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

X093A1

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

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ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X093A1 • 276/277
HEALTH CARE CLAIM STATUS REQUEST AND RESPONSE

National Electronic Data Interchange
Transaction Set Implementation Guide

A
D
D
E
N
D
A

Health Care Claim
Status Request
and Response
276/277
ASC X12N 276/277 (004010X093A1)

October 2002
OCTOBER 2002

004010X093A1 • 276/277
HEALTH CARE CLAIM STATUS REQUEST AND RESPONSE

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.

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X093A1 • 276/277
HEALTH CARE CLAIM STATUS REQUEST AND RESPONSE

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

OCTOBER 2002

004010X093A1 • 276/277
HEALTH CARE CLAIM STATUS REQUEST AND RESPONSE

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

OCTOBER 2002

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IMPLEMENTATION GUIDE

004010X093A1 • 276/277
HEALTH CARE CLAIM STATUS REQUEST AND RESPONSE

1 Introduction to Modified Pages
This document is addenda to the X12N Health Care Claim Status Request and
Response Implementation Guide, originally published May 2000 as 004010X093.
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 004010X093 Implementation Guide. Since the X12N
004010X093 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 Status Request and Response Implementation Guide, originally published May 2000 as 004010X093
and incorporating the changes identified in the Addenda, the value used in GS08
must be “004010X093A1".
Each of the changes made to the 004010X093 Implementation Guide has been
annotated with a note in red and a line pointing to the location of the change. For
convenience, the affected 004010X093 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

004010X093A1 • 276/277
HEALTH CARE CLAIM STATUS REQUEST AND RESPONSE

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

Note Changed

2.2.3.3.2
Note Changed

004010X093A1 • 276/277
HEALTH CARE CLAIM STATUS REQUEST AND RESPONSE

TRN02 = 1722634842
The value shown is a unique trace or reference number from the originator of
the transaction. This number is to be returned by the receiver of the transaction. An example is an internal patient control number or other unique identifier
within the originator's system.

REF Segment at the Claim Level
The REF segment identifies the specific claim in question. The payer’s primary
identifier frequently - payer claim control number - and the institutional type of bill,
which is a supplemental identifier, are found in the REF segment. The medical record number, a supplemental identifier for the provider’s use, also is located in
the REF segment. The REF segment can be repeated a maximum of three times
in this location.
The following are coding examples of the REF segment:

REF*1K*9918046987~
REF*BLT*131~
REF*EA*JS980503LAB~
REF*1K*9918046987~

Payer’s claim control number
Institutional type of bill
Provider’s medical record
number

Note Changed

Within the REF,
REF01 = 1K
This value indicates that the next data element contains the payer’s assigned
claim number.
REF02 = 9918046987
The value shown is the actual claim number assigned by the payer for this claim.
In subsequent transaction set exchanges involving this claim, the provider returns
the value found in this element to the payer. The payer locates the “key” data element (i.e., the claim number in this element) for his or her data files/databases.
When REF01 is BLT, REF02 contains the institutional type of bill (e.g., 131).
When REF01 is EA, REF02 contains the patient’s medical record number assigned by the provider.
The sequence of the appearance of 1K, BLT or EA segments is not significant,
but the segments must be contiguous.

2.2.3.3.3

AMT Segment
The AMT segment indicates the total monetary amount of the billed services on
the claim.
The following is a coding example of the AMT segment:

AMT*T3*75~
Within the AMT,
AMT01 = T3
This is the amount code qualifier. When it is populated with T3, the subsequent data value is known to be total submitted charges.

OCTOBER 2002

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ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

X04010X093A1 • 276
X04010X093A1 • 276

Table 2 - Subscriber Detail
PAGE #

POS. # SEG. ID

NAME

USAGE

REPEAT

70
72

010
040

HL
DMG

LOOP ID - 2000D SUBSCRIBER LEVEL
Subscriber Level
Subscriber Demographic Information

050

NM1

LOOP ID - 2100D SUBSCRIBER NAME
Subscriber Name

S
S
S
S
S
S
S

1
1
1
1
1
1
1

S
S
R

1
1
1

77
78
80
82
84
85
87

090
100
100
100
100
110
120

TRN
REF
REF
REF
REF
AMT
DTP

LOOP ID - 2200D CLAIM SUBMITTER TRACE
NUMBER
Usage Changed
Claim Submitter Trace Number
Payer Claim Identification Number
Institutional Bill Type Identification
Medical Record Identification
Group Number
Claim Submitted Charges
Claim Service Date

89
92
94

130
140
150

SVC
REF
DTP

LOOP ID - 2210D SERVICE LINE INFORMATION
Service Line Information
Service Line Item Identification
Service Line Date

LOOP REPEAT

>1
R
S

1
1
1

Loop Repeat Changed
R

1
>1

Table 2 - Dependent Detail
PAGE #

POS. # SEG. ID

NAME

95
97

010
040

HL
DMG

LOOP ID - 2000E DEPENDENT LEVEL
Dependent Level
Dependent Demographic Information

