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IMPLEMENTATION GUIDE
004010X096A1 • 837
HEALTH CARE CLAIM: INSTITUTIONAL
National Electronic Data Interchange
Transaction Set Implementation Guide
A
D
D
E
N
D
A
Health Care Claim:
Institutional
837
ASC X12N 837 (004010X096A1)
October 2002
OCTOBER 2002
1
004010X096A1 • 837
HEALTH CARE CLAIM: INSTITUTIONAL
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
004010X096A1 • 837
HEALTH CARE CLAIM: INSTITUTIONAL
Table of Contents
Introduction .................................................................................................. 5
Modified pages............................................................................................ 7
OCTOBER 2002
3
004010X096A1 • 837
HEALTH CARE CLAIM: INSTITUTIONAL
4
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X096A1 • 837
HEALTH CARE CLAIM: INSTITUTIONAL
1 Introduction to Modified Pages
This document is addenda to the X12N Health Care Claim: Institutional Implementation Guide, originally published May 2000 as 004010X096. 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 004010X096 Implementation Guide. Since the X12N
004010X096 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: Institutional Implementation Guide, originally published May 2000 as 004010X096 and incorporating the
changes identified in the Addenda, the value used in GS08 must be
“004010X096A1".
Each of the changes made to the 004010X096 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
004010X096 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
004010X096A1 • 837
HEALTH CARE CLAIM: INSTITUTIONAL
6
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X096A1 • 837
004010X096A1 • 837
IMPLEMENTATION
837
Health Care Claim: Institutional
Table 1 - Header
PAGE #
POS. # SEG. ID
NAME
USAGE
REPEAT
56
57
60
005
010
015
ST
BHT
REF
Transaction Set Header
Beginning of Hierarchical Transaction
Transmission Type Identification
R
R
R
1
1
1
61
64
020
045
NM1
PER
LOOP ID - 1000A SUBMITTER NAME
Submitter Name
Submitter EDI Contact Information
R
R
1
2
67
020
NM1
LOOP ID - 1000B RECEIVER NAME
Receiver Name
R
1
LOOP REPEAT
1
1
Table 2 - Billing/Pay-To Provider Detail
PAGE #
POS. # SEG. ID
NAME
USAGE
REPEAT
69
71
73
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
76
79
80
82
85
87
015
025
030
035
035
040
NM1
N3
N4
REF
REF
PER
LOOP ID - 2010AA BILLING PROVIDER NAME
Billing Provider Name
Billing Provider Address
Billing Provider City/State/ZIP Code
Billing Provider Secondary Identification
Credit/Debit Card Billing Information
Billing Provider Contact Information
R
R
R
S
S
S
1
1
1
8
8
2
91
94
95
97
015
025
030
035
NM1
N3
N4
REF
LOOP ID - 2010AB PAY-TO PROVIDER NAME
Pay-To Provider Name
Pay-To Provider Address
Pay-To Provider City/State/ZIP Code
Pay-To Provider Secondary Identification
S
R
R
S
1
1
1
5
LOOP REPEAT
>1
R
S
S
1
1
1
1
1
Table 2 - Subscriber Detail
PAGE #
POS. # SEG. ID
NAME
USAGE
99
101
001
005
HL
SBR
LOOP ID - 2000B SUBSCRIBER HIERARCHICAL
LEVEL
Subscriber Hierarchical Level
PAT Segment Deleted
Subscriber Information
106
109
015
025
NM1
N3
LOOP ID - 2010BA SUBSCRIBER NAME
Subscriber Name
Subscriber Address
REPEAT
LOOP REPEAT
>1
R
R
1
1
R
S
1
1
1
004010X096A1 • 837
OCTOBER 2002
Original Page Number 47 Dated May 2000
7
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X096A1 • 837
182
180
REF
184
185
188
190
192
193
195
197
199
200
203
205
213
220
228
234
180
180
180
180
180
180
180
180
185
190
190
216
220
220
220
231
REF
REF
REF
REF
REF
REF
REF
REF
K3
NTE
NTE
CR6
CRC
CRC
CRC
HI
237
239
248
250
263
274
286
295
304
311
313
231
231
231
231
231
231
231
231
231
240
241
HI
HI
HI
HI
HI
HI
HI
HI
HI
QTY
HCP
Claim Identification Number For Clearinghouses and
Other Transmission Intermediaries
Document Identification Code
Original Reference Number (ICN/DCN)
Investigational Device Exemption Number
Service Authorization Exception Code
Peer Review Organization (PRO) Approval Number
Prior Authorization or Referral Number
Medical Record Number
Demonstration Project Identifier
File Information
Claim Note
Billing Note
Home Health Care Information
Home Health Functional Limitations
Home Health Activities Permitted
Home Health Mental Status
Principal, Admitting, E-Code and Patient Reason For Visit
Diagnosis Information
Diagnosis Related Group (DRG) Information
Other Diagnosis Information
Principal Procedure Information
Other Procedure Information
Occurrence Span Information
Occurrence Information
Value Information
Condition Information
Treatment Code Information
Claim Quantity
Claim Pricing/Repricing Information
S
S
1
12
S
1
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
2
1
1
1
1
2
1
1
10
10
1
1
3
3
2
1
S
S
S
S
S
S
S
S
S
S
S
1
2
1
2
2
2
2
2
2
4
1
319
321
242
243
CR7
HSD
LOOP ID - 2305 HOME HEALTH CARE PLAN
INFORMATION
Home Health Care Plan Information
Health Care Services Delivery
326
329
331
250
255
271
NM1
PRV
REF
LOOP ID - 2310A ATTENDING PHYSICIAN NAME
Attending Physician Name
Attending Physician Specialty Information
Attending Physician Secondary Identification
S
S
S
1
1
5
333
338
250
271
NM1
REF
LOOP ID - 2310B OPERATING PHYSICIAN NAME
Operating Physician Name
Operating Physician Secondary Identification
S
S
1
5
345
250
271
NM1
REF
LOOP ID - 2310C OTHER PROVIDER NAME
Other Provider Name
Other Provider Secondary Identification
S
S
1
5
347
352
353
355
250
265
270
271
NM1
N3
N4
REF
LOOP ID - 2310E SERVICE FACILITY NAME
Service Facility Name
Service Facility Address
Service Facility City/State/Zip Code
Service Facility Secondary Identification
357
363
369
370
371
290
295
300
300
300
SBR
CAS
AMT
AMT
AMT
LOOP ID - 2320 OTHER SUBSCRIBER INFORMATION
Other Subscriber Information
Claim Level Adjustment
Payer Prior Payment
Coordination of Benefits (COB) Total Allowed Amount
Coordination of Benefits (COB) Total Submitted Charges
PRV
Segments
340
deleted
8
Original Page Number 49 Dated May 2000
Repeat Changed
Usage Changed
6
1
Usage
Changed
1
1
Loop 2310D Deleted
1
S
R
R
S
1
1
1
5
S
S
S
S
S
1
5
1
1
1
10
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X096A1 • 837
AMT
AMT
DMG
OI
MIA
MOA
Diagnostic Related Group (DRG) Outlier Amount
Coordination of Benefits (COB) Total Medicare Paid
Amount
Medicare Paid Amount - 100%
Medicare Paid Amount - 80%
Coordination of Benefits (COB) Medicare A Trust Fund
Paid Amount
Coordination of Benefits (COB) Medicare B Trust Fund
Paid Amount
Coordination of Benefits (COB) Total Non-covered Amount
Coordination of Benefits (COB) Total Denied Amount
Other Subscriber Demographic Information
Other Insurance Coverage Information
Medicare Inpatient Adjudication Information
Medicare Outpatient Adjudication Information
325
332
340
355
NM1
N3
N4
REF
LOOP ID - 2330A OTHER SUBSCRIBER NAME
Other Subscriber Name
Other Subscriber Address
Other Subscriber City/State/ZIP Code
Other Subscriber Secondary Information
408
410
411
413
414
325
332
340
350
355
NM1
N3
N4
DTP
REF
416
355
REF
LOOP ID - 2330B OTHER PAYER NAME
Other Payer Name
Other Payer Address
Other Payer City/State/ZIP Code
Claim Adjudication Date
Other Payer Secondary Identification and Reference
Number
Other Payer Prior Authorization or Referral Number
NM1
REF
LOOP ID - 2330C OTHER PAYER PATIENT
INFORMATION
Other Payer Patient Information
Other Payer Patient Identification Number
NM1
REF
LOOP ID - 2330D OTHER PAYER ATTENDING
PROVIDER
Other Payer Attending Provider
