 Number
R
S
S
S
1
1
1
3
NM1
REF
LOOP ID - 2010BC CREDIT/DEBIT CARD HOLDER
NAME
Credit/Debit Card Holder Name
Credit/Debit Card Information
120
123
015
035
LOOP REPEAT
>1
R
R
1
1
1
1
1
S
S
1
3
N2 Segment Deleted
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 2010BC 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
125
127
001
007
HL
PAT
LOOP ID - 2000C PATIENT HIERARCHICAL LEVEL
Patient Hierarchical Level
Patient Information
S
R
1
1
129
132
133
135
137
139
015
025
030
032
035
035
NM1
N3
N4
DMG
REF
REF
LOOP ID - 2010CA PATIENT NAME
Patient Name
N2 Segment
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
141
148
149
151
152
153
155
130
135
135
135
135
135
135
CLM
DTP
DTP
DTP
DTP
DTP
DTP
LOOP ID - 2300 CLAIM INFORMATION
Claim Information
Date - Admission
Date - Discharge
Date - Referral
Date - Accident
Date - Appliance Placement
Date - Service
R
S
S
S
S
S
S
1
1
1
1
1
5
1
8
Original Page Number 46 Dated May 2000
LOOP REPEAT
>1
1
Deleted
100
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X097A1 • 837
157
159
161
164
165
166
168
170
172
174
145
150
155
175
175
180
180
180
180
180
DN1
DN2
PWK
AMT
AMT
REF
REF
REF
REF
REF
176
190
NTE
Orthodontic Total Months of Treatment
S
Tooth Status
S
Claim Supplemental Information
S
Patient Amount Paid
S
Credit/Debit Card - Maximum Amount
S
Predetermination Identification
S
Service Authorization Exception Code
S
Original Reference Number (ICN/DCN)
Segment Name S
Prior Authorization or Referral Number
S
Changed
Claim Identification Number for Clearinghouses and Other
S
Transmission Intermediaries
Claim Note
S
S
S
S
1
1
5
S
S
S
1
1
5
S
Deleted
S
1
5
S
S
S
1
1
1
178
181
183
250
255
271
NM1
PRV
REF
LOOP ID - 2310A REFERRING PROVIDER NAME
Referring Provider Name
N2 Deleted
Referring Provider Specialty Information
Referring Provider Secondary Identification
185
188
190
250
255
271
NM1
PRV
REF
LOOP ID - 2310B RENDERING PROVIDER NAME
Rendering Provider Name
N2 Deleted
Rendering Provider Specialty Information
Rendering Provider Secondary Identification
192
195
250
271
NM1
REF
LOOP ID - 2310C SERVICE FACILITY LOCATION
Service Facility Location
N2
Service Facility Location Secondary Identification
New Loop Added
197
200
202
250
255
271
NM1
PRV
REF
204
208
215
216
217
218
290
295
300
300
300
300
SBR
CAS
AMT
AMT
AMT
AMT
219
220
221
222
224
300
300
300
305
310
226
229
230
232
234
236
239
240
242
244
1
35
10
1
1
5
1
1
2
1
20
2
1
Usage
Changed
1
LOOP ID - 2310D ASSISTANT SURGEON NAME
Assistant Surgeon Name
Assistant Surgeon Specialty Information
Assistant Surgeon Secondary Identification
1
S
S
S
S
S
S
1
5
1
1
1
1
AMT
AMT
AMT
DMG
OI
LOOP ID - 2320 OTHER SUBSCRIBER INFORMATION
Other Subscriber Information
Claim Adjustment
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) Patient Paid Amount
Other Insured Demographic Information
Other Insurance Coverage Information
S
S
S
S
R
1
1
1
1
1
325
332
340
355
NM1
N3
N4
REF
LOOP ID - 2330A OTHER SUBSCRIBER NAME
Other Subscriber Name
N2 Deleted
Other Subscriber Address
Other Subscriber City/State/Zip Code
Other Subscriber Secondary Identification
R
S
S
S
1
1
1
3
325
345
350
355
355
355
NM1
PER
DTP
REF
REF
REF
LOOP ID - 2330B OTHER PAYER NAME
Other Payer Name
N2 Deleted
Other Payer Contact Information
Claim Paid Date
Segment Name
Other Payer Secondary Identifier
Changed
Other Payer Prior Authorization or Referral Number
Other Payer Claim Adjustment Indicator
R
S
S
S
S
S
1
2
1
3
2
1
OCTOBER 2002
Repeat
Changed
10
1
1
Repeat
Changed
Original Page Numbers 47 and 48 Dated May 2000
9
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X097A1 • 837
246
248
250
252
325
355
325
355
NM1
REF
LOOP ID - 2330C OTHER PAYER PATIENT
INFORMATION
Other Payer Patient Information
Other Payer Patient Identification
NM1
REF
LOOP ID - 2330D OTHER PAYER REFERRING
PROVIDER
Other Payer Referring Provider
Other Payer Referring Provider Identification
254
256
325
355
NM1
REF
LOOP ID - 2330E OTHER PAYER RENDERING
PROVIDER
Other Payer Rendering Provider
Other Payer Rendering Provider Identification
258
259
265
268
270
272
274
276
278
279
281
283
284
285
365
380
382
455
455
455
455
460
470
470
470
475
475
485
LX
SV3
TOO
DTP
DTP
DTP
DTP
QTY
REF
REF
REF
AMT
AMT
NTE
LOOP ID - 2400 LINE COUNTER
Line Counter
Dental Service
Tooth Information
Date - Service
Date - Prior Placement
Date - Appliance Placement
Date - Replacement
Anesthesia Quantity
Service Predetermination Identification
Prior Authorization or Referral Number
Line Item Control Number
Approved Amount
New
Sales Tax Amount
Line Note
286
289
291
500
505
525
NM1
PRV
REF
LOOP ID - 2420A RENDERING PROVIDER NAME
Rendering Provider Name
Rendering Provider Specialty Information
N2 Deleted
Rendering Provider Secondary Identification
NM1
REF
LOOP ID - 2420B OTHER PAYER PRIOR
AUTHORIZATION OR REFERRAL NUMBER
Other Payer Prior Authorization or Referral Number
Other Payer Prior Authorization or Referral Number
293
296
500
525
New Loop Added
1
S
S
1
3
1
S
S
1
3
1
S
S
1
3
R
R
S
S
S
S
S
S
S
Segment
Name Changed S
S
S
Segment Added S
S
1
1
32
1
1
1
1
5
1
2
1
1
1
10
50
1
S
S
S
1
1
5
Name Changed
S
S
1
2
298
301
303
500
505
525
NM1
PRV
REF
LOOP ID - 2420C ASSISTANT SURGEON NAME
Assistant Surgeon Name
Assistant Surgeon Specialty Information
Assistant Surgeon Secondary Identification
S
S
S
1
1
1
305
309
316
317
540
545
550
555
SVD
CAS
DTP
SE
LOOP ID - 2430 LINE ADJUDICATION INFORMATION
Line Adjudication Information
Service Adjustment
Line Adjudication Date
Transaction Set Trailer
S
S
R
R
1
99
1
1
10
Original Page Number 48 Dated May 2000
Repeat
Changed
Usage
Changed
1
Repeat
Changed
1
25
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X097A1 • 837 • REF
TRANSMISSION TYPE IDENTIFICATION
TRANSMISSION• TYPE
004010X097A1
837 • REF
IDENTIFICATION
IMPLEMENTATION
TRANSMISSION TYPE IDENTIFICATION
Usage: REQUIRED
Repeat: 1
Notes:
1
168
1. The information carried in this REF is identical to that carried in the
GS08. Because the commercial translator community is roughly
evenly split on where they look for the implementation guide type, this
number is carried in both places.