050

NM1

LOOP ID - 2100E DEPENDENT NAME
Dependent Name

102
104
106
108
110
112

090
100
100
100
110
120

TRN
REF
REF
REF
AMT
DTP

114
118
119
121

130
140
150
160

SVC
REF
DTP
SE

USAGE

REPEAT

>1
S
R

1
1

Loop Repeat Changed
R

LOOP ID - 2200E CLAIM SUBMITTER TRACE NUMBER
Claim Submitter Trace Number
Payer Claim Identification Number
Institutional Bill Type Identification
Medical Record Identification
Claim Submitted Charges
Claim Service Date

R
S
S
S
S
S

1
1
1
1
1
1

LOOP ID - 2210E SERVICE LINE INFORMATION
Service Line Information
Service Line Item Identification
Service Line Date
Transaction Set Trailer

S
S
S
R

1
1
1
1

Original Page Number 46 dated May 2000

LOOP REPEAT

1
>1

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

X04010X093A1 • 276 • 2100D • NM1
SUBSCRIBER NAME

SUBSCRIBER
X04010X093A1NAME
• 276 • 2100D • NM1

IMPLEMENTATION

SUBSCRIBER NAME
Loop Repeat Changed

Loop: 2100D — SUBSCRIBER NAME Repeat: 1
Usage: REQUIRED
Repeat: 1

Example: NM1✽QC✽1✽SMITH✽FRED✽✽✽✽MI✽123456789A~ or
NM1✽IL✽1✽SMITH✽ROBERT✽✽✽✽MI✽9876543210~

1
115
STANDARD

NM1 Individual or Organizational Name
Level: Detail
Position: 050
Loop: 2100 Repeat: >1
Requirement: Optional
Max Use: 1
Purpose: To supply the full name of an individual or organizational entity
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

Entity ID
Code

NM1 ✽
M

NM107

✽

2/3

✽

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

1/2

✽
O

ID
Code

1036

Name
First

AN 1/35

NM109

✽

NM104

AN 2/80

706

Entity
Relat Code

1037

Name
Middle

✽

AN 1/25

NM110

✽

NM105

AN 1/25

2/2

AN 1/10

Entity ID
Code
O

1038

Name
Prefix

✽

NM111

✽

NM106

2/3

ELEMENT SUMMARY

USAGE

REF.
DES.

REQUIRED

NM101

DATA
ELEMENT

NAME

ATTRIBUTES

Entity Identifier Code

2/3

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

1012

OCTOBER 2002

DEFINITION

Insured or Subscriber

Patient
Use this code only when the subscriber is the
patient.

Original Page Number 74 dated May 2000

004010X093A1 • 276 • 2200D • TRN
CLAIM SUBMITTER TRACE NUMBER

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X093A1
CLAIM
SUBMITTER
NUMBER
• 276TRACE
• 2200D
• TRN

IMPLEMENTATION

CLAIM SUBMITTER TRACE NUMBER
Loop: 2200D — CLAIM SUBMITTER TRACE NUMBER Repeat: >1
Usage Changed

Usage: SITUATIONAL
Repeat: 1
Notes:

5
116

1. This segment is required if the subscriber is the patient. If the
subscriber is not the patient do not use this segment, use TRN
segment in Loop 2200E.

Note 1. Changed

2. Use this segment to convey a unique trace or reference number from
the originator of the transaction to be returned by the receiver of the
transaction.

6
116

Note
7 3. Changed
116

3. The TRN segment is required by the ASC X12 syntax when Loop ID2200D is used.

Example: TRN✽1✽1722634842~

4
113
STANDARD

TRN Trace
Level: Detail
Position: 090
Loop: 2200 Repeat: >1
Requirement: Optional
Max Use: 1
Purpose: To uniquely identify a transaction to an application
DIAGRAM

TRN01

TRN ✽

481

Trace Type
Code
M

1/2

TRN02

✽

127

Reference
Ident
M

TRN03

509

TRN04

✽ Originating ✽
Company ID

AN 1/30

AN 10/10

127

Reference
Ident
O

AN 1/30

ELEMENT SUMMARY

USAGE

REF.
DES.

REQUIRED

TRN01

DATA
ELEMENT

481

NAME

ATTRIBUTES

Trace Type Code

1/2

Code identifying which transaction is being referenced
CODE

Original Page Number 77 dated May 2000

DEFINITION

Current Transaction Trace Numbers

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

REQUIRED

TRN02

127

004010X093A1 • 276 • 2200D • TRN
CLAIM SUBMITTER TRACE NUMBER

Reference Identification

1/30

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

Alias Added

SEMANTIC:

Note Added
1000104

Number

Account Number

TRN02 provides unique identification for the transaction.

This data element corresponds to the CLM01 data element of the
ASC X12N Dental, Institutional, and Professional Implementation
Guide(s). Paper based claims may not require a Patient Account
Number for adjudication. When inquiring on paper based claims the
trace number is required to be returned in the TRN of the 277
Health Care Claim Status Response transaction in TRN02.

NOT USED

TRN03

509

Originating Company Identifier

10/10

NOT USED

TRN04

127

Reference Identification

1/30

OCTOBER 2002

Original Page Number 77 dated May 2000

004010X093A1 • 276 • 2200D • REF
PAYER CLAIM IDENTIFICATION NUMBER

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X093A1
PAYER
CLAIM IDENTIFICATION
NUMBER
• 276 • 2200D • REF

IMPLEMENTATION

PAYER CLAIM IDENTIFICATION NUMBER
Loop: 2200D — CLAIM SUBMITTER TRACE NUMBER
Usage: SITUATIONAL
Repeat: 1
Notes:

1
117

1. Use this only if the subscriber is the patient.

2
117

2. This is the payer’s assigned control number, also known as, Internal
Control Number (ICN), Document Control Number (DCN), or Claim
Control Number (CCN). This should be sent on claim inquiries when
the number is known.