Other Payer Attending Provider Identification
S
R
1
3
S
R
1
3
372
374
300
300
AMT
AMT
376
378
380
300
300
300
AMT
AMT
AMT
382
300
AMT
384
385
386
388
390
395
300
300
305
310
315
320
398
402
404
406
418
420
422
424
325
355
325
355
1
1
S
S
S
1
1
1
S
1
S
S
S
R
S
S
1
1
1
1
1
1
R
S
S
S
1
1
1
3
R
S
S
S
S
1
1
1
1
2
S
1
1
1
1
S
S
1
3
1
S
R
426
428
325
355
NM1
REF
LOOP ID - 2330E OTHER PAYER OPERATING
PROVIDER
Other Payer Operating Provider
Other Payer Operating Provider Identification
430
432
325
355
NM1
REF
LOOP ID - 2330F OTHER PAYER OTHER PROVIDER
Other Payer Other Provider
Other Payer Other Provider Identification
1
3
1
434
436
325
355
NM1
REF
LOOP ID - 2330H OTHER PAYER SERVICE FACILITY
PROVIDER
Other Payer Service Facility Provider
Other Payer Service Facility Provider Identification
438
439
444
448
450
452
453
365
375
420
455
455
475
475
LX
SV2
PWK
DTP
DTP
AMT
AMT
LOOP ID - 2400 SERVICE LINE NUMBER
Service Line Number
Institutional Service Line
SV4 Segment
Line Supplemental Information
Service Line Date
Assessment Date
Service Tax Amount
Facility Tax Amount
OCTOBER 2002
S
S
1
Loop 2330G Deleted
S
R
1
3
R
R
S
S
S
S
S
1
1
5
1
1
1
1
1
999
Deleted
Original Page Numbers 50 and 51 Dated May 2000
9
004010X096A1 • 837
454
492
HCP Segment Added
HCP
Line Pricing/Repricing Information
459
462
465
494
495
496
LIN
CTP
REF
LOOP ID - 2410 DRUG IDENTIFICATION
Drug Identification
Drug Pricing
Prescription Number
467
472
500
525
NM1
REF
479
500
525
481
486
500
525
PRV
Segments
deleted 474
488
492
500
501
10
540
545
550
555
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
S
New 2410 Loop
Added
S
1
25
S
S
1
1
1
LOOP ID - 2420A ATTENDING PHYSICIAN NAME
Attending Physician Name
Attending Physician Secondary Identification
S
S
1
1
NM1
REF
LOOP ID - 2420B OPERATING PHYSICIAN NAME
Operating Physician Name
Operating Physician Secondary Identification
S
S
1
1
NM1
REF
LOOP ID - 2420C OTHER PROVIDER NAME
Other Provider Name
Other Provider Secondary Identification
S
S
1
1
SVD
CAS
DTP
SE
LOOP ID - 2430 SERVICE LINE ADJUDICATION
INFORMATION
Service Line Adjudication Information
Service Line Adjustment
Service Adjudication Date
Transaction Set Trailer
Original Page Number 51 Dated May 2000
1
1
1
Loop 2420D Deleted
S
S
S
R
25
1
99
1
1
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X096A1 • 837 • REF
TRANSMISSION TYPE IDENTIFICATION
TRANSMISSION• TYPE
004010X096A1
837 • REF
IDENTIFICATION
IMPLEMENTATION
TRANSMISSION TYPE IDENTIFICATION
Usage: REQUIRED
Repeat: 1
Example Changed
Example: REF✽87✽004010X096A1~
5
168
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:
2188
Note Changed
Type Code
R0203
When piloting the transaction set, this value is 004010X096DA1.
When sending the transaction set in a production mode, this value
is 004010X096A1.
NOT USED
REF03
352
Description
X
NOT USED
REF04
C040
REFERENCE IDENTIFIER
O
OCTOBER 2002
AN
1/80
Original Page Number 60 Dated May 2000
11
004010X096A1 • 837 • 2000A • PRV
BILLING/PAY-TO PROVIDER SPECIALTY INFORMATION
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
BILLING/PAY-TO
004010X096A1 • 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:
025
210
6
1. Required when adjudication is known to be impacted by the provider
taxonomy code, and the Service Facility 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-2310E is not used.
Note 1. Changed
0
222
2. PRV02 qualifies PRV03.
3
183
Example: PRV✽BI✽ZZ✽203BA0200N~
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
12
DEFINITION
BI
Billing
PT
Pay-To
Original Page Number 71 Dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X096A1 • 837 • 2010BA • REF
PROPERTY AND CASUALTY CLAIM NUMBER
004010X096A1
PROPERTY
AND
CASUALTY
• 837
• 2010BACLAIM
• REFNUMBER
IMPLEMENTATION
PROPERTY AND CASUALTY CLAIM NUMBER
Loop: 2010BA — SUBSCRIBER NAME
Usage: SITUATIONAL
Repeat: 1
Notes:
4
189
1. This is a property and casualty payer-assigned claim number. It is
required on property and casualty claims. Providers receive this
number from the property and casualty payer during eligibility
determinations or some other communication with that payer. See
Section 4.2, Property and Casualty, for additional information about
property and casualty claims.
5
189
2. In the case where the patient is the same person as the subscriber,
the property and casualty claim number is placed in Loop ID-2010BA.
In the case where the patient is a different person than the subscriber,
this number is placed in Loop ID-2010CA. This number should be
transmitted in only one place.
New
025
210Note 3. Added
7
3. Not required for HIPAA (The statutory definition of a health plan does
not specifically include workers’ compensation programs, property
and casualty programs, or disability insurance programs, and,
consequently, we are not requiring them to comply with the
standards.) but may be required for other uses.
Example: REF✽Y4✽4445555~
6
189
STANDARD
REF Reference Identification
Level: Detail
Position: 035
Loop: 2010
Requirement: Optional
Max Use: 20
Purpose: To specify identifying information
Syntax:
1. R0203
At least one of REF02 or REF03 is required.
DIAGRAM
REF01
REF
✽
M
OCTOBER 2002
128
Reference
Ident Qual
ID
2/3
REF02
127
Reference
Ident
✽
X
AN 1/30
REF03
352
✽ Description ✽
X
AN 1/80
REF04
C040
Reference
Identifier
~
O
Original Page Number 119 Dated May 2000
13
004010X096A1 • 837 • 2000C • PAT
PATIENT INFORMATION
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X096A1
PATIENT
INFORMATION
• 837 • 2000C • PAT
NOT USED
PAT05
1250
Date Time Period Format Qualifier
X
ID
2/3
NOT USED
PAT06
1251
Date Time Period
X
AN
1/35
NOT USED
PAT07
355
Unit or Basis for Measurement Code
X
ID
2/2
NOT USED
PAT08
81
Weight
X
R
1/10
NOT USED
PAT09
1073
Yes/No Condition or Response Code
O
ID
1/1
Usage Changed
14
Original Page Number 144 Dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X096A1 • 837 • 2010CA • REF
PROPERTY AND CASUALTY CLAIM NUMBER
004010X096A1
PROPERTY
AND
CASUALTY
CLAIM
• 837
• 2010CA
• REFNUMBER
IMPLEMENTATION
PROPERTY AND CASUALTY CLAIM NUMBER
Loop: 2010CA — PATIENT NAME
Usage: SITUATIONAL
Repeat: 1
Notes:
0
191
1. This is a property and casualty payer-assigned claim number. It is
required on property and casualty claims. Providers receive this
number from the property and casualty payer during eligibility
determinations or some other communication with that payer. See
Section 4.2, Property and Casualty, for additional information about
property and casualty claims.
2. In the case where the patient is the same person as the subscriber,
the property and casualty claim number is placed in Loop ID-2010BA.
In the case where the patient is a different person than the subscriber,
this number is placed in Loop ID-2010CA. This number should be
transmitted in only one place.
1
191
New
025
210Note 3. Added
7
3. Not required for HIPAA (The statutory definition of a health plan does
not specifically include workers’ compensation programs, property
and casualty programs, or disability insurance programs, and,
consequently, we are not requiring them to comply with the
standards.) but may be required for other uses.
Example: REF✽Y4✽4445555~
2
191
STANDARD
REF Reference Identification
Level: Detail
Position: 035
Loop: 2010
Requirement: Optional
Max Use: 20
Purpose: To specify identifying information
Syntax:
1. R0203
At least one of REF02 or REF03 is required.