Example Changed
Example: REF✽87✽004010X097A1~
4
136
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:
1682
Note Changed
1683
OCTOBER 2002
Type Code
R0203
When piloting the transaction set, this value is 004010X097DA1.
When sending the transaction set in a production mode, this value
is 004010X097A1.
Original Page Number 57 Dated May 2000
11
004010X097A1 • 837 • 2000A • PRV
BILLING/PAY-TO PROVIDER SPECIALTY INFORMATION
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
BILLING/PAY-TO
004010X097A1 • 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:
012
100
0
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
4
169
2. If the Billing or Pay-to Provider is also the Rendering Provider, and
Loop 2310B is not used, this PRV segment is required.
5
169
3. This PRV is not used when the Billing or Pay-to Provider is a group
and the individual Rendering Provider is in Loop ID-2310B. The PRV
segment is then coded with the Rendering Provider in Loop ID-2310B.
6
197
4. PRV02 qualifies PRV03.
2
169
Example: PRV✽PT✽ZZ✽1223S0112Y~
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
1221
Provider
Code
PRV ✽
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
BI
12
Original Page Number 71 Dated May 2000
DEFINITION
Billing
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X097A1 • 837 • 2010BB • N4
PAYER CITY/STATE/ZIP CODE
004010X097A1
PAYER
CITY/STATE/ZIP
CODE • N4
• 837 • 2010BB
IMPLEMENTATION
PAYER CITY/STATE/ZIP CODE
Loop: 2010BB — PAYER NAME
Usage: SITUATIONAL
Repeat: 1
Notes:
2
174
1. Payer Address is required when the Submitter intends for the claim to
be printed to paper at the next EDI location (e.g., clearinghouse).
Example: N4✽CENTERVILLE✽PA✽17111~
8
103
STANDARD
N4 Geographic Location
Level: Detail
Position: 030
Loop: 2010
Requirement: Optional
Max Use: 1
Purpose: To specify the geographic place of the named party
Syntax:
1. C0605
If N406 is present, then N405 is required.
DIAGRAM
N401
N4
19
City
Name
✽
O
N402
✽
AN 2/30
156
State or
Prov Code
O
ID
N403
2/2
116
Postal
Code
✽
O
ID
3/15
N404
26
Country
Code
✽
O
ID
2/3
N405
309
Location
Qualifier
✽
X
ID
N406
1/2
310
Location
Identifier
✽
O
~
AN 1/30
ELEMENT SUMMARY
REF.
DES.
USAGE
REQUIRED
N401
DATA
ELEMENT
19
NAME
ATTRIBUTES
City Name
O
AN
2/30
Free-form text for city name
INDUSTRY: Payer
ALIAS: Payer’s
City Name
City
COMMENT: A combination of either N401 through N404, or N405 and N406 may be
adequate to specify a location.
NSF Reference:
1747
1747
DA1-06.0
Note Deleted
OCTOBER 2002
Original Page Number 122 Dated May 2000
13
004010X097A1 • 837 • 2300 • CLM
CLAIM INFORMATION
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
CLAIM
004010X097A1
INFORMATION
• 837 • 2300 • CLM
REQUIRED
CLM05
C023
HEALTH CARE SERVICE LOCATION
INFORMATION
O
To provide information that identifies the place of service or the type of bill related
to the location at which a health care service was rendered
1441
ALIAS: Place
1236
1236
NSF Reference:
1517
CLM05 applies to all service lines unless it is over written at the line
level.
REQUIRED
of Service Code
FA0-07.0
CLM05 - 1
1331
Facility Code Value
M
AN
1/2
Code identifying the type of facility where services were performed; the
first and second positions of the Uniform Bill Type code or the Place of
Service code from the Electronic Media Claims National Standard Format
INDUSTRY: Facility
Type Code
Use this element for codes identifying a place of service
from code source 237. As a courtesy, the codes are listed
below; however, the code list is thought to be complete at
the time of publication of this implementation guide. Since
this list is subject to change, only codes contained in the
document available from code source 237 are to be
supported in this transaction and take precedence over any
and all codes listed here.