New
010
100 Note 3. Added
1

3. The authors recommend sending this segment on claim inquires
when the information is known. It will provide a direct look up key into
the payer’s adjudication system and will reduce the possibility of
returning more claim status information than was intended. For
example, when a claim status inquiry is performed and many claims
meet the conditions of the inquiry all will be returned. By providing
the information within this particular segment the search criteria is
narrowed to the specific claim in question.
4. The total number of REF segments in the 2200 Loop cannot exceed 3.

New
009
100Note 4. Added
5

Example: REF✽1K✽9918046987~

0
117
STANDARD

REF Reference Identification
Level: Detail
Position: 100
Loop: 2200
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
ID

2/3

REF02

127

Reference
Ident

✽
X

AN 1/30

REF03

✽

352

Description
X

Original Page Number 78 dated May 2000

AN 1/80

REF04

✽

C040

Reference
Identifier

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X093A1 • 276 • 2200D • REF
PAYER CLAIM IDENTIFICATION NUMBER

ELEMENT SUMMARY

USAGE

REF.
DES.

REQUIRED

REF01

DATA
ELEMENT

128

NAME

ATTRIBUTES

Reference Identification Qualifier

2/3

1/30

Code qualifying the Reference Identification

1082

Examples of this element include ICN, DCN, CCN.

1173

Submit this element if the payer supplied it previously.
CODE

Note Deleted
REQUIRED

REF02

127

DEFINITION

Payor’s Claim Number

Reference Identification

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

Alias Deleted

SYNTAX:

Claim Control Number

R0203

NOT USED

REF03

352

Description

NOT USED

REF04

C040

REFERENCE IDENTIFIER

OCTOBER 2002

Original Page Number 79 dated May 2000

1/80

004010X093A1 • 276 • 2200D • REF
INSTITUTIONAL BILL TYPE IDENTIFICATION

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

INSTITUTIONAL• BILL
004010X093A1
276 •TYPE
2200D
IDENTIFICATION
• REF

IMPLEMENTATION

INSTITUTIONAL BILL TYPE IDENTIFICATION
Loop: 2200D — CLAIM SUBMITTER TRACE NUMBER
Usage: SITUATIONAL
Repeat: 1
Notes:

0
107

1. This segment is the institutional bill type submitted on the original
claim. The institutional bill type consists of the two position, Facility
Type Code, and the one position, Claim Frequency Code. The payer
may use it as a primary lookup key.

Note 1. Changed

New Note 3. Added

2. Only use this segment if the subscriber is the patient and bill type is
being sent in the inquiry request in connection with an institutional
bill.

2
117

3. The total number of REF segments in the 2200 Loop cannot exceed 3.

2
111

Example: REF✽BLT✽111~

7
105
STANDARD

REF Reference Identification
Level: Detail
Position: 100
Loop: 2200
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

2/3

REF02

127

Reference
Ident

✽
X

REF03

✽

AN 1/30

352

Description
X

AN 1/80

REF04

C040

Reference
Identifier

✽

ELEMENT SUMMARY

USAGE

REF.
DES.

REQUIRED

REF01

DATA
ELEMENT

128

NAME

ATTRIBUTES

Reference Identification Qualifier

2/3

Code qualifying the Reference Identification
CODE

BLT

Original Page Number 80 dated May 2000

DEFINITION

Billing Type

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

REQUIRED

REF02

127

004010X093A1 • 276 • 2200D • REF
INSTITUTIONAL BILL TYPE IDENTIFICATION

Reference Identification

1/30

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

Type Identifier

R0203

Found on UB92 - record 40 - 4
As submitted on the Institutional 837 claim in composite element
CLM05.
Found on UB92 paper form locator 4

1000106
Note Changed

Required for institutional claims inquiries.

1098
NOT USED

REF03

352

Description

NOT USED

REF04

C040

REFERENCE IDENTIFIER

OCTOBER 2002

Original Page Number 81 dated May 2000

1/80

004010X093A1 • 276 • 2200D • REF
MEDICAL RECORD IDENTIFICATION

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X093A1
MEDICAL
RECORD
• 276IDENTIFICATION
• 2200D • REF

IMPLEMENTATION

MEDICAL RECORD IDENTIFICATION
Loop: 2200D — CLAIM SUBMITTER TRACE NUMBER
Usage: SITUATIONAL
Repeat: 1
Notes:

5
115

1. This is the Medical Record number submitted on the original claim
and should be sent when available from the submitted claim.

8
102

2. Use this only if the subscriber is the patient.

New
009
100 Note 3. Added
5

3. The total number of REF segments in the 2200 Loop cannot exceed 3.

Example: REF✽EA✽J354789~

5
105
STANDARD

REF Reference Identification
Level: Detail
Position: 100
Loop: 2200
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

2/3

REF02

127

Reference
Ident

✽
X

REF03

352

REF04

✽ Description ✽

AN 1/30

AN 1/80

C040

Reference
Identifier

ELEMENT SUMMARY

USAGE

REF.
DES.