DIAGRAM
REF01
REF
✽
M
OCTOBER 2002
128
Reference
Ident Qual
ID
2/3
REF02
127
Reference
Ident
✽
X
AN 1/30
REF03
352
REF04
✽ Description ✽
X
AN 1/80
C040
Reference
Identifier
~
O
Original Page Number 155 Dated May 2000
15
004010X096A1 • 837 • 2300 • CLM
CLAIM INFORMATION
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
CLAIM
004010X096A1
INFORMATION
• 837 • 2300 • CLM
REQUIRED
CLM09
1363
Release of Information Code
O
ID
1/1
Code indicating whether the provider has on file a signed statement by the patient
authorizing the release of medical data to other organizations
0
1195
UB-92 Reference [UB-92 Name]:
1195
2001195
EMC v.6.0 Reference:
52 (A-C) [Release of Information Certification Indicator]
Record Type 30 Field No. 16 (Sequence 01-03)
CODE
A
Appropriate Release of Information on File at Health
Care Service Provider or at Utilization Review
Organization
I
Informed Consent to Release Medical Information
for Conditions or Diagnoses Regulated by Federal
Statutes
M
The Provider has Limited or Restricted Ability to
Release Data Related to a Claim
UB-92 Reference [UB-92 Name]:
1321
1321
1321
1321
52 Code R [Restricted or Modified Release]
EMC v.6.0 Reference:
Record Type 30 Field No. 16 Code R
N
No, Provider is Not Allowed to Release Data
UB-92 Reference [UB-92 Name]:
1273
1273
1274
1274
DEFINITION
52 Code N [No Release]
Usage Changed
O
On file at Payor or at Plan Sponsor
Y
Yes, Provider has a Signed Statement Permitting
Release of Medical Billing Data Related to a Claim
UB-92 Reference [UB-92 Name]:
52 Code Y [Yes]
NOT USED
CLM10
1351
Patient Signature Source Code
O
NOT USED
CLM11
C024
RELATED CAUSES INFORMATION
O
NOT USED
CLM12
1366
Special Program Code
NOT USED
CLM13
1073
NOT USED
CLM14
NOT USED
NOT USED
NOT USED
16
ID
1/1
O
ID
2/3
Yes/No Condition or Response Code
O
ID
1/1
1338
Level of Service Code
O
ID
1/3
CLM15
1073
Yes/No Condition or Response Code
O
ID
1/1
CLM16
1360
Provider Agreement Code
O
ID
1/1
CLM17
1029
Claim Status Code
O
ID
1/2
Original Page Numbers 161 to 163 Dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X096A1 • 837 • 2300 • REF
DOCUMENT IDENTIFICATION CODE
DOCUMENT
004010X096A1
IDENTIFICATION
CODE
• 837 • 2300 • REF
IMPLEMENTATION
DOCUMENT IDENTIFICATION CODE
Loop: 2300 — CLAIM INFORMATION
Usage: SITUATIONAL
Repeat Count Changed
Repeat: 2
Notes:
7
100
1. Reference numbers at this position apply to the entire claim.
2. This segment is used to convey submittal of HCFA-485 and HCFA-486
data OR HCFA-486 data only.
6
170
Example Changed
Example: REF✽DD✽485~
025
210
8
STANDARD
REF Reference Identification
Level: Detail
Position: 180
Loop: 2300
Requirement: Optional
Max Use: 30
Purpose: To specify identifying information
Syntax:
1. R0203
At least one of REF02 or REF03 is required.
DIAGRAM
REF01
REF ✽
128
Reference
Ident Qual
M
ID
2/3
REF02
127
Reference
Ident
✽
X
REF03
352
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
DD
REQUIRED
REF02
127
DEFINITION
Document Identification Code
Reference Identification
Reference information as defined for a particular Transaction Set or as specified
by the Reference Identification Qualifier
INDUSTRY: Document
SYNTAX:
New Note Added
2001195
OCTOBER 2002
Control Identifier
R0203
Use the form name as shown in the example. If both the 485 and
486 forms are being sent, repeat the segment.
Original Page Number 189 Dated May 2000
17
004010X096A1 • 837 • 2300 • CR6
HOME HEALTH CARE INFORMATION
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
HOME
004010X096A1
HEALTH•CARE
837 • INFORMATION
2300 • CR6
IMPLEMENTATION
HOME HEALTH CARE INFORMATION
Loop: 2300 — CLAIM INFORMATION
Usage: SITUATIONAL
Repeat: 1
Notes:
9
170
Note 1. Changed
1
230
1. This segment is required for Home Health claims when applicable.
Example: CR6✽4✽941101✽RD8✽1994110119941231✽941015✽N✽Y✽I✽✽✽✽✽941101✽✽✽✽A~
STANDARD
CR6 Home Health Care Certification
Level: Detail
Position: 216
Loop: 2300
Requirement: Optional
Max Use: 1
Purpose: To supply information related to the certification of a home health care patient
Syntax:
1. P0304
If either CR603 or CR604 is present, then the other is required.
2. P091011
If either CR609, CR610 or CR611 are present, then the others are required.
3. P151617
If either CR615, CR616 or CR617 are present, then the others are required.
DIAGRAM
CR601
CR6 ✽
923
Prognosis
Code
M
ID
CR607
CR602
✽
1/1
M
1073
Resp Code
M
ID
CR613
O
DT
CR619
373
CR614
O
DT
ID
✽
O
373
CR620
DT
O
DT
ID
CR609
1/1
X
DT
373
CR615
X
373
CR621
1250
O
Original Page Number 210 Dated May 2000
DT
ID
CR616
X
8/8
1137
ID
1/1
ID
CR612
1073
1/1
373
Date
✽
O
1384
Patient Loc
Code
X
O
AN 1/15
CR617
✽
CR606
✽ Yes/No Cond
Resp Code
Medical
Code Value
X
1251
AN 1/35
DT
CR611
2/2
Date Time
Period
✽
2/3
O
✽
373
Date
✽
235
Prod/Serv
ID Qual
X
CR605
AN 1/35
CR610
✽
DT
CR618
8/8
373
Date
✽
O
DT
8/8
373
Date
✽
8/8
ID
X
8/8
1251
Date Time
Period
✽
373
Date Time
format Qual
8/8
CR604
2/3
Date
✽
✽
1250
Date Time
format Qual
X
1322
Date
✽
8/8
8/8
Date
8/8
Date
✽
18
M
CR603
✽
Certificate
Type Code
1/1
Date
✽
DT
CR608
✽ Yes/No Cond ✽
373
Date
~
8/8
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
004010X096A1 • 837 • 2300 • HI
IMPLEMENTATION GUIDE
PRINCIPAL, ADMITTING, E-CODE AND PATIENT REASON FOR VISIT DIAGNOSIS INFO
PRINCIPAL,
004010X096A1
ADMITTING,
E-CODE
• 837 • 2300
• HI AND PATIENT REASON FOR VISIT DIAGNOSIS INFO
IMPLEMENTATION
PRINCIPAL, ADMITTING, E-CODE AND
PATIENT REASON FOR VISIT DIAGNOSIS
INFORMATION
Loop: 2300 — CLAIM INFORMATION
Usage Changed
Usage: SITUATIONAL
Repeat: 1
Notes:
026
210
0
1. Required on all claims and encounters except claims for Religious
Non-medical claims (Bill Types 4XX and 5XX) and hospital other (Bill
Types 14X).
Note 1. Changed
0
198
2. The Admitting Diagnosis is required on all inpatient admission claims
and encounters.
1
198
3. An E-Code diagnosis is required whenever a diagnosis is needed to
describe an injury, poisoning or adverse effect.
010
100
0
4. The Patient Reason for Visit Diagnosis is required for all unscheduled
outpatient visits.
Example: HI✽BK:9976~
2
198
STANDARD
HI Health Care Information Codes
Level: Detail
Position: 231
Loop: 2300
Requirement: Optional
Max Use: 25
Purpose: To supply information related to the delivery of health care
DIAGRAM
HI01
HI ✽
C022
Health Care
Code Info.
HI02
✽
M
HI07
✽
C022
Health Care
Code Info.
HI03
✽
O
C022
Health Care
Code Info.
O
HI04
✽
O
HI08
✽
C022
Health Care
Code Info.
C022
Health Care
Code Info.
HI09
✽
O
HI05
✽
O
C022
Health Care
Code Info.
O
C022
Health Care
Code Info.
HI10
✽
C022
Health Care
Code Info.
HI06
✽
O
C022
Health Care
Code Info.
HI11
✽
O
C022
Health Care
Code Info.
O
C022
Health Care
Code Info.
HI12
✽
O
C022
Health Care
Code Info.
~
O
ELEMENT SUMMARY
USAGE
REQUIRED
REF.
DES.
HI01
DATA
ELEMENT
C022
NAME
ATTRIBUTES
HEALTH CARE CODE INFORMATION
M
To send health care codes and their associated dates, amounts and quantities
OCTOBER 2002
Original Page Number 227 Dated May 2000
19
004010X096A1 • 837 • 2310A • NM1
ATTENDING PHYSICIAN NAME
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
ATTENDING
004010X096A1
PHYSICIAN
NAME
• 837 • 2310A
• NM1
IMPLEMENTATION
ATTENDING PHYSICIAN NAME
Loop: 2310A — ATTENDING PHYSICIAN NAME Repeat: 1
Usage: SITUATIONAL
Repeat: 1
Notes:
031
210
0
1. Information in Loop ID-2310 applies to the entire claim unless it is
overridden on a service line by the presence of Loop ID-2420 with the
same value in NM101.
Note 1. Changed
8
189
2. Because the usage of this segment is “Situational” this is not a
syntactically required loop. If this loop is used, then this segment is a
“Required” segment. See Appendix A for further details on ASC X12
nomenclature.
5
196
3. Required on all inpatient claims or encounters.
0
199
4. Required to indicate the Primary Physician responsible on a Home
Health Agency Plan of Treatment.