1000095
11
12
21
22
31
35
Office
Home
Inpatient Hospital
Outpatient Hospital
Skilled Nursing Facility
Adult Living Care Facility
NOT USED
CLM05 - 2
1332
Facility Code Qualifier
O
ID
1/2
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
Codes and Notes Deleted
INDUSTRY: Claim
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 Code
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:
1237
1237
NSF Reference:
EA0-35.0
CODE
14
DEFINITION
N
No
Y
Yes
Original Page Number 152 Dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
SITUATIONAL
CLM12
1366
004010X097A1 • 837 • 2300 • CLM
CLAIM INFORMATION
Special Program Code
O
ID
2/3
Code indicating the Special Program under which the services rendered to the
patient were performed
INDUSTRY: Special
Program Indicator
1777
1777
NSF Reference:
1778
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
05
Disability
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
NOT USED
CLM16
1360
Provider Agreement Code
O
ID
1/1
NOT USED
CLM17
1029
Claim Status Code
O
ID
1/2
NOT USED
CLM18
1073
Yes/No Condition or Response Code
O
ID
1/1
SITUATIONAL
CLM19
1383
Claim Submission Reason Code
O
ID
2/2
Code identifying reason for claim submission
ALIAS: Predetermination
CLM19 is required when the entire claim is being submitted for
Predetermination of Benefits.
1000151
Replaced Note
CODE
PB
SITUATIONAL
CLM20
of Benefits Code
1514
DEFINITION
Predetermination of Dental Benefits
Delay Reason Code
O
ID
1/2
Code indicating the reason why a request was delayed
1775
This element may be used if a particular claim is being transmitted
in response to a request for information (e.g., a 277), and the
response has been delayed.
1776
Required when claim is submitted late (past contracted date of
filing limitations) and any of the codes below apply.
CODE
OCTOBER 2002
DEFINITION
1
Proof of Eligibility Unknown or Unavailable
2
Litigation
Original Page Number 155 Dated May 2000
15
004010X097A1 • 837 • 2300 • REF
PRIOR AUTHORIZATION OR REFERRAL NUMBER
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
PRIOR
004010X097A1
AUTHORIZATION
OR•REFERRAL
REF
NUMBER
• 837 • 2300
IMPLEMENTATION
PRIOR AUTHORIZATION OR REFERRAL
Segment Name Changed
NUMBER
Loop: 2300 — CLAIM INFORMATION
Usage: SITUATIONAL
Repeat Changed
Repeat: 2
Notes:
5
179
1. Numbers at this position apply to the entire claim unless they are
overridden in the REF segment in Loop ID-2400. A reference
identification is considered to be overridden if the value in REF01 is
the same in both the Loop ID-2300 REF segment and the Loop ID-2400
REF segment. In that case, the Loop ID-2400 REF applies only to that
specific line.
Note 2. Changed
012
100
2
2. Required where services on this claim were preauthorized or where a
referral is involved. Generally, preauthorization/referral numbers are
those numbers assigned by the payer/UMO to authorize a service
prior to its being performed. The referral or prior authorization
number carried in this REF is specific to the destination payer
reported in the 2010BB loop. If other payers have similar numbers for
this claim, report that information in the 2330 loop REF which holds
that payer’s information.
New Note 3. Added
012
100
3
3. This segment should not be used for Predetermination of Benefits.
Example: REF✽9F✽12345~
5
203
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 ✽
M
16
128
Reference
Ident Qual
ID
2/3
REF02
127
Reference
Ident
✽
X
AN 1/30
REF03
✽
352
Description
X
Original Page Number 181 Dated May 2000
AN 1/80
REF04
✽
C040
Reference
Identifier
~
O
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X097A1 • 837 • 2300 • REF
PRIOR AUTHORIZATION OR REFERRAL NUMBER
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
New Code Added
REQUIRED
REF02
127
DEFINITION
9F
Referral Number
G1
Prior Authorization Number
Reference Identification
Reference information as defined for a particular Transaction Set or as specified
by the Reference Identification Qualifier
INDUSTRY: Referral
SYNTAX:
Number
R0203
NOT USED
REF03
352
Description
X
NOT USED
REF04
C040
REFERENCE IDENTIFIER
O
OCTOBER 2002
AN
1/80
Original Page Number 182 Dated May 2000
17
004010X097A1 • 837 • 2310A • PRV
REFERRING PROVIDER SPECIALTY INFORMATION
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
REFERRING
004010X097A1
PROVIDER
SPECIALTY
• 837 • 2310A
• PRV INFORMATION
IMPLEMENTATION
REFERRING PROVIDER SPECIALTY
INFORMATION
Loop: 2310A — REFERRING PROVIDER NAME
Usage: SITUATIONAL
Repeat: 1
Notes:
012
100
4
1. Required when adjudication is known to be impacted by provider
taxonomy code.
Note 1. Changed
6
197
2. PRV02 qualifies PRV03.
6
183
Example: PRV✽RF✽ZZ✽1223E0200Y~
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
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
RF
18
Original Page Number 190 Dated May 2000
DEFINITION
Referring
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X097A1 • 837 • 2310B • PRV
RENDERING PROVIDER SPECIALTY INFORMATION
RENDERING
004010X097A1
PROVIDER
SPECIALTY
• 837 • 2310B
• PRV INFORMATION
IMPLEMENTATION
RENDERING PROVIDER SPECIALTY
INFORMATION
Loop: 2310B — RENDERING PROVIDER NAME
Usage: SITUATIONAL
Usage Changed
Repeat: 1
Notes:
6
184
1. The PRV segment in Loop ID-2310 applies to the entire claim unless
overridden on the service line level by the presence of the PRV
segment with the same value in PRV01.
6
197
2. PRV02 qualifies PRV03.
New Note 3. Added
012
100
4
3. Required when adjudication is known to be impacted by provider
taxonomy code.
Example: PRV✽PE✽ZZ✽1223E0200Y~
5
184
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
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
PE
OCTOBER 2002
DEFINITION
Performing
Original Page Number 198 Dated May 2000
19
004010X097A1 • 837 • 2310D • NM1
ASSISTANT SURGEON NAME
INDIVIDUAL OR ORGANIZATIONAL NAME
NM1
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
New Loop and Segment Added
004010X097A1
ASSISTANT SURGEON
NAME• NM1
• 837 • 2310D
IMPLEMENTATION
ASSISTANT SURGEON NAME
Loop: 2310D — ASSISTANT SURGEON NAME Repeat: 1
Usage: SITUATIONAL
Repeat: 1
Notes:
013
100
6
1. Information in the Loop ID-2310 applies to the entire claim unless
overridden on a service line by the presence of loop ID-2420 with the
same value in the NM101.