REQUIRED

REF01

DATA
ELEMENT

128

NAME

ATTRIBUTES

Reference Identification Qualifier

2/3

Code qualifying the Reference Identification
CODE

Original Page Number 82 dated May 2000

DEFINITION

Medical Record Identification Number

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

REQUIRED

REF02

127

004010X093A1 • 276 • 2200D • REF
MEDICAL RECORD IDENTIFICATION

Reference Identification

1/30

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

Record Number

R0203

Found on UB92 record 20 field 25
As submitted on the Dental, Institutional, and Professional 837
Claim in Medical Record Number segment in REF02 (EA)
Found on UB92 paper form locator 23

1000107

Note Changed

NOT USED

REF03

352

Description

NOT USED

REF04

C040

REFERENCE IDENTIFIER

OCTOBER 2002

1/80

Original Page Number 82 dated May 2000

X04010X093A1 • 276 • 2200D • REF
GROUP NUMBER

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

GROUP
X04010X093A1
NUMBER
• 276 • 2200D • REF

IMPLEMENTATION

New REF segment added

GROUP NUMBER

Loop: 2200D — CLAIM SUBMITTER TRACE NUMBER
Usage: SITUATIONAL
Repeat: 1
Notes:

009
100
2

1. This REF segment is used to identify the location or Application
System Number believed to contain the claim being inquired upon.
For example, if a payer has multiple adjudication systems processing
the same type of claim (e.g. professional or Institutional) and this
Location Number points to the proper system that contains
information about the claim being inquired upon.
In Institutional claim situations where REF01 contains LU the inquirer
must determine which REF segment (Bill Type or Medical Record
Number) not to be included in the inquiry transaction.
2. The total number of REF segments in the 2200 loop cannot exceed 3.

009
100
3
5
105

Example: REF✽LU✽SYS5963~

STANDARD

REF Reference Identification
Level: Detail
Position: 100
Loop: 2200
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

2/3

REF02

127

Reference
Ident

✽
X

REF03

✽

AN 1/30

352

Description
X

AN 1/80

REF04

C040

Reference
Identifier

✽

ELEMENT SUMMARY

USAGE

REF.
DES.

REQUIRED

REF01

DATA
ELEMENT

128

NAME

ATTRIBUTES

Reference Identification Qualifier

2/3

Code qualifying the Reference Identification
CODE

DEFINITION

Location Number

New Page Inserted after original page number 83 dated May 2000

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

REQUIRED

REF02

127

X04010X093A1 • 276 • 2200D • REF
GROUP NUMBER

Reference Identification

1/30

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

Number

R0203

NOT USED

REF03

352

Description

NOT USED

REF04

C040

REFERENCE IDENTIFIER

OCTOBER 2002

1/80

New Page Inserted after original page number 83 dated May 2000

X04010X093A1 • 276 • 2100E • NM1
DEPENDENT NAME

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

X04010X093A1NAME
DEPENDENT
• 276 • 2100E • NM1

IMPLEMENTATION

DEPENDENT NAME
Loop Repeat Changed

Loop: 2100E — DEPENDENT NAME Repeat: 1
Usage: REQUIRED
Repeat: 1

Example: NM1✽QC✽1✽SMITH✽JOSEPH✽L✽✽✽✽MI✽12345678902~

3
115
STANDARD

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

Entity ID
Code

NM1 ✽
M

NM107

✽

2/3

✽

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

NM109

ID
Code

706

2/2

1037

Name
Middle

✽

Entity
Relat Code
X

NM105

AN 1/25

NM110

✽

AN 2/80

1036

Name
First

✽

AN 1/35

✽

1/2

NM104

AN 1/25

AN 1/10

Entity ID
Code
O

1038

Name
Prefix

✽

NM111

✽

NM106

2/3

ELEMENT SUMMARY

USAGE

REF.
DES.

REQUIRED

NM101

DATA
ELEMENT

NAME

ATTRIBUTES

Entity Identifier Code

2/3

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

QC
REQUIRED

NM102

1065

DEFINITION

Patient

Entity Type Qualifier

1/1

Code qualifying the type of entity
SEMANTIC:

NM102 qualifies NM103.

CODE

Original Page Number 98 dated May 2000

DEFINITION

Person

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X093A1 • 276 • 2200E • TRN
CLAIM SUBMITTER TRACE NUMBER

CLAIM
004010X093A1
SUBMITTER
NUMBER
• 276TRACE
• 2200E
• TRN

IMPLEMENTATION

CLAIM SUBMITTER TRACE NUMBER
Loop: 2200E — CLAIM SUBMITTER TRACE NUMBER Repeat: >1
Usage: REQUIRED
Repeat: 1
Notes:

6
117

1. Use of this segment is required if the patient is someone other than
the subscriber.
2. Use this segment to convey a unique trace or reference number from
the originator of the transaction to be returned by the receiver of the
transaction.