Example: NM1✽71✽1✽JONES✽JOHN✽✽✽✽XX✽12345678~
5
101
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
1. Loop 2310 contains information about the rendering, referring, or attending
provider.
Set Notes:
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
ID
1/2
1035
Name Last/
Org Name
O
66
ID Code
Qualifier
X
✽
1/1
NM108
✽
NM103
X
Original Page Number 321 Dated May 2000
O
67
ID
Code
AN 2/80
ID
O
706
2/2
1037
Name
Middle
✽
Entity
Relat Code
X
NM105
AN 1/25
NM110
✽
1036
Name
First
✽
AN 1/35
NM109
✽
NM104
AN 1/25
ID
O
AN 1/10
98
Entity ID
Code
O
1038
Name
Prefix
✽
NM111
✽
NM106
~
2/3
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X096A1 • 837 • 2310A • PRV
ATTENDING PHYSICIAN SPECIALTY INFORMATION
ATTENDING
004010X096A1
PHYSICIAN
SPECIALTY
• 837 • 2310A
• PRV INFORMATION
IMPLEMENTATION
ATTENDING PHYSICIAN SPECIALTY
INFORMATION
Loop: 2310A — ATTENDING PHYSICIAN NAME
Usage: SITUATIONAL
Usage Changed
Repeat: 1
Notes:
6
200
1. The PRV segment in Loop ID-2310 applies to the entire claim unless
overridden on the service line level by the presence of a PRV segment
with the same value in PRV01.
7
200
2. Use code value AT to report the specialty of the attending physician.
Use code value SU when the physician is responsible for the patient’s
Home Health Plan of Treatment.
0
222
3. PRV02 qualifies PRV03.
New Note 4. Added
026
210
1
4. Required when the billing provider is a billing service and taxonomy is
know to impact the adjudication of the claim.
Example: PRV✽AT✽ZZ✽363LP0200N~
8
200
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
OCTOBER 2002
DEFINITION
AT
Attending
SU
Supervising
Original Page Number 324 Dated May 2000
21
004010X096A1 • 837 • 2310B • NM1
OPERATING PHYSICIAN NAME
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
OPERATING
004010X096A1
PHYSICIAN
NAME
• 837 • 2310B
• NM1
IMPLEMENTATION
OPERATING PHYSICIAN NAME
Loop: 2310B — OPERATING PHYSICIAN NAME Repeat: 1
Usage: SITUATIONAL
Repeat: 1
Notes:
031
210
0
1. Information in Loop ID-2310 applies to the entire claim unless it is
overridden on a service line by the presence of Loop ID-2420 with the
same value in NM101.
Note 1. Changed
2
173
2. This segment is required when any surgical procedure code is listed
on this claim.
3
201
3. Because the usage of this segment is “Situational” this is not a
syntactically required loop. If this loop is used, then this segment is a
“Required” segment. See Appendix A for further details on ASC X12
nomenclature.
Example: NM1✽72✽1✽MEYERS✽JANE✽✽✽✽XX✽12345678~
9
139
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
✽
22
98
Entity ID
Code
ID
O
66
NM109
ID Code
Qualifier
X
ID
✽
1/2
1035
Name Last/
Org Name
1/1
NM108
✽
NM103
X
Original Page Number 328 Dated May 2000
O
67
AN 2/80
ID
O
706
2/2
1037
Name
Middle
✽
Entity
Relat Code
X
NM105
AN 1/25
NM110
✽
1036
Name
First
✽
AN 1/35
ID
Code
✽
NM104
ID
O
AN 1/10
98
Entity ID
Code
O
1038
Name
Prefix
✽
AN 1/25
NM111
✽
NM106
~
2/3
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X096A1 • 837 • 2310C • NM1
OTHER PROVIDER NAME
004010X096A1
OTHER
PROVIDER
• 837NAME
• 2310C • NM1
IMPLEMENTATION
OTHER PROVIDER NAME
Loop: 2310C — OTHER PROVIDER NAME Repeat: 1
Usage: SITUATIONAL
Repeat: 1
Notes:
4
101
1. Information in Loop ID-2310 applies to the entire claim unless it is
overridden on a service line by the presence of Loop ID-2420 with the
same value in NM101.
Note 1. Changed
8
189
2. Because the usage of this segment is “Situational” this is not a
syntactically required loop. If this loop is used, then this segment is a
“Required” segment. See Appendix A for further details on ASC X12
nomenclature.
Note
8 3. Replaced
189
3. Required when the claim/encounter involves an other provider such
as, but not limited to: Referring Provider, Ordering Provider, Assisting
Provider, etc.
Note 4. Deleted
Example: NM1✽73✽1✽DOE✽JOHN✽A✽✽✽34✽201749586~
1
202
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
✽
OCTOBER 2002
98
Entity ID
Code
ID
O
66
NM109
ID Code
Qualifier
X
ID
✽
1/2
1035
Name Last/
Org Name
1/1
NM108
✽
NM103
X
O
67
ID
O
706
2/2
1037
Name
Middle
✽
Entity
Relat Code
X
NM105
AN 1/25
NM110
✽
AN 2/80
1036
Name
First
✽
AN 1/35
ID
Code
✽
NM104
ID
O
AN 1/10
98
Entity ID
Code
O
1038
Name
Prefix
✽
AN 1/25
NM111
✽
NM106
~
2/3
Original Page Number 335 Dated May 2000
23
004010X096A1 • 837 • 2400 • SV2
INSTITUTIONAL SERVICE LINE
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
INSTITUTIONAL
004010X096A1 • SERVICE
837 • 2400
LINE
• SV2
ELEMENT SUMMARY
USAGE
REQUIRED
REF.
DES.
SV201
DATA
ELEMENT
234
NAME
ATTRIBUTES
Product/Service ID
X
AN
1/48
Identifying number for a product or service
INDUSTRY: Service
SYNTAX:
Line Revenue Code
R0102
SEMANTIC:
SV201 is the revenue code.
1677
1182
UB-92 Reference [UB-92 Name]:
1182
2001182
2100161
2100162
EMC v.6.0 Reference:
2100254
See Code Source 132: National Uniform Billing Committee (NUBC)
Codes.
SITUATIONAL
42 [Revenue Code]
Record Type 50 Field No. 4, 11, 12, 13
Record Type 60 Field No. 4, 13, 14
Record Type 61 Field No. 4, 14, 15
SV202
C003
COMPOSITE MEDICAL PROCEDURE
IDENTIFIER
X
To identify a medical procedure by its standardized codes and applicable
modifiers
1678
ALIAS: Service
1678
1230
UB-92 Reference [UB-92 Name]:
2100304 New Note Added
This data element required for outpatient claims when an
appropriate HCPCS exists for the service line item.
44 (HCPCS) [HCPCS/Rates/HIPPS Rate Codes]
Note Deleted
REQUIRED
Line Procedure Code
SV202 - 1
235
Product/Service ID Qualifier
M
ID
2/2
Code identifying the type/source of the descriptive number used in
Product/Service ID (234)
INDUSTRY: Product
or Service ID Qualifier
The NDC number is used for reporting prescribed drugs
and biologics when required by government regulation, or
as deemed by the provider to enhance claim
reporting/adjudication processes. The NDC number is
reported in the LIN segment of Loop ID-2410.
2100304
New Note Added
CODE
HC
2083
DEFINITION
Health Care Financing Administration Common
Procedural Coding System (HCPCS) Codes
Because the AMA’s CPT codes are also level 1
HCPCS codes, they are reported under HC.
CODE SOURCE 130: Health Care Financing Administration
Common Procedural Coding System
24
Original Page Number 446 Dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
Codes N1, N2, N3 and N4 Deleted
004010X096A1 • 837 • 2400 • SV2
INSTITUTIONAL SERVICE LINE
IV
Home Infusion EDI Coalition (HIEC) Product/Service
Code
This code set is not allowed for use under HIPAA at
the time of this writing. The qualifier can only be
used: 1) If a new rule names HIEC as an allowable
code set under HIPAA. 2) For Property & Casualty
claims/encounters that are not covered under HIPAA.
2100262 New Note Added
CODE SOURCE 513: Home Infusion EDI Coalition (HIEC)
Product/Service Code List
ZZ
Use code ZZ to convey the Health Insurance
Prospective Payment System (HIPPS) Skilled
Nursing Facility Rate Code. This code list is
available from:
Division of Institutional Care
Health Care Financing Administration
S1-03-06
7500 Security Boulevard
Baltimore, MD 21244-1850
2100219
REQUIRED
Mutually Defined
SV202 - 2
234
Product/Service ID
M
AN
1/48
AN
2/2
Identifying number for a product or service
INDUSTRY: Procedure
ALIAS: HCPCS
Code
Procedure Code
1183
1000090
UB-92 Reference [UB-92 Name]:
1000090
2100090
2100199
EMC v.6.0 Reference:
SITUATIONAL
44 (HCPCS) [HCPCS/Rates/HIPPS Rate Codes]
Record Type 60 Field No. 5, 13, 14
Record Type 61 Field No. 5, 14, 15
SV202 - 3
1339
Procedure Modifier
O
This identifies special circumstances related to the performance of the
service, as defined by trading partners
ALIAS: HCPCS
Modifier 1
1184
1000091
UB-92 Reference [UB-92 Name]:
1000091
2100091
EMC v.6.0 Reference:
1066
Use this modifier for the first procedure code modifier.