013
100
7
2. Because the usage of this segment is “situational” this is not a
syntactically required loop. If the loop is used, then it is a “required”
segment. See Appendix A for further details on ASC X12
nomenclature and X12 syntax rules.
013
100
8
3. Required when the Assistant Surgeon information is needed to
facilitate reimbursement of the claim.
015
100
3
4. The Assistant Surgeon information must not be used when the
Rendering Provider loop (Loop ID-2310B) is also present for the claim.
Example: NM1✽DD✽1✽SMITH✽JOHN✽S✽✽✽34✽123456789~
015
100
4
STANDARD
NM1 Individual or Organizational Name
Level: Detail
Position: 250
Loop: 2310 Repeat: 9
Requirement: Optional
Max Use: 1
Purpose: To supply the full name of an individual or organizational entity
Set Notes:
1. Loop 2310 contains information about the rendering, referring, or attending
provider.
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.
DIAGRAM
NM101
NM1
M
ID
NM107
O
NM102
✽
2/3
AN 1/10
1065
Entity Type
Qualifier
M
1039
Name
Suffix
✽
20
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
AN 2/80
New Page inserted after page 208 dated May 2000
ID
2/2
1037
Name
Middle
O
706
Entity
Relat Code
X
NM105
✽
AN 1/25
NM110
✽
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
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
New Segment Added
004010X097A1 • 837 • 2310D • NM1
ASSISTANT SURGEON NAME
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
The entity identifier in NM101 applies to all segments in Loop ID2310.
1000139
CODE
DEFINITION
DD
REQUIRED
NM102
1065
Assistant Surgeon
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
INDUSTRY: Assistant
ALIAS: Assistant
SITUATIONAL
NM104
1036
Last or Organization Name
Surgeon Last Name
Name First
Individual first name
INDUSTRY: Assistant
Required if NM102 = 1 (person).
1542
SITUATIONAL
Surgeon First Name
NM105
1037
Name Middle
Individual middle name or initial
INDUSTRY: Assistant
Surgeon Middle Name
Required when middle name/initial of person is known.
1824
NOT USED
NM106
1038
Name Prefix
O
AN
1/10
SITUATIONAL
NM107
1039
Name Suffix
O
AN
1/10
X
ID
1/2
Suffix to individual name
INDUSTRY: Assistant
Required if known.
1675
REQUIRED
Surgeon Name Suffix
NM108
66
Identification Code Qualifier
Code designating the system/method of code structure used for Identification
Code (67)
SYNTAX:
P0809
CODE
OCTOBER 2002
DEFINITION
24
Employer’s Identification Number
34
Social Security Number
New Page inserted after page 208 dated May 2000
21
004010X097A1 • 837 • 2310D • NM1
ASSISTANT SURGEON NAME
New Segment Added
XX
REQUIRED
NM109
67
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
Health Care Financing Administration National
Provider Identifier
Required value if the National Provider ID is
mandated for use. Otherwise, one of the other listed
codes may be used.
Identification Code
X
AN
2/80
Code identifying a party or other code
INDUSTRY: Assistant
ALIAS: Assistant
SYNTAX:
Surgeon Identifier
Surgeon’s Primary Identification Number
P0809
NOT USED
NM110
706
Entity Relationship Code
X
ID
2/2
NOT USED
NM111
98
Entity Identifier Code
O
ID
2/3
22
New Page inserted after page 208 dated May 2000
OCTOBER 2002
New Segment Added
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
PROVIDER INFORMATION
PRV
004010X097A1 • 837 • 2310D • PRV
ASSISTANT SURGEON SPECIALTY INFORMATION
004010X097A1
ASSISTANT
SURGEON
SPECIALTY
• 837 • 2310D
• PRV INFORMATION
IMPLEMENTATION
ASSISTANT SURGEON SPECIALTY
INFORMATION
Loop: 2310D — ASSISTANT SURGEON NAME
Usage: SITUATIONAL
Repeat: 1
Notes:
013
100
6
1. Information in the Loop ID-2310 applies to the entire claim unless
overridden on a service line by the presence of loop ID-2420 with the
same value in the NM101.
2. Required when the Assistant Surgeon specialty information is needed
to facilitate reimbursement of the claim.
014
100
1
Example: PRV✽AS✽ZZ✽1223S0112Y~
014
100
0
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
AS
OCTOBER 2002
DEFINITION
Assistant Surgeon
New Page inserted after page 208 dated May 2000
23
004010X097A1 • 837 • 2310D • PRV
New Segment
ASSISTANT SURGEON SPECIALTY INFORMATION
REQUIRED
PRV02
128
Added
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
Reference Identification Qualifier
M
ID
2/3
Code qualifying the Reference Identification
CODE
ZZ
Mutually Defined
ZZ is used to indicate the “Health Care Provider
Taxonomy” code list (provider specialty code) which
is available on the Washington Publishing Company
web site: http://www.wpc-edi.com. This taxonomy is
maintained by the Blue Cross Blue Shield
Association and ANSI ASC X12N TG2 WG15.
1697
REQUIRED
DEFINITION
PRV03
127
Reference Identification
M
AN
1/30
Reference information as defined for a particular Transaction Set or as specified
by the Reference Identification Qualifier
INDUSTRY: Provider
ALIAS: Provider
Taxonomy Code
Specialty Code
NOT USED
PRV04
156
State or Province Code
O
NOT USED
PRV05
C035
PROVIDER SPECIALTY INFORMATION
O
NOT USED
PRV06
1223
Provider Organization Code
O
24
New Page inserted after page 208 dated May 2000
ID
2/2
ID
3/3
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
REFERENCE IDENTIFICATION
REF
004010X097A1 • 837 • 2310D • REF
New Segment AddedASSISTANT SURGEON
SECONDARY IDENTIFICATION
004010X097A1
ASSISTANT
SURGEON
SECONDARY
• 837 • 2310D
• REF IDENTIFICATION
IMPLEMENTATION
ASSISTANT SURGEON SECONDARY
IDENTIFICATION
Loop: 2310D — ASSISTANT SURGEON NAME
Usage: SITUATIONAL
Repeat: 1
Notes:
3
184
1. Use this REF segment only if a second number is necessary to
identify the provider. The primary identification number should be
contained in the NM109.