7
117

Note
010
1003. Changed
8

3. The TRN segment is required by the ASC X12 syntax when Loop ID2200E is used.

Example: TRN✽1✽1722634842~

6
113
STANDARD

TRN Trace
Level: Detail
Position: 090
Loop: 2200 Repeat: >1
Requirement: Optional
Max Use: 1
Purpose: To uniquely identify a transaction to an application
DIAGRAM

TRN01

TRN ✽

481

Trace Type
Code
M

1/2

TRN02

✽

127

Reference
Ident
M

TRN03

509

TRN04

✽ Originating ✽
Company ID

AN 1/30

AN 10/10

127

Reference
Ident
O

AN 1/30

ELEMENT SUMMARY

USAGE

REF.
DES.

REQUIRED

TRN01

DATA
ELEMENT

481

NAME

ATTRIBUTES

Trace Type Code

1/2

Code identifying which transaction is being referenced
CODE

OCTOBER 2002

DEFINITION

Current Transaction Trace Numbers

Original Page Number 101 dated May 2000

004010X093A1 • 276 • 2200E • TRN
CLAIM SUBMITTER TRACE NUMBER

REQUIRED

TRN02

127

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

Reference Identification

1/30

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

Alias Added

SEMANTIC:

Number

Account Number

TRN02 provides unique identification for the transaction.

1000104
Note Added

NOT USED

TRN03

509

Originating Company Identifier

10/10

NOT USED

TRN04

127

Reference Identification

1/30

Original Page Number 101 dated May 2000

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X093A1 • 276 • 2200E • REF
PAYER CLAIM IDENTIFICATION NUMBER

PAYER
004010X093A1
CLAIM IDENTIFICATION
NUMBER
• 276 • 2200E • REF

IMPLEMENTATION

PAYER CLAIM IDENTIFICATION NUMBER
Loop: 2200E — CLAIM SUBMITTER TRACE NUMBER
Usage: SITUATIONAL
Note Changed

Repeat: 1
Notes:

009
100
4

1. Use this segment only if the patient is someone other than the
subscriber.

009
100
8

2. This is the payer’s assigned control number, also known as, Internal
Control Number (ICN), Document Control Number (DCN), or Claim
Control Number (CCN).

009
100
9

009
100Note 4. Added
5
New

Example: REF✽1K✽9918046987~

2
118
STANDARD

REF Reference Identification
Level: Detail
Position: 100
Loop: 2200
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 ✽

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

Original Page Number 103 dated May 2000

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

X04010X093A1 • 277
X04010X093A1 • 277

Table 2 - Subscriber Detail
PAGE #

POS. # SEG. ID

NAME

USAGE

REPEAT

148
150

010
040

HL
DMG

LOOP ID - 2000D SUBSCRIBER LEVEL
Subscriber Level
Subscriber Demographic Information

152

050

NM1

LOOP ID - 2100D SUBSCRIBER NAME
Subscriber Name

S
R
S
S
S
S

1
1
1
1
1
1

S
S
S
S

1
1
1
1

155
156
167
169
171
173

090
100
110
110
110
120

TRN
STC
REF
REF
REF
DTP

LOOP ID - 2200D CLAIM SUBMITTER TRACE
NUMBER
Usage Changed
Claim Submitter Trace Number
Claim Level Status Information
Payer Claim Identification Number
Institutional Bill Type Identification
Medical Record Identification
Claim Service Date

175
179
189
190

180
190
200
210

SVC
STC
REF
DTP

LOOP ID - 2220D SERVICE LINE INFORMATION
Service Line Information
Service Line Status Information
Service Line Item Identification
Service Line Date

LOOP REPEAT

>1
R
S

1
1

Loop Repeat Changed
R

1
>1

Table 2 - Dependent Detail
PAGE #

POS. # SEG. ID

NAME

192
194

010
040

HL
DMG

LOOP ID - 2000E DEPENDENT LEVEL
Dependent Level
Dependent Demographic Information

196

050

NM1

LOOP ID - 2100E DEPENDENT NAME
Dependent Name

199
201
212
214
216
218

090
100
110
110
110
120

TRN
STC
REF
REF
REF
DTP

220
223
233
234
236

180
190
200
210
270

SVC
STC
REF
DTP
SE

USAGE

REPEAT

>1
S
R

1
1

Loop Repeat Changed
R

LOOP ID - 2200E CLAIM SUBMITTER TRACE NUMBER
Claim Submitter Trace Number
Claim Level Status Information
Payer Claim Identification Number
Institutional Bill Type Identification
Medical Record Identification
Claim Service Date

R
R
R
S
S
S

1
1
1
1
1
1

LOOP ID - 2220E SERVICE LINE INFORMATION
Service Line Information
Service Line Status Information
Service Line Item Identification
Service Line Date
Transaction Set Trailer

S
S
S
S
R

1
1
1
1
1

24 Original Page Number 122 dated May 2000

LOOP REPEAT

1
>1

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

X04010X093A1 • 277 • 2000D • DMG
SUBSCRIBER DEMOGRAPHIC INFORMATION

SUBSCRIBER
X04010X093A1DEMOGRAPHIC
DMG
• 277 • 2000D • INFORMATION

IMPLEMENTATION

SUBSCRIBER DEMOGRAPHIC INFORMATION
Loop: 2000D — SUBSCRIBER LEVEL
Usage changed from Required to Situational
Usage: SITUATIONAL
New Note

Repeat: 1
Notes:

009
100
4

1. Required when the subscriber is the patient. Not used when the
subscriber is not the patient.

Example: DMG✽D8✽19330706✽M~

2
107
STANDARD

DMG Demographic Information
Level: Detail
Position: 040
Loop: 2000
Requirement: Optional
Max Use: 1
Purpose: To supply demographic information
1. The DMG segment may only appear at the Subscriber (HL03=22) or
Dependent (HL03=23) level.