1754
This data element is required when the Provider needs to
convey additional clarification for the associated procedure
code.
OCTOBER 2002
Original Page Numbers 446 and 447 Dated May 2000
44 (HCPCS) [HCPCS/Rates/HIPPS Rate Codes]
Record Type 60 Field No. 9, 13, 14
25
004010X096A1 • 837 • 2400 • DTP
SERVICE LINE DATE
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
SERVICE
004010X096A1
LINE DATE
• 837 • 2400 • DTP
IMPLEMENTATION
SERVICE LINE DATE
Loop: 2400 — SERVICE LINE NUMBER
Usage: SITUATIONAL
Repeat: 1
Notes:
8
209
1. Required on outpatient claims when revenue, procedure, HIEC or drug
codes are reported in the SV2 segment.
024
210
5
2. In cases where a drug is being billed on a service line, the Date of
Service DTP may be used to indicate the range of dates through which
the drug will be used by the patient. Use RD8 for this purpose.
024
210
6
3. In cases where a drug is being billed on a service line, the Date of
Service DTP is used to indicate the date the prescription was written
(or otherwise communicated by the prescriber if not written).
New Note 4. Added
026
210
4
4. Assessment Date DTP is not used when this segment is present.
Example: DTP✽472✽D8✽19960819~
6
149
STANDARD
DTP Date or Time or Period
Level: Detail
Position: 455
Loop: 2400
Requirement: Optional
Max Use: 15
Purpose: To specify any or all of a date, a time, or a time period
DIAGRAM
DTP01
DTP ✽
374
Date/Time
Qualifier
M
ID
3/3
DTP02
✽
1250
Date Time
format Qual
M
ID
DTP03
✽
2/3
1251
Date Time
Period
M
~
AN 1/35
ELEMENT SUMMARY
USAGE
REQUIRED
REF.
DES.
DTP01
DATA
ELEMENT
374
NAME
ATTRIBUTES
Date/Time Qualifier
M
ID
3/3
Code specifying type of date or time, or both date and time
INDUSTRY: Date
CODE
472
2214
26
Original Page Number 456 Dated May 2000
Time Qualifier
DEFINITION
Service
Use RD8 in DTP02 to indicate begin/end or from/to
dates.
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
REQUIRED
DTP02
1250
004010X096A1 • 837 • 2400 • DTP
SERVICE LINE DATE
Date Time Period Format Qualifier
M
ID
2/3
Code indicating the date format, time format, or date and time format
SEMANTIC:
DTP02 is the date or time or period format that will appear in DTP03.
CODE
Note Deleted
REQUIRED
DTP03
1251
DEFINITION
D8
Date Expressed in Format CCYYMMDD
RD8
Range of Dates Expressed in Format CCYYMMDDCCYYMMDD
Date Time Period
M
AN
1/35
Expression of a date, a time, or range of dates, times or dates and times
INDUSTRY: Service
Date
0
2101
UB-92 Reference [UB-92 Name]:
2101
1533
1415
EMC v.6.0 Reference:
OCTOBER 2002
45 [Service Date]
Record Type 60 Field No. 12, 13, 14
Record Type 61 Field No. 9, 14, 15
Original Page Number 457 Dated May 2000
27
004010X096A1 • 837 • 2400 • DTP
ASSESSMENT DATE
DATE OR TIME OR PERIOD
DTP
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
ASSESSMENT
004010X096A1 DATE
• 837 • 2400 • DTP
IMPLEMENTATION
ASSESSMENT DATE
Loop: 2400 — SERVICE LINE NUMBER
Usage: SITUATIONAL
Repeat: 1
Notes:
9
210
1. Required when an assessment date is necessary (i.e. Medicare PPS
processing).
024
210
8
2. Refer to Code Source 132 National Uniform Billing Committee (NUBC)
Codes for instructions on the use of this date.
New Note 3. Added
026
210
5
3. Service date DTP is not used when this segment is present.
Example: DTP✽866✽19981210~
8
210
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
866
REQUIRED
DTP02
1250
Time Qualifier
DEFINITION
Examination
Date Time Period Format Qualifier
Code indicating the date format, time format, or date and time format
SEMANTIC:
DTP02 is the date or time or period format that will appear in DTP03.
CODE
D8
28
Original Page Number 458 Dated May 2000
DEFINITION
Date Expressed in Format CCYYMMDD
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X096A1 • 837 • 2400 • HCP
LINE PRICING/REPRICING INFORMATION
New Segment Added
LINE
004010X096A1
PRICING/REPRICING
• 837 • 2400INFORMATION
• HCP
IMPLEMENTATION
LINE PRICING/REPRICING INFORMATION
Loop: 2400 — SERVICE LINE NUMBER
Usage: SITUATIONAL
Repeat: 1
Notes:
026
210
7
1. Used only by repricers as needed. This information is specific to the
destination payer reported in the 2010BB loop.
Example: HCP✽03✽100✽10✽RPO12345~
8
106
STANDARD
HCP Health Care Pricing
Level: Detail
Position: 492
Loop: 2400
Requirement: Optional
Max Use: 1
Purpose: To specify pricing or repricing information about a health care claim or line item
Syntax:
1. R0113
At least one of HCP01 or HCP13 is required.
2. P0910
If either HCP09 or HCP10 is present, then the other is required.
3. P1112
If either HCP11 or HCP12 is present, then the other is required.
DIAGRAM
HCP01
HCP
1473
HCP02
Pricing
✽
✽
Methodology
X
ID
HCP07
2/2
O
R
HCP13
O
782
Monetary
Amount
✽
R
HCP08
✽
782
Monetary
Amount
O
901
HCP14
O
234
1526
Reject
✽
✽ Policy Comp ✽
Reason Code
Code
X
OCTOBER 2002
ID
2/2
O
ID
1/2
R
HCP09
X
ID
HCP15
ID
O
O
AN 1/48
R
HCP11
✽
118
Rate
✽
234
Product/
Service ID
X
HCP05
AN 1/30
HCP10
✽
2/2
127
Reference
Ident
✽
235
1/9
ID
O
355
2/2
127
Reference
Ident
✽
Unit/Basis
Meas Code
X
HCP06
AN 1/30
HCP12
380
Quantity
✽
X
R
1/15
1527
Exception
Code
O
HCP04
1/18
Prod/Serv
ID Qual
✽
AN 1/48
782
Monetary
Amount
✽
1/18
Product/
Service ID
1/18
HCP03
~
1/2
New Page inserted after page 443 dated May 2000
29
004010X096A1 • 837 • 2400 • HCP
LINE PRICING/REPRICING INFORMATION
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
New Segment Added
ELEMENT SUMMARY
USAGE
REF.
DES.
REQUIRED
HCP01
DATA
ELEMENT
1473
NAME
ATTRIBUTES
Pricing Methodology
X
ID
2/2
Code specifying pricing methodology at which the claim or line item has been
priced or repriced
ALIAS: Pricing/Repricing
SYNTAX:
R0113
Trading partners need to agree on which codes to use in this data
element. There do not appear to be standard definitions for the
code elements.
1398
CODE
REQUIRED
Methodology
HCP02
782
DEFINITION
00
Zero Pricing (Not Covered Under Contract)
01
Priced as Billed at 100%
02
Priced at the Standard Fee Schedule
03
Priced at a Contractual Percentage
04
Bundled Pricing
05
Peer Review Pricing
06
Per Diem Pricing
07
Flat Rate Pricing
08
Combination Pricing
09
Maternity Pricing
10
Other Pricing
11
Lower of Cost
12
Ratio of Cost
13
Cost Reimbursed
14
Adjustment Pricing
Monetary Amount
O
R
1/18
Monetary amount
INDUSTRY: Repriced
Allowed Amount
ALIAS: Pricing/Repricing
SEMANTIC:
30
Allowed Amount
HCP02 is the allowed amount.
New Page inserted after page 443 dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
New Segment Added
SITUATIONAL
Monetary Amount
HCP03
782
004010X096A1 • 837 • 2400 • HCP
LINE PRICING/REPRICING INFORMATION
O
R
1/18
Monetary amount
INDUSTRY: Repriced
Saving Amount
ALIAS: Pricing/Repricing
SEMANTIC:
HCP03 is the savings amount.
This data element is required when it is necessary to report
Savings Amount on claims which has been priced or repriced.
1398
SITUATIONAL
Saving Amount
HCP04
127
Reference Identification
O
AN
1/30
Reference information as defined for a particular Transaction Set or as specified
by the Reference Identification Qualifier
INDUSTRY: Repriced
Organizational Identifier
ALIAS: Pricing/Repricing
SEMANTIC:
HCP04 is the repricing organization identification number.