Example: REF✽0B✽12345~
014
100
2
STANDARD
REF Reference Identification
Level: Detail
Position: 271
Loop: 2310
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
✽
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
Code qualifying the Reference Identification
CODE
OCTOBER 2002
DEFINITION
0B
State License Number
1A
Blue Cross Provider Number
1B
Blue Shield Provider Number
1C
Medicare Provider Number
1D
Medicaid Provider Number
1E
Dentist License Number
New Page inserted after page 208 dated May 2000
25
004010X097A1 • 837 • 2310D • REF
ASSISTANT SURGEON SECONDARY IDENTIFICATION New
REQUIRED
REF02
127
Segment Added
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
1H
CHAMPUS Identification Number
G2
Provider Commercial Number
LU
Location Number
TJ
Federal Taxpayer’s Identification Number
X4
Clinical Laboratory Improvement Amendment
Number
X5
State Industrial Accident Provider Number
Reference Identification
X
AN
1/30
Reference information as defined for a particular Transaction Set or as specified
by the Reference Identification Qualifier
INDUSTRY: Assistant
ALIAS: Assistant
SYNTAX:
Surgeon Secondary Identifier
Surgeon Secondary Identification Number
R0203
NOT USED
REF03
352
Description
X
NOT USED
REF04
C040
REFERENCE IDENTIFIER
O
26
New Page inserted after page 208 dated May 2000
AN
1/80
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X097A1 • 837 • 2320 • CAS
CLAIM ADJUSTMENT
CLAIM
004010X097A1
ADJUSTMENT
• 837 • 2320 • CAS
IMPLEMENTATION
CLAIM ADJUSTMENT
Loop: 2320 — OTHER SUBSCRIBER INFORMATION
Usage: SITUATIONAL
Repeat: 5
2
117
Notes:
1. Submitters should use the CAS segment to report claim level
adjustments from prior payers that cause the amount paid to differ
from the amount originally charged.
2Note 2. Changed
117
2. If it is necessary to send more than one Group Code at the claim level,
repeat the CAS segment.
3
117
3. Codes and associated amounts should come from the 835s
(Remittance Advice) received on the claim. If no previous payments
have been made, omit this segment. See the 835 for definitions of the
group codes (CAS01).
9
158
4. Required if the claim has been adjudicated by payer identified in this
loop and has claim level adjustment information.
2
185
5. To locate the claim adjustment reason codes that are used in CAS02,
05, 08, 11, 14 and 17 see the Washington Publishing Company
website: http://www.wpc-edi.com. Follow the buttons to Code Lists Claim Adjustment Reason Codes.
OCTOBER 2002
Original Page Number 213 Dated May 2000
27
004010X097A1 • 837 • 2330B • REF
OTHER PAYER PRIOR AUTHORIZATION OR REFERRAL NUMBER
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
OTHER
004010X097A1
PAYER•PRIOR
837 • 2330B
AUTHORIZATION
OR REFERRAL NUMBER
• REF
IMPLEMENTATION
OTHER PAYER PRIOR AUTHORIZATION OR
REFERRAL NUMBER
Segment Name Changed
Loop: 2330B — OTHER PAYER NAME
Usage: SITUATIONAL
Repeat Changed
Repeat: 2
Notes:
012
100
6
1. Used when the payer identified in this loop has given a prior
authorization or referral number to this claim. This element is
primarily used in payer-to-payer COB situations.
Note 1. Changed
4
201
2. There can only be a maximum of three REF segments in any one
iteration of the 2330 loop.
New Note 3. Added
012
100
3
3. This segment should not be used for Predetermination of Benefits.
Example: REF✽9F✽AB333-Y5~
7
195
STANDARD
REF Reference Identification
Level: Detail
Position: 355
Loop: 2330
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
✽
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
CODE
New Code Added
28
DEFINITION
9F
Referral Number
G1
Prior Authorization Number
Original Page Number 249 Dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X097A1 • 837 • 2330C • NM1
OTHER PAYER PATIENT INFORMATION
004010X097A1
OTHER
PAYER•PATIENT
837 • 2330C
INFORMATION
• NM1
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
REQUIRED
NM109
67
DEFINITION
Member Identification Number
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
OCTOBER 2002
Original Page Number 254 Dated May 2000
29
004010X097A1 • 837 • 2400 • SV3
DENTAL SERVICE
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
DENTAL
004010X097A1
SERVICE
• 837 • 2400 • SV3
REQUIRED
SV301 - 2
234
Product/Service ID
M
AN
1/48
O
AN
2/2
Identifying number for a product or service
INDUSTRY: Procedure
NSF Reference:
1286
1286
SITUATIONAL
Code
FA0-09.0
SV301 - 3
1339
Procedure Modifier
This identifes special circumstances related to the performance of the
service, as defined by trading partners
ALIAS: Procedure
Code Modifier
1287
1287
NSF Reference:
1071
Use this modifier for the first procedure code modifier.
Note Changed
1000127
A modifier must be from code source 135 (American Dental
Association) found in the ’Code on Dental Procedures and
Nomenclature’, if such modifier is available.
SITUATIONAL
FA0-10.0
SV301 - 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
Code Modifier
1288
1288
NSF Reference:
1072
Use this modifier for the second procedure code modifier.
FA0-11.0
Note Changed
A modifier must be from code source 135 (American Dental
Association) found in the ’Code on Dental Procedures and
Nomenclature’, if such modifier is available.
1000127
SITUATIONAL
SV301 - 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
Code Modifier
1289
1289
NSF Reference:
1073
Use this modifier for the third procedure code modifier.
Note Changed
1000127
A modifier must be from code source 135 (American Dental
Association) found in the ’Code on Dental Procedures and
Nomenclature’, if such modifier is available.
30
FA0-12.0
Original Page Number 267 Dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
SITUATIONAL
SV301 - 6
004010X097A1 • 837 • 2400 • SV3
DENTAL SERVICE
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
Code Modifier
1290
1290
NSF Reference:
1074
Use this modifier for the fourth procedure code modifier.
1000127 Note Changed
A modifier must be from code source 135 (American Dental
Association) found in the ’Code on Dental Procedures and
Nomenclature’, if such modifier is available.