Set Notes:
Syntax:

1. P0102
If either DMG01 or DMG02 is present, then the other is required.

DIAGRAM

DMG01

DMG ✽

1250

Date Time
format Qual
X

✽
X

DMG08

Country
Code
2/3

✽

1251

Date Time
Period

2/3

DMG07

✽

DMG02

1068

Gender
Code

✽

AN 1/35

659

Basis of
Verif Code
O

DMG03

DMG09

✽
O

1067

DMG05

1109

DMG06

1066

Marital
Race or
✽
✽
✽ Citizenship
Status Code
Ethnic Code
Status Code
1/1

1/1

1/2

380

Quantity

1/2

DMG04

1/15

ELEMENT SUMMARY

USAGE

REF.
DES.

REQUIRED

DMG01

DATA
ELEMENT

1250

NAME

ATTRIBUTES

Date Time Period Format Qualifier

2/3

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

P0102

CODE

OCTOBER 2002

DEFINITION

Date Expressed in Format CCYYMMDD

Original Page Number 148 dated May 2000

X04010X093A1 • 277 • 2100D • NM1
SUBSCRIBER NAME

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

SUBSCRIBER
X04010X093A1NAME
• 277 • 2100D • NM1

IMPLEMENTATION

SUBSCRIBER NAME
Loop Repeat Changed

Loop: 2100D — SUBSCRIBER NAME Repeat: 1
Usage: REQUIRED
Repeat: 1

Example: NM1✽QC✽1✽SMITH✽FRED✽✽✽✽MI✽123456789A~ or
NM1✽IL✽1✽SMITH✽ROBERT✽✽✽✽MI✽9876543210~

5
116
STANDARD

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

Entity ID
Code

NM1 ✽
M

NM107

✽

2/3

✽

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

1/2

ID
Code
AN 2/80

706

1037

Name
Middle

✽

Entity
Relat Code
X

NM105

AN 1/25

NM110

✽

1036

Name
First

✽

AN 1/35

NM109

✽

NM104

AN 1/25

2/2

AN 1/10

Entity ID
Code
O

1038

Name
Prefix

✽

NM111

✽

NM106

2/3

ELEMENT SUMMARY

USAGE

REF.
DES.

REQUIRED

NM101

DATA
ELEMENT

NAME

ATTRIBUTES

Entity Identifier Code

2/3

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

Insured or Subscriber

Patient

1026

DEFINITION

Original Page Number 150 dated May 2000

Use this only when the subscriber is the patient.

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X093A1 • 277 • 2200D • TRN
CLAIM SUBMITTER TRACE NUMBER

004010X093A1
CLAIM
SUBMITTER
NUMBER
• 277TRACE
• 2200D
• TRN

IMPLEMENTATION

CLAIM SUBMITTER TRACE NUMBER
Loop: 2200D — CLAIM SUBMITTER TRACE NUMBER Repeat: >1
Usage Changed

Usage: SITUATIONAL
Repeat: 1
Notes:

009
100
6

1. This segment is required if the subscriber is the patient. If the
subscriber is not the patient do not use this segment, use TRN
segment in Loop 2200E.

Note 1. Changed

2. This trace number is the trace or reference number from the originator
of the transaction that was provided at the corresponding level within
the 276 (Health Care Claim Status Request) transaction.

008
100
5

Note
009
1003. Changed
8

3. The TRN segment is required by the ASC X12 syntax when Loop ID2200D is used.

Example: TRN✽2✽172263482~

009
100
1
STANDARD

TRN Trace
Level: Detail
Position: 090
Loop: 2200 Repeat: >1
Requirement: Optional
Max Use: 1
Purpose: To uniquely identify a transaction to an application
DIAGRAM

TRN01

TRN ✽

481

Trace Type
Code
M

1/2

TRN02

✽

127

Reference
Ident
M

TRN03

509

TRN04

✽ Originating ✽
Company ID

AN 1/30

AN 10/10

127

Reference
Ident
O

AN 1/30

ELEMENT SUMMARY

USAGE

REF.
DES.

REQUIRED

TRN01

DATA
ELEMENT

481

NAME

ATTRIBUTES

Trace Type Code

1/2

Code identifying which transaction is being referenced
CODE

OCTOBER 2002

DEFINITION

Referenced Transaction Trace Numbers

Original Page Number 153 dated May 2000

004010X093A1 • 277 • 2200D • TRN
CLAIM SUBMITTER TRACE NUMBER

REQUIRED

TRN02

127

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

Reference Identification

1/30

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

Alias Added

SEMANTIC:

Number

Account Number

TRN02 provides unique identification for the transaction.