This data element is required when it is necessary to report
Repricing Organization ID on claims which has been priced or
repriced.
1398
SITUATIONAL
Organizational Identifier
HCP05
118
Rate
O
R
1/9
Rate expressed in the standard monetary denomination for the currency specified
INDUSTRY: Repricing
Per Diem or Flat Rate Amount
ALIAS: Pricing/Repricing
SEMANTIC:
HCP05 is the pricing rate associated with per diem or flat rate repricing.
This data element is required when it is necessary to report Pricing
Rate on claims which has been priced or repriced.
1398
SITUATIONAL
Rate
HCP06
127
Reference Identification
O
AN
1/30
Reference information as defined for a particular Transaction Set or as specified
by the Reference Identification Qualifier
INDUSTRY: Repriced
ALIAS: Approved
SEMANTIC:
Approved Ambulatory Patient Group Code
APG Code, Pricing
HCP06 is the approved DRG code.
HCP06, HCP07, HCP08, HCP10, and HCP12 are fields that will contain
different values from the original submitted values.
COMMENT:
This data element is required when it is necessary to report
Approved DRG Code on claims which has been priced or repriced.
1398
SITUATIONAL
HCP07
782
Monetary Amount
O
R
1/18
Monetary amount
INDUSTRY: Repriced
ALIAS: Approved
SEMANTIC:
1398
OCTOBER 2002
Approved Ambulatory Patient Group Amount
APG Amount, Pricing
HCP07 is the approved DRG amount.
This data element is required when it is necessary to report
Approved DRG Amount on claims which has been priced or
repriced.
New Page inserted after page 443 dated May 2000
31
004010X096A1 • 837 • 2400 • HCP
LINE PRICING/REPRICING INFORMATION
New Segment Added
SITUATIONAL
Product/Service ID
HCP08
234
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
O
AN
1/48
Identifying number for a product or service
INDUSTRY: Repriced
ALIAS: Approved
SEMANTIC:
Revenue Code
HCP08 is the approved revenue code.
This data element is required when it is necessary to report
Approved Revenue Code on claims which has been priced or
repriced.
1398
SITUATIONAL
Approved Revenue Code
HCP09
235
Product/Service ID Qualifier
X
ID
2/2
Code identifying the type/source of the descriptive number used in
Product/Service ID (234)
SYNTAX:
P0910
Required when HCP10 exists.
1398
CODE
HC
DEFINITION
Health Care Financing Administration Common
Procedural Coding System (HCPCS) Codes
This code includes Current Procedural Terminology
(CPT) and HCPCS coding.
2214
CODE SOURCE 130: Health Care Financing Administration
Common Procedural Coding System
SITUATIONAL
HCP10
234
Product/Service ID
X
AN
1/48
Identifying number for a product or service
INDUSTRY: Procedure
Code
ALIAS: Pricing/Repricing
SYNTAX:
P0910
SEMANTIC:
HCP10 is the approved procedure code.
This data element is required when it is necessary to report
Approved HCPCS Code on claims which has been priced or
repriced.
1398
SITUATIONAL
Approved Procedure Code
HCP11
355
Unit or Basis for Measurement Code
X
ID
2/2
Code specifying the units in which a value is being expressed, or manner in which
a measurement has been taken
SYNTAX:
P1112
CODE
SITUATIONAL
HCP12
380
DEFINITION
DA
Days
UN
Unit
Quantity
X
R
1/15
Numeric value of quantity
INDUSTRY: Repricing
Approved Service Unit Count
ALIAS: Pricing/Repricing
SYNTAX:
P1112
SEMANTIC:
1398
32
Approved Units or Inpatient Days
HCP12 is the approved service units or inpatient days.
This data element is required when it is necessary to report
Approved Service Unit Count on claims which has been priced or
repriced.
New Page inserted after page 443 dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
SITUATIONAL
HCP13
901
New Segment Added
004010X096A1 • 837 • 2400 • HCP
LINE PRICING/REPRICING INFORMATION
Reject Reason Code
X
ID
2/2
Code assigned by issuer to identify reason for rejection
ALIAS: Reject
SYNTAX:
Reason Code
R0113
HCP13 is the rejection message returned from the third party
organization.
SEMANTIC:
This data element is required when it is necessary to report
Rejection Message on claims which has been priced or repriced.
1398
CODE
SITUATIONAL
HCP14
1526
DEFINITION
T1
Cannot Identify Provider as TPO (Third Party
Organization) Participant
T2
Cannot Identify Payer as TPO (Third Party
Organization) Participant
T3
Cannot Identify Insured as TPO (Third Party
Organization) Participant
T4
Payer Name or Identifier Missing
T5
Certification Information Missing
T6
Claim does not contain enough information for repricing
Policy Compliance Code
O
ID
1/2
Code specifying policy compliance
This data element is required when it is necessary to report Policy
Compliance Code on claims which has been priced or repriced.
1398
CODE
SITUATIONAL
HCP15
1527
DEFINITION
1
Procedure Followed (Compliance)
2
Not Followed - Call Not Made (Non-Compliance Call
Not Made)
3
Not Medically Necessary (Non-Compliance NonMedically Necessary)
4
Not Followed Other (Non-Compliance Other)
5
Emergency Admit to Non-Network Hospital
Exception Code
O
ID
1/2
Code specifying the exception reason for consideration of out-of-network health
care services
1398
This data element is required when it is necessary to report
Exception Reason Code on claims which have been priced or
repriced.
SEMANTIC:
HCP15 is the exception reason generated by a third party organization.
CODE
OCTOBER 2002
DEFINITION
1
Non-Network Professional Provider in Network
Hospital
2
Emergency Care
New Page inserted after page 443 dated May 2000
33
004010X096A1 • 837 • 2400 • HCP
LINE PRICING/REPRICING INFORMATION
34
New Segment Added
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
3
Services or Specialist not in Network
4
Out-of-Service Area
5
State Mandates
6
Other
New Page inserted after page 443 dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
New Loop and Segment Added
004010X096A1 • 837 • 2410 • LIN
DRUG IDENTIFICATION
DRUG
004010X096A1
IDENTIFICATION
• 837 • 2410 • LIN
IMPLEMENTATION
DRUG IDENTIFICATION
Loop: 2410 — DRUG IDENTIFICATION Repeat: 25
Usage: SITUATIONAL
Repeat: 1
Notes:
027
210
9
1. The NDC number is used for reporting prescribed drugs and biologics
when required by government regulation, or as deemed by the
provider to enhance claim reporting/adjudication processes. The NDC
number is reported in the LIN segment of Loop ID-2410.
2. Use Loop ID 2410 to specify billing/reporting for drugs provided that
may be part of the service(s) described in SV2.
028
210
0
Example: LIN✽N4✽12345123412~
8
106
STANDARD
LIN Item Identification
Level: Detail
Position: 494
Loop: 2410 Repeat: >1
Requirement: Optional
Max Use: 1
Purpose: To specify basic item identification data
Set Notes:
Syntax:
1. Loop 2410 contains compound drug components, quantities and prices.
1. P0405
If either LIN04 or LIN05 is present, then the other is required.
2. P0607
If either LIN06 or LIN07 is present, then the other is required.
3. P0809
If either LIN08 or LIN09 is present, then the other is required.
4. P1011
If either LIN10 or LIN11 is present, then the other is required.
5. P1213
If either LIN12 or LIN13 is present, then the other is required.
6. P1415
If either LIN14 or LIN15 is present, then the other is required.
7. P1617
If either LIN16 or LIN17 is present, then the other is required.
8. P1819
If either LIN18 or LIN19 is present, then the other is required.
9. P2021
If either LIN20 or LIN21 is present, then the other is required.
OCTOBER 2002
New Page inserted after page 443 dated May 2000
35
004010X096A1 • 837 • 2410 • LIN
DRUG IDENTIFICATION
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
New Segment Added
10. P2223
If either LIN22 or LIN23 is present, then the other is required.
11. P2425
If either LIN24 or LIN25 is present, then the other is required.
12. P2627
If either LIN26 or LIN27 is present, then the other is required.
13. P2829
If either LIN28 or LIN29 is present, then the other is required.
14. P3031
If either LIN30 or LIN31 is present, then the other is required.