FA0-36.0
NOT USED
SV301 - 7
REQUIRED
SV302
352
782
Description
Monetary Amount
O
AN
1/80
O
R
1/18
O
AN
1/2
Monetary amount
INDUSTRY: Line
ALIAS: Line
SEMANTIC:
Item Charge Amount
Charge Amount
SV302 is a submitted charge amount.
1291
1291
NSF Reference:
1605
Zero “0" is an acceptable value for this element.
SITUATIONAL
FA0-13.0
SV303
1331
Facility Code Value
Code identifying the type of facility where services were performed; the first and
second positions of the Uniform Bill Type code or the Place of Service code from
the Electronic Media Claims National Standard Format
INDUSTRY: Facility
Type Code
SV303 is the place of service code representing the location where the
dental treatment was rendered.
SEMANTIC:
1896
Required if the Place of Service is different than the Place of
Service reported in the CLM segment in the 2300 loop.
1000095
Use this element for codes identifying a place of service from code
source 237. As a courtesy, the codes are listed below; however, the
code list is thought to be complete at the time of publication of this
implementation guide. Since this list is subject to change, only
codes contained in the document available from code source 237
are to be supported in this transaction and take precedence over
any and all codes listed here.
11
12
21
22
31
35
SITUATIONAL
SV304
C006
Office
Home
Inpatient Hospital
Outpatient Hospital
Skilled Nursing Facility
Adult Living Care Facility
ORAL CAVITY DESIGNATION
O
To identify one or more areas of the oral cavity
1594
OCTOBER 2002
Required to report areas of the mouth that are being treated.
Original Page Number 268 Dated May 2000
31
004010X097A1 • 837 • 2400 • DTP
DATE - SERVICE
DATE OR TIME OR PERIOD
DTP
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
DATE
004010X097A1
- SERVICE
• 837 • 2400 • DTP
IMPLEMENTATION
DATE - SERVICE
Loop: 2400 — LINE COUNTER
Usage: SITUATIONAL
Repeat: 1
Notes:
2
160
1. Required if the service date is different than the service date reported
at the DTP segment in the 2300 loop and the service was performed.
Replaced Note 1.
Example: DTP✽472✽D8✽19980108~
9
104
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
472
REQUIRED
DTP02
1250
Time Qualifier
DEFINITION
Service
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
32
Original Page Number 273 Dated May 2000
DEFINITION
Date Expressed in Format CCYYMMDD
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X097A1 • 837 • 2400 • REF
PRIOR AUTHORIZATION OR REFERRAL NUMBER
PRIOR
004010X097A1
AUTHORIZATION
OR•REFERRAL
REF
NUMBER
• 837 • 2400
IMPLEMENTATION
PRIOR AUTHORIZATION OR REFERRAL
Segment Name Changed
NUMBER
Loop: 2400 — LINE COUNTER
Usage: SITUATIONAL
Repeat Changed
Repeat: 2
Notes:
Note 1. Changed
1. Required if service line involved a prior authorization number or
referral number that is different than the number reported at the claim.
New
012
100 Note 2. Added
3
2. This segment should not be used for Predetermination of Benefits.
012
100
8
Example: REF✽9F✽123456567~
3
190
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
Description
✽
AN 1/30
X
REF04
✽
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
New Code Added
REQUIRED
REF02
127
DEFINITION
9F
Referral Number
G1
Prior Authorization Number
Reference Identification
Reference information as defined for a particular Transaction Set or as specified
by the Reference Identification Qualifier
INDUSTRY: Referral
SYNTAX:
OCTOBER 2002
Number
R0203
Original Page Number 284 Dated May 2000
33
004010X097A1 • 837 • 2400 • AMT
SALES TAX AMOUNT
New Segment Added
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
SALES
004010X097A1
TAX AMOUNT
• 837 • 2400 • AMT
IMPLEMENTATION
SALES TAX AMOUNT
Loop: 2400 — LINE COUNTER
Usage: SITUATIONAL
Repeat: 1
Notes:
013
100
1
1. Required if sales tax applies to service line and submitter is required
to report that information to the receiver.
Example: AMT✽T✽45~
013
100
0
STANDARD
AMT Monetary Amount
Level: Detail
Position: 475
Loop: 2400
Requirement: Optional
Max Use: 15
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
DEFINITION
T
REQUIRED
AMT02
782
Tax
Monetary Amount
Monetary amount
INDUSTRY: Sales
NOT USED
34
AMT03
478
Tax Amount
Credit/Debit Flag Code
New Page inserted after page 287 dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X097A1 • 837 • 2420A • PRV
RENDERING PROVIDER SPECIALTY INFORMATION
RENDERING
004010X097A1
PROVIDER
SPECIALTY
• 837 • 2420A
• PRV INFORMATION
IMPLEMENTATION
RENDERING PROVIDER SPECIALTY
INFORMATION
Loop: 2420A — RENDERING PROVIDER NAME
Usage Changed
Usage: SITUATIONAL
Repeat: 1
Notes:
6
197
1. PRV02 qualifies PRV03.
New Note 2. Added
012
100
4
2. Required when adjudication is known to be impacted by provider
taxonomy code.
Example: PRV✽PE✽ZZ✽1223P0300Y~
2
192
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
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
PE
OCTOBER 2002
DEFINITION
Performing
Original Page Number 292 Dated May 2000
35
004010X097A1 • 837 • 2420B • REF
OTHER PAYER PRIOR AUTHORIZATION OR REFERRAL NUMBER
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
OTHER
004010X097A1
PAYER•PRIOR
837 • 2420B
AUTHORIZATION
OR REFERRAL NUMBER
• REF
IMPLEMENTATION
OTHER PAYER PRIOR AUTHORIZATION OR
Segment Name Changed
REFERRAL NUMBER
Loop: 2420B — OTHER PAYER REFERRAL NUMBER
Usage: SITUATIONAL
Repeat Changed
Repeat: 2
Notes:
2
197
1. Used when COB Payer (listed in 2330B loop) has one or more linelevel referral numbers for this service line.
New Note 2. Added
012
100
3
2. This segment should not be used for Predetermination of Benefits.
Example: REF✽9F✽AB333-Y6~
0
197
STANDARD
REF Reference Identification
Level: Detail
Position: 525
Loop: 2420
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 ✽
128
Reference
Ident Qual
M
ID
2/3
REF02
127
Reference
Ident
✽
X
REF03
352
Description
✽
AN 1/30
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
X
AN
1/30
Code qualifying the Reference Identification
CODE
New Code Added
REQUIRED
REF02
127
DEFINITION
9F
Referral Number
G1
Prior Authorization Number
Reference Identification
Reference information as defined for a particular Transaction Set or as specified
by the Reference Identification Qualifier
INDUSTRY: Other
SYNTAX:
36
Payer Prior Authorization or Referral Number
R0203
Original Page Number 300 Dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
INDIVIDUAL OR ORGANIZATIONAL NAME
NM1
New Loop and Segment Added
004010X097A1 • 837 • 2420C • NM1
ASSISTANT SURGEON NAME
004010X097A1
ASSISTANT SURGEON
NAME• NM1
• 837 • 2420C
IMPLEMENTATION
ASSISTANT SURGEON NAME
Loop: 2420C — ASSISTANT SURGEON NAME Repeat: 1
Usage: SITUATIONAL
Repeat: 1
Notes:
014
100
4
1. Required if the Assistant Surgeon information in this Loop ID-2420C is
different from the Assistant Surgeon information supplied in the Loop
ID-2310D.
013
100
7
2. Because the usage of this segment is “situational” this is not a
syntactically required loop. If the loop is used, then it is a “required”
segment. See Appendix A for further details on ASC X12
nomenclature and X12 syntax rules.
013
100
8
3. Required when the Assistant Surgeon information is needed to
facilitate reimbursement of the claim.
015
100
5
4. The Assistant Surgeon information must not be used when the
Rendering Provider loop (Loop ID-2420A) is also present for the claim.
Example: NM1✽DD✽1✽SMITH✽JOHN✽S✽✽✽34✽123456789~
015
100
4
STANDARD
NM1 Individual or Organizational Name
Level: Detail
Position: 500
Loop: 2420 Repeat: 10
Requirement: Optional
Max Use: 1
Purpose: To supply the full name of an individual or organizational entity
Set Notes:
Syntax:
1. Loop 2420 contains information about the rendering, referring, or attending
provider on a service line level. These segments override the information in
the claim - level segments if the entity identifier codes in each NM1
segment are the same.
1. P0809
If either NM108 or NM109 is present, then the other is required.
2. C1110
If NM111 is present, then NM110 is required.
OCTOBER 2002
New Page inserted after page 300 dated May 2000
37
004010X097A1 • 837 • 2420C • NM1
ASSISTANT SURGEON NAME
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
New Segment Added
DIAGRAM
NM101
98
Entity ID
Code
NM1 ✽
M
ID
NM107
O
✽
2/3
ID
ID
✽
66
NM109
NM104
O
67
X
X
ID
O
706
1037
Name
Middle
✽
Entity
Relat Code
✽
AN 2/80
NM105
AN 1/25
NM110
ID
Code
1036
Name
First
✽
AN 1/35
✽
1/2
1035
Name Last/
Org Name
O
ID Code
Qualifier
X
NM103
1/1
NM108
✽
AN 1/10
1065
Entity Type
Qualifier
M
1039
Name
Suffix
✽
NM102
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
The entity identifier in NM101 applies to all segments in Loop ID2310.
1000139
CODE
DD
REQUIRED
NM102
1065
DEFINITION
Assistant Surgeon
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
INDUSTRY: Assistant
ALIAS: Assistant
SITUATIONAL
NM104
1036
Surgeon Last or Organization Name
Surgeon Last Name
Name First
Individual first name
INDUSTRY: Assistant
Required if NM102 = 1 (person).
1542
SITUATIONAL
Surgeon First Name
NM105
1037
Name Middle
Individual middle name or initial
INDUSTRY: Assistant
Surgeon Middle Name
Required when middle name/initial of person is known.
1824
NOT USED
NM106
1038
Name Prefix
O
AN
1/10
SITUATIONAL
NM107
1039
Name Suffix
O
AN
1/10
Suffix to individual name
INDUSTRY: Assistant
1555
Surgeon Name Suffix
Required if known.
38 New Page inserted after page 300 dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
New Segment Added
REQUIRED
Identification Code Qualifier
NM108
66
004010X097A1 • 837 • 2420C • NM1
ASSISTANT SURGEON NAME
X
ID
1/2
Code designating the system/method of code structure used for Identification
Code (67)
SYNTAX:
P0809
CODE
REQUIRED
NM109
67
DEFINITION
24
Employer’s Identification Number
34
Social Security Number
XX
Health Care Financing Administration National
Provider Identifier
Required value if the National Provider ID is
mandated for use. Otherwise, one of the other listed
codes may be used.
Identification Code
X
AN
2/80
Code identifying a party or other code
INDUSTRY: Assistant
ALIAS: Assistant
SYNTAX:
Surgeon Identifier
Surgeon’s Primary Identification Number
P0809
NOT USED
NM110
706
Entity Relationship Code
X
ID
2/2
NOT USED
NM111
98
Entity Identifier Code
O
ID
2/3
OCTOBER 2002
New Page inserted after page 300 dated May 2000
39
004010X097A1 • 837 • 2420C • PRV
ASSISTANT SURGEON SPECIALTY INFORMATION
PROVIDER INFORMATION
PRV
New Segment Added ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X097A1
ASSISTANT
SURGEON
SPECIALTY
• 837 • 2420C
• PRV INFORMATION
IMPLEMENTATION
ASSISTANT SURGEON SPECIALTY
INFORMATION
Loop: 2420C — ASSISTANT SURGEON NAME
Usage: SITUATIONAL
Repeat: 1
Notes:
6
197
1. PRV02 qualifies PRV03.
2. Required when the Assistant Surgeon specialty information is needed
to facilitate reimbursement of the claim.
014
100
1
Example: PRV✽AS✽ZZ✽1223S0112Y~
014
100
0
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
AS
DEFINITION
Assistant Surgeon
40 New Page inserted after page 300 dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
REQUIRED
PRV02
128
New Segment Added
004010X097A1 • 837 • 2420C • PRV
ASSISTANT SURGEON SPECIALTY INFORMATION
Reference Identification Qualifier
M
ID
2/3
Code qualifying the Reference Identification
CODE
DEFINITION
ZZ
Mutually Defined
ZZ is used to indicate the “Health Care Provider
Taxonomy” code list (provider specialty code) which
is available on the Washington Publishing Company
web site: http://www.wpc-edi.com. This taxonomy is
maintained by the Blue Cross Blue Shield
Association and ANSI ASC X12N TG2 WG15.