1000099
Note Added

NOT USED

TRN03

509

Originating Company Identifier

10/10

NOT USED

TRN04

127

Reference Identification

1/30

Original Page Number 153 dated May 2000

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X093A1 • 277 • 2200D • REF
PAYER CLAIM IDENTIFICATION NUMBER

004010X093A1
PAYER
CLAIM IDENTIFICATION
NUMBER
• 277 • 2200D • REF

IMPLEMENTATION

PAYER CLAIM IDENTIFICATION NUMBER
Loop: 2200D — CLAIM SUBMITTER TRACE NUMBER
Usage: SITUATIONAL
Repeat: 1
Notes:

008
100
7

1. Use this only if the subscriber is the patient.

008
100
8

New
009
100 Note 3. Added
5

3. The total number of REF segments in the 2200 Loop cannot exceed 3.

Example: REF✽1K✽9918046987~

5
119
STANDARD

REF Reference Identification
Level: Detail
Position: 110
Loop: 2200
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

2/3

REF02

127

Reference
Ident

✽
X

REF03

✽

AN 1/30

352

Description
X

REF04

✽

AN 1/80

C040

Reference
Identifier

ELEMENT SUMMARY

USAGE

REF.
DES.

REQUIRED

REF01

DATA
ELEMENT

128

NAME

ATTRIBUTES

Reference Identification Qualifier

2/3

Code qualifying the Reference Identification

Examples of this element include: ICN, DCN and CCN.

1197

CODE

DEFINITION

Payor’s Claim Number

Note Deleted

OCTOBER 2002

Original Page Number 165 dated May 2000

004010X093A1 • 277 • 2200D • REF
PAYER CLAIM IDENTIFICATION NUMBER

REQUIRED

REF02

127

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

Reference Identification

1/30

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

Alias Deleted

SYNTAX:

Claim Control Number

R0203

NOT USED

REF03

352

Description

NOT USED

REF04

C040

REFERENCE IDENTIFIER

Original Page Number 166 dated May 2000

1/80

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X093A1 • 277 • 2200D • REF
INSTITUTIONAL BILL TYPE IDENTIFICATION

INSTITUTIONAL• BILL
004010X093A1
277 •TYPE
2200D
IDENTIFICATION
• REF

IMPLEMENTATION

INSTITUTIONAL BILL TYPE IDENTIFICATION
Loop: 2200D — CLAIM SUBMITTER TRACE NUMBER
Usage: SITUATIONAL
Repeat: 1
Notes:

Note 1. Changed

New Note 3. Added

8
110

2. Use when subscriber is the patient.

2
7
1

3. The total number of REF segments in the 2200 Loop cannot exceed 3.

7
110

Example: REF✽BLT✽111~

4
106
STANDARD

REF Reference Identification
Level: Detail
Position: 110
Loop: 2200
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

2/3

REF02

127

Reference
Ident

✽
X

REF03

✽

AN 1/30

352

Description
X

REF04

✽

AN 1/80

C040

Reference
Identifier

ELEMENT SUMMARY

USAGE

REF.
DES.

REQUIRED

REF01

DATA
ELEMENT

128

NAME

ATTRIBUTES

Reference Identification Qualifier

2/3

Code qualifying the Reference Identification
CODE

BLT

OCTOBER 2002

DEFINITION

Billing Type

Original Page Number 167 dated May 2000

004010X093A1 • 277 • 2200D • REF
MEDICAL RECORD IDENTIFICATION

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X093A1
MEDICAL
RECORD
• 277IDENTIFICATION
• 2200D • REF

IMPLEMENTATION

MEDICAL RECORD IDENTIFICATION
Loop: 2200D — CLAIM SUBMITTER TRACE NUMBER
Usage: SITUATIONAL
Repeat: 1
Notes:

4
114

1. This is the Medical Record number submitted on the original claim
and should be returned when available from the the submitted claim.

6
102

2. Use this only when the subscriber is the patient.

New Note 3. Added
2
7
1

3. The total number of REF segments in the 2200 Loop cannot exceed 3.

Example: REF✽EA✽J354789~

2
106
STANDARD

REF Reference Identification
Level: Detail
Position: 110
Loop: 2200
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

2/3

REF02

127

Reference
Ident

✽
X

REF03

352

REF04

✽ Description ✽

AN 1/30

AN 1/80

C040

Reference
Identifier

ELEMENT SUMMARY

USAGE

REF.
DES.

REQUIRED

REF01

DATA
ELEMENT

128

NAME

ATTRIBUTES

Reference Identification Qualifier

2/3

Code qualifying the Reference Identification
CODE

Original Page Number 169 dated May 2000

DEFINITION

Medical Record Identification Number

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

X04010X093A1 • 277 • 2100E • NM1
DEPENDENT NAME

X04010X093A1NAME
DEPENDENT
• 277 • 2100E • NM1

IMPLEMENTATION

DEPENDENT NAME
Loop Repeat Changed

Loop: 2100E — DEPENDENT NAME Repeat: 1
Usage: REQUIRED
Repeat: 1

Example: NM1✽QC✽1✽SMITH✽JOSEPH✽✽✽✽MI✽01234567802~

3
103
STANDARD

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

Entity ID
Code

NM1 ✽
M

NM107

✽

2/3

✽

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

NM109

ID
Code

706

2/2

1037

Name
Middle

✽

Entity
Relat Code
X

NM105

AN 1/25

NM110

✽

AN 2/80

1036

Name
First

✽

AN 1/35

✽

1/2

NM104

AN 1/25

AN 1/10

Entity ID
Code
O

1038

Name
Prefix

✽

NM111

✽

NM106

2/3

ELEMENT SUMMARY

USAGE

REF.
DES.