DIAGRAM
LIN01
350
Assigned
ID
LIN ✽
O
X
X
X
AN 1/48
LIN25
✽
X
X
235
ID
X
X
2/2
X
ID
235
LIN27
X
AN 1/48
ID
LIN11
ID
ID
LIN23
X
235
LIN29
2/2
X
235
ID
LIN18
X
235
ID
LIN24
X
235
ID
LIN30
2/2
235
Prod/Serv
ID Qual
✽
AN 1/48
2/2
Prod/Serv
ID Qual
✽
234
2/2
Prod/Serv
ID Qual
✽
AN 1/48
Product/
Service ID
✽
X
234
Product/
Service ID
2/2
Prod/Serv
ID Qual
✽
AN 1/48
2/2
Prod/Serv
ID Qual
X
X
ID
LIN12
234
Product/
Service ID
✽
X
234
235
Prod/Serv
ID Qual
✽
AN 1/48
LIN17
235
LIN28
✽
X
✽
LIN06
AN 1/48
Product/
Service ID
✽
2/2
Prod/Serv
ID Qual
X
234
Product/
Service ID
✽
2/2
AN 1/48
235
235
LIN22
✽
✽
2/2
234
Product/
Service ID
X
Prod/Serv
ID Qual
X
234
Product/
Service ID
ID
LIN16
✽
AN 1/48
LIN21
✽
X
LIN05
2/2
Prod/Serv
ID Qual
✽
234
Product/
Service ID
ID
LIN10
AN 1/48
LIN15
✽
2/2
Prod/Serv
ID Qual
✽
X
X
234
235
Prod/Serv
ID Qual
✽
AN 1/48
Product/
Service ID
✽
LIN04
X
ID
2/2
234
Product/
Service ID
✽
LIN09
Prod/Serv
ID Qual
LIN26
AN 1/48
LIN31
ID
X
234
Product/
Service ID
235
235
LIN20
✽
✽
2/2
234
Product/
Service ID
M
Prod/Serv
ID Qual
X
234
Product/
Service ID
ID
LIN14
✽
AN 1/48
LIN19
✽
X
LIN03
2/2
Prod/Serv
ID Qual
✽
234
Product/
Service ID
ID
LIN08
AN 1/48
LIN13
✽
M
234
Product/
Service ID
235
Prod/Serv
ID Qual
✽
AN 1/20
LIN07
✽
LIN02
~
AN 1/48
ELEMENT SUMMARY
USAGE
NOT USED
36
REF.
DES.
LIN01
DATA
ELEMENT
350
NAME
Assigned Identification
New Page inserted after page 443 dated May 2000
ATTRIBUTES
O
AN
1/20
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
REQUIRED
LIN02
235
004010X096A1 • 837 • 2410 • LIN
DRUG IDENTIFICATION
New Segment Added
Product/Service ID Qualifier
M
ID
2/2
Code identifying the type/source of the descriptive number used in
Product/Service ID (234)
COMMENT: LIN02 through LIN31 provide for fifteen different product/service IDs for
each item. For example: Case, Color, Drawing No., U.P.C. No., ISBN No., Model
No., or SKU.
CODE
DEFINITION
N4
National Drug Code in 5-4-2 Format
CODE SOURCE 240:
REQUIRED
LIN03
234
National Drug Code by Format
Product/Service ID
M
AN
1/48
Identifying number for a product or service
ALIAS: National
Drug Code
NOT USED
LIN04
235
Product/Service ID Qualifier
X
ID
2/2
NOT USED
LIN05
234
Product/Service ID
X
AN
1/48
NOT USED
LIN06
235
Product/Service ID Qualifier
X
ID
2/2
NOT USED
LIN07
234
Product/Service ID
X
AN
1/48
NOT USED
LIN08
235
Product/Service ID Qualifier
X
ID
2/2
NOT USED
LIN09
234
Product/Service ID
X
AN
1/48
NOT USED
LIN10
235
Product/Service ID Qualifier
X
ID
2/2
NOT USED
LIN11
234
Product/Service ID
X
AN
1/48
NOT USED
LIN12
235
Product/Service ID Qualifier
X
ID
2/2
NOT USED
LIN13
234
Product/Service ID
X
AN
1/48
NOT USED
LIN14
235
Product/Service ID Qualifier
X
ID
2/2
NOT USED
LIN15
234
Product/Service ID
X
AN
1/48
NOT USED
LIN16
235
Product/Service ID Qualifier
X
ID
2/2
NOT USED
LIN17
234
Product/Service ID
X
AN
1/48
NOT USED
LIN18
235
Product/Service ID Qualifier
X
ID
2/2
NOT USED
LIN19
234
Product/Service ID
X
AN
1/48
NOT USED
LIN20
235
Product/Service ID Qualifier
X
ID
2/2
NOT USED
LIN21
234
Product/Service ID
X
AN
1/48
NOT USED
LIN22
235
Product/Service ID Qualifier
X
ID
2/2
NOT USED
LIN23
234
Product/Service ID
X
AN
1/48
NOT USED
LIN24
235
Product/Service ID Qualifier
X
ID
2/2
NOT USED
LIN25
234
Product/Service ID
X
AN
1/48
NOT USED
LIN26
235
Product/Service ID Qualifier
X
ID
2/2
NOT USED
LIN27
234
Product/Service ID
X
AN
1/48
NOT USED
LIN28
235
Product/Service ID Qualifier
X
ID
2/2
NOT USED
LIN29
234
Product/Service ID
X
AN
1/48
NOT USED
LIN30
235
Product/Service ID Qualifier
X
ID
2/2
NOT USED
LIN31
234
Product/Service ID
X
AN
1/48
OCTOBER 2002
New Page inserted after page 443 dated May 2000
37
004010X096A1 • 837 • 2410 • CTP
DRUG PRICING
PRICING INFORMATION
CTP
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
New Segment Added
DRUG
004010X096A1
PRICING• 837 • 2410 • CTP
IMPLEMENTATION
DRUG PRICING
Loop: 2410 — DRUG IDENTIFICATION
Usage: SITUATIONAL
Repeat: 1
Notes:
028
210
3
1. Required when it is necessary to provide a price specific to the NDC
provided in LIN03 that is different than the price reported in SV203.
Example: CTP✽✽✽1.15✽2✽UN~
8
106
STANDARD
CTP Pricing Information
Level: Detail
Position: 495
Loop: 2410
Requirement: Optional
Max Use: 1
Purpose: To specify pricing information
Syntax:
1. P0405
If either CTP04 or CTP05 is present, then the other is required.
2. C0607
If CTP06 is present, then CTP07 is required.
3. C0902
If CTP09 is present, then CTP02 is required.
4. C1002
If CTP10 is present, then CTP02 is required.
5. C1103
If CTP11 is present, then CTP03 is required.
DIAGRAM
CTP01
CTP ✽
687
Class of
Trade Code
O
ID
CTP07
X
X
649
R
1/10
236
Price ID
Code
✽
2/2
Multiplier
✽
CTP02
ID
CTP08
3/3
O
X
782
R
212
Unit
Price
✽
Monetary
Amount
✽
CTP03
R
CTP09
✽
1/18
1/17
ID
X
639
R
CTP10
O
CTP05
✽
1/15
AN 1/10
C001
Composite
Unit of Mea
CTP06
✽
X
499
Condition
Value
✽
2/2
380
Quantity
✽
Basis Unit
Price Code
O
CTP04
O
CTP11
✽
N0
ID
3/3
289
Mult Price
Quantity
O
648
Price Mult
Qualifier
~
1/2
ELEMENT SUMMARY
USAGE
NOT USED
38
REF.
DES.
CTP01
DATA
ELEMENT
687
NAME
Class of Trade Code
New Page inserted after page 443 dated May 2000
ATTRIBUTES
O
ID
2/2
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
New Segment Added
004010X096A1 • 837 • 2410 • CTP
DRUG PRICING
NOT USED
CTP02
236
Price Identifier Code
X
ID
3/3
REQUIRED
CTP03
212
Unit Price
X
R
1/17
X
R
1/15
ID
2/2
Price per unit of product, service, commodity, etc.
ALIAS: Drug
SYNTAX:
REQUIRED
CTP04
380
Unit Price
C1103
Quantity
Numeric value of quantity
ALIAS: National
SYNTAX:
REQUIRED
CTP05
C001
Drug Unit Count
P0405
COMPOSITE UNIT OF MEASURE
X
To identify a composite unit of measure
ALIAS: Unit/Basis
2100286
REQUIRED
CTP05 - 1
355
of Measurement
Unit or Basis for Measurement Code
M
Code specifying the units in which a value is being expressed, or
manner in which a measurement has been taken
ALIAS: Code
CODE
Qualifier
DEFINITION
F2
International Unit
GR
Gram
ML
Milliliter
UN
Unit
NOT USED
CTP05 - 2
1018
Exponent
O
R
1/15
NOT USED
CTP05 - 3
649
Multiplier
O
R
1/10
NOT USED
CTP05 - 4
355
Unit or Basis for Measurement Code
O
ID
2/2
NOT USED
CTP05 - 5
1018
Exponent
O
R
1/15
NOT USED
CTP05 - 6
649
Multiplier
O
R
1/10
NOT USED
CTP05 - 7
355
Unit or Basis for Measurement Code
O
ID
2/2
NOT USED
CTP05 - 8
1018
Exponent
O
R
1/15
NOT USED
CTP05 - 9
649
Multiplier
O
R
1/10
NOT USED
CTP05 - 10
355
Unit or Basis for Measurement Code
O
ID
2/2
NOT USED
CTP05 - 11
1018
Exponent
O
R
1/15
NOT USED
CTP05 - 12
649
Multiplier
O
R
1/10
NOT USED
CTP05 - 13
355
Unit or Basis for Measurement Code
O
ID
2/2
NOT USED
CTP05 - 14
1018
Exponent
O
R
1/15
NOT USED
CTP05 - 15
649
Multiplier
O
R
1/10
NOT USED
CTP06
648
Price Multiplier Qualifier
O
ID
3/3
NOT USED
CTP07
649
Multiplier
X
R
1/10
NOT USED
CTP08
782
Monetary Amount
O
R
1/18
NOT USED
CTP09
639
Basis of Unit Price Code
O
ID
2/2
NOT USED
CTP10
499
Condition Value
O
AN
1/10
NOT USED
CTP11
289
Multiple Price Quantity
O
N0
1/2
OCTOBER 2002
New Page inserted after page 443 dated May 2000
39
004010X096A1 • 837 • 2410 • REF
PRESCRIPTION NUMBER
REFERENCE IDENTIFICATION
REF
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
New Segment Added
PRESCRIPTION
004010X096A1 • NUMBER
837 • 2410 • REF
IMPLEMENTATION
PRESCRIPTION NUMBER
Loop: 2410 — DRUG IDENTIFICATION
Usage: SITUATIONAL
Repeat: 1
Notes:
028
210
9
1. Required if dispense of the drug has been done with an assigned Rx
number.