1697
REQUIRED
PRV03
127
Reference Identification
M
AN
1/30
Reference information as defined for a particular Transaction Set or as specified
by the Reference Identification Qualifier
INDUSTRY: Provider
ALIAS: Provider
Taxonomy Code
Specialty Code
NOT USED
PRV04
156
State or Province Code
O
NOT USED
PRV05
C035
PROVIDER SPECIALTY INFORMATION
O
NOT USED
PRV06
1223
Provider Organization Code
O
OCTOBER 2002
ID
2/2
ID
3/3
New Page inserted after page 300 dated May 2000
41
004010X097A1 • 837 • 2420C • REF
New
ASSISTANT SURGEON SECONDARY IDENTIFICATION
REFERENCE IDENTIFICATION
REF
Segment Added ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X097A1
ASSISTANT
SURGEON
SECONDARY
• 837 • 2420C
• REF IDENTIFICATION
IMPLEMENTATION
ASSISTANT SURGEON SECONDARY
IDENTIFICATION
Loop: 2420C — ASSISTANT SURGEON NAME
Usage: SITUATIONAL
Repeat: 1
Notes:
3
184
1. Use this REF segment only if a second number is necessary to
identify the provider. The primary identification number should be
contained in the NM109.
Example: REF✽0B✽12345~
014
100
2
STANDARD
REF Reference Identification
Level: Detail
Position: 525
Loop: 2420
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
✽
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
Code qualifying the Reference Identification
CODE
DEFINITION
0B
State License Number
1A
Blue Cross Provider Number
1B
Blue Shield Provider Number
1C
Medicare Provider Number
1D
Medicaid Provider Number
1E
Dentist License Number
42 New Page inserted after page 300 dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
REQUIRED
REF02
127
New Segment Added
004010X097A1 • 837 • 2420C • REF
ASSISTANT SURGEON SECONDARY IDENTIFICATION
1H
CHAMPUS Identification Number
G2
Provider Commercial Number
LU
Location Number
TJ
Federal Taxpayer’s Identification Number
X4
Clinical Laboratory Improvement Amendment
Number
X5
State Industrial Accident Provider Number
Reference Identification
X
AN
1/30
Reference information as defined for a particular Transaction Set or as specified
by the Reference Identification Qualifier
INDUSTRY: Assistant
ALIAS: Assistant
SYNTAX:
Surgeon Secondary Identifier
Surgeon Secondary Identification Number
R0203
NOT USED
REF03
352
Description
X
NOT USED
REF04
C040
REFERENCE IDENTIFIER
O
OCTOBER 2002
AN
1/80
New Page inserted after page 300 dated May 2000
43
004010X097A1 • 837 • 2430 • SVD
LINE ADJUDICATION INFORMATION
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
LINE
004010X097A1
ADJUDICATION
2430 • SVD
• 837 •INFORMATION
SITUATIONAL
SVD03 - 3
1339
Procedure Modifier
O
AN
2/2
This identifies special circumstances related to the performance of the
service, as defined by trading partners
1071
Use this modifier for the first procedure code modifier.
1938
Required when a modifier clarifies/improves the reporting
accuracy of the associated procedure code.
New Note Added
1000127
A modifier must be from code source 135 (American Dental
Association) found in the ’Code on Dental Procedures and
Nomenclature’, if such modifier is available.
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
1072
Use this modifier for the second procedure code modifier.
1938
Required when a modifier clarifies/improves the reporting
accuracy of the associated procedure code.
New Note Added
A modifier must be from code source 135 (American Dental
Association) found in the ’Code on Dental Procedures and
Nomenclature’, if such modifier is available.
1000127
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
1073
Use this modifier for the third procedure code modifier.
1938
Required when a modifier clarifies/improves the reporting
accuracy of the associated procedure code.
New Note Added
1000127
A modifier must be from code source 135 (American Dental
Association) found in the ’Code on Dental Procedures and
Nomenclature’, if such modifier is available.
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
1074
Use this modifier for the fourth procedure code modifier.
1938
Required when a modifier clarifies/improves the reporting
accuracy of the associated procedure code.
New Note Added
1000127
A modifier must be from code source 135 (American Dental
Association) found in the ’Code on Dental Procedures and
Nomenclature’, if such modifier is available.
SITUATIONAL
SVD03 - 7
352
Description
O
AN
1/80
A free-form description to clarify the related data elements and their
content
INDUSTRY: Procedure
Required if SVC01-7 was returned in the 835 transaction.
2028
NOT USED
44
Code Description
SVD04
234
Product/Service ID
Original Page Number 303 Dated May 2000
O
AN
1/48
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X097A1 • 837
HEALTH CARE CLAIM: DENTAL
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
45
004010X097A1 • 837
HEALTH CARE CLAIM: DENTAL
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.
46
Original Page Number A.6 dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
FUNCTIONAL GROUP HEADER
GS
004010X097A1 • 837 • GS
FUNCTIONAL GROUP HEADER
004010X097A1GROUP
FUNCTIONAL
GS
• 002 • HEADER
IMPLEMENTATION
FUNCTIONAL GROUP HEADER
Example: GS✽HC✽SENDER CODE✽RECEIVER
CODE✽19940331✽0802✽1✽X✽004010X097A1~
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
47
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X097A1 • 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
DEFINITION
004010X097A1 Draft Standards Approved for Publication by ASC
X12 Procedures Review Board through October
1997, as published in this implementation guide.
When using the X12N Health Care Claim: Dental
Implementation Guide, originally published May
2000 as 004010X097 and incorporating the changes
identified in the Addenda, the value used in GS08
must be “004010X097A1”.
004010X097A1 • 837
48
Original Page Number B.9 dated May 2000
OCTOBER 2002
| File Type | application/pdf |
| File Modified | 2002-10-31 |
| File Created | 2001-08-31 |