REQUIRED

NM101

DATA
ELEMENT

NAME

ATTRIBUTES

Entity Identifier Code

2/3

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

QC
REQUIRED

NM102

1065

DEFINITION

Patient

Entity Type Qualifier

1/1

Code qualifying the type of entity
SEMANTIC:

NM102 qualifies NM103.

CODE

OCTOBER 2002

DEFINITION

Person

Original Page Number 194 dated May 2000

004010X093A1 • 277 • 2200E • TRN
CLAIM SUBMITTER TRACE NUMBER

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

CLAIM
004010X093A1
SUBMITTER
NUMBER
• 277TRACE
• 2200E
• TRN

IMPLEMENTATION

CLAIM SUBMITTER TRACE NUMBER
Loop: 2200E — CLAIM SUBMITTER TRACE NUMBER Repeat: >1
Usage: REQUIRED
Repeat: 1
Notes:

8
119

1. Use of this segment is required if the patient is someone other than
the subscriber.

9
119

2. Use this segment to convey a unique trace or reference number from
the originator of the transaction to be returned by the receiver of the
transaction.

0
010
100

3. The TRN segment is required by the ASC X12 syntax when Loop ID2200E is used.

Note Changed

Example: TRN✽2✽1722634842~

6
008
100
STANDARD

TRN Trace
Level: Detail
Position: 090
Loop: 2200 Repeat: >1
Requirement: Optional
Max Use: 1
Purpose: To uniquely identify a transaction to an application
DIAGRAM

TRN01

TRN ✽

481

Trace Type
Code
M

1/2

TRN02

✽

127

Reference
Ident
M

TRN03

509

TRN04

✽ Originating ✽
Company ID

AN 1/30

AN 10/10

127

Reference
Ident
O

AN 1/30

ELEMENT SUMMARY

USAGE

REF.
DES.

REQUIRED

TRN01

DATA
ELEMENT

481

NAME

ATTRIBUTES

Trace Type Code

1/2

Code identifying which transaction is being referenced
CODE

Original Page Number 197 dated May 2000

DEFINITION

Referenced Transaction Trace Numbers

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

REQUIRED

TRN02

127

004010X093A1 • 277 • 2200E • TRN
CLAIM SUBMITTER TRACE NUMBER

Reference Identification

1/30

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

Alias Added

ALIAS: Patient
SEMANTIC:

Number

Account Number

TRN02 provides unique identification for the transaction.

Note Added
1000099

NOT USED

TRN03

509

Originating Company Identifier

10/10

NOT USED

TRN04

127

Reference Identification

1/30

OCTOBER 2002

Original Page Number 197 dated May 2000

004010X093A1 • 276/277
HEALTH CARE CLAIM STATUS REQUEST AND RESPONSE

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

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.

Original Page Number A.5 dated May 2000

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X093A1 • 276/277
HEALTH CARE CLAIM STATUS REQUEST AND RESPONSE

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

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.

A.1.3.1.3

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.

OCTOBER 2002

Original Page Number A.6 dated May 2000

004010X093A1 • 276/277 • GS
FUNCTIONAL GROUP HEADER
FUNCTIONAL GROUP HEADER
GS

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X093A1GROUP
FUNCTIONAL
GS
• 002 • HEADER

IMPLEMENTATION

FUNCTIONAL GROUP HEADER
Example: GS✽HN✽SENDER CODE✽RECEIVER
CODE✽19940331✽0802✽1✽X✽004010X093A1~

005
100
4

Changed example

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

GS07

GS02

2/2

455

GS08

✽ Responsible ✽
Agency Code
M

1/2

142

GS03

✽ Application ✽
Send’s Code
AN 2/15

AN 2/15

GS04

373

Date

✽
M

GS05

✽
8/8

337

Time
M

GS06

✽
4/8

Group Ctrl
Number
M

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

2/2

Code identifying a group of application related transaction sets
CODE

REQUIRED

GS02

142

DEFINITION

Health Care Claim Status Notification (277)

Health Care Claim Status Request (276)

Application Sender’s Code

2/15

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

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

8/8

Date expressed as CCYYMMDD
SEMANTIC:

1000011

GS04 is the group date.

Use this date for the functional group creation date.

Original Page Number B.8 dated May 2000

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

REQUIRED

GS05

337

004010X093A1 • 276/277 • GS
FUNCTIONAL GROUP HEADER

Time

4/8

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:

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

1000012
REQUIRED

GS05 is the group time.

GS06

Group Control Number

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

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

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

1091

OCTOBER 2002

DEFINITION

004010X093A1 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 Status
Request and Response Implementation Guide,
originally published May 2000 as 004010X093 and
incorporating the changes identified in the Addenda,
the value used in GS08 must be “004010X093A1".

Original Page Number B.9 dated May 2000

004010X093A1 • 276/277
FUNCTIONAL GROUP HEADER

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

OCTOBER 2002

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