2. In cases where a compound drug is being billed, the components of
the compound will all have the same prescription number. Payers
receiving the claim can relate all the components by matching the
prescription number.
7
208
Example: REF✽XZ✽123456~
028
210
8
STANDARD
REF Reference Identification
Level: Detail
Position: 496
Loop: 2410
Requirement: Optional
Max Use: 1
Purpose: To specify identifying information
Syntax:
1. R0203
At least one of REF02 or REF03 is required.
DIAGRAM
REF01
REF ✽
128
Reference
Ident Qual
M
ID
2/3
REF02
127
Reference
Ident
✽
X
REF03
✽
AN 1/30
352
Description
X
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
Code qualifying the Reference Identification
ALIAS: Code
CODE
XZ
40
Qualifier
DEFINITION
Pharmacy Prescription Number
New Page inserted after page 443 dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
REQUIRED
REF02
127
New Segment Added
Reference Identification
004010X096A1 • 837 • 2410 • REF
PRESCRIPTION NUMBER
X
AN
1/30
Reference information as defined for a particular Transaction Set or as specified
by the Reference Identification Qualifier
ALIAS: Prescription
SYNTAX:
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 443 dated May 2000
41
004010X096A1 • 837 • 2420A • NM1
ATTENDING PHYSICIAN NAME
INDIVIDUAL OR ORGANIZATIONAL NAME
NM1
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X096A1
ATTENDING PHYSICIAN
NAME
• 837 • 2420A
• NM1
IMPLEMENTATION
ATTENDING PHYSICIAN NAME
Loop: 2420A — ATTENDING PHYSICIAN NAME Repeat: 1
Usage: SITUATIONAL
Repeat: 1
Notes:
3
185
1. Because the usage of this segment is “Situational” this is not a
syntactically required loop. If this loop is used, then this segment is a
“Required” segment. See Appendix A for further details on ASC X12
nomenclature.
Note 2. Changed
029
210
0
2. Required when line level provider information is known to impact
adjudication.
Example: NM1✽71✽1✽JONES✽JOHN✽✽✽SR.✽24✽123456789~
1
211
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:
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.
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
✽
42
98
Entity ID
Code
ID
ID
1/2
1035
Name Last/
Org Name
O
66
ID Code
Qualifier
X
✽
1/1
NM108
✽
NM103
X
Original Page Number 462 Dated May 2000
O
67
ID
Code
AN 2/80
ID
O
706
2/2
1037
Name
Middle
✽
Entity
Relat Code
X
NM105
AN 1/25
NM110
✽
1036
Name
First
✽
AN 1/35
NM109
✽
NM104
AN 1/25
ID
O
AN 1/10
98
Entity ID
Code
O
1038
Name
Prefix
✽
NM111
✽
NM106
~
2/3
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X096A1 • 837 • 2420B • NM1
OPERATING PHYSICIAN NAME
OPERATING
004010X096A1
PHYSICIAN
NAME
• 837 • 2420B
• NM1
IMPLEMENTATION
OPERATING PHYSICIAN NAME
Loop: 2420B — OPERATING PHYSICIAN NAME Repeat: 1
Usage: SITUATIONAL
Repeat: 1
Notes:
8
189
1. Because the usage of this segment is “Situational” this is not a
syntactically required loop. If this loop is used, then this segment is a
“Required” segment. See Appendix A for further details on ASC X12
nomenclature.
Note 2. Changed
029
210
0
2. Required when line level provider information is known to impact
adjudication.
Example: NM1✽72✽1✽MEYERS✽JANE✽I✽✽✽34✽129847263~
2
212
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:
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.
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
✽
OCTOBER 2002
98
Entity ID
Code
ID
ID
1/2
1035
Name Last/
Org Name
O
66
ID Code
Qualifier
X
✽
1/1
NM108
✽
NM103
X
O
67
ID
Code
AN 2/80
ID
O
706
2/2
1037
Name
Middle
✽
Entity
Relat Code
X
NM105
AN 1/25
NM110
✽
1036
Name
First
✽
AN 1/35
NM109
✽
NM104
AN 1/25
ID
O
AN 1/10
98
Entity ID
Code
O
1038
Name
Prefix
✽
NM111
✽
NM106
~
2/3
Original Page Number 469 Dated May 2000
43
004010X096A1 • 837 • 2420C • NM1
OTHER PROVIDER NAME
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X096A1
OTHER
PROVIDER
• 837NAME
• 2420C • NM1
IMPLEMENTATION
OTHER PROVIDER NAME
Loop: 2420C — OTHER PROVIDER NAME Repeat: 1
Usage: SITUATIONAL
Repeat: 1
Notes:
8
189
1. Because the usage of this segment is “Situational” this is not a
syntactically required loop. If this loop is used, then this segment is a
“Required” segment. See Appendix A for further details on ASC X12
nomenclature.
Note 2. Changed
029
210
0
2. Required when line level provider information is known to impact
adjudication.
Note 3. Replaced
029
210
0
3. Required when the claim/encounter involves an other provider such
as, but not limited to: Referring Provider, Ordering Provider, Assisting
Provider, etc.
Note 4. Deleted
Example: NM1✽73✽1✽JONES✽JOHN✽✽✽SR.✽24✽123456789~
0
214
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.
44
Original Page Number 476 Dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X096A1 • 837 • 2430 • SVD
SERVICE LINE ADJUDICATION INFORMATION
SERVICE
004010X096A1
LINE ADJUDICATION
INFORMATION
• 837 • 2430 • SVD
ELEMENT SUMMARY
USAGE
REF.
DES.
REQUIRED
SVD01
DATA
ELEMENT
67
NAME
ATTRIBUTES
Identification Code
M
AN
2/80
Code identifying a party or other code
INDUSTRY: Payer
SEMANTIC:
SVD01 is the payer identification code.
EMC v.6.0 Reference:
2324
2001569
REQUIRED
Identifier
Record Type 30 Field No. 5, 6 (This must match one of the
corresponding loops: 2010BC - Payer Name, or 2330B - Other Payer
Name.)
SVD02
782
Monetary Amount
M
R
1/18
Monetary amount
INDUSTRY: Service
ALIAS: Service
SEMANTIC:
SITUATIONAL
SVD03
C003
Line Paid Amount
Line Amount Paid
SVD02 is the amount paid for this service line.
COMPOSITE MEDICAL PROCEDURE
IDENTIFIER
O
To identify a medical procedure by its standardized codes and applicable
modifiers
Required when returned on an 835 payment for this claim or when
needed to identify the service line adjudicated.
2325
REQUIRED
SVD03 - 1
235
Product/Service ID Qualifier
M
ID
2/2
Code identifying the type/source of the descriptive number used in
Product/Service ID (234)
INDUSTRY: Product
or Service ID Qualifier
The NDC number is used for reporting prescribed drugs
and biologics when required by government regulation, or
as deemed by the provider to enhance claim
reporting/adjudication processes. The NDC number is
reported in the LIN segment of Loop ID-2410.
2100304
New Note Added
CODE
HC
DEFINITION
Health Care Financing Administration Common
Procedural Coding System (HCPCS) Codes
Because the AMA’s CPT codes are also level 1
HCPCS codes, they are reported under HC.
2153
CODE SOURCE 130: Health Care Financing Administration
Common Procedural Coding System
IV
2100262
New Note Added
Codes N1, N2, N3, and N4 Deleted
OCTOBER 2002
Home Infusion EDI Coalition (HIEC) Product/Service
Code
This code set is not allowed for use under HIPAA at
the time of this writing. The qualifier can only be
used: 1) If a new rule names HIEC as an allowable
code set under HIPAA. 2) For Property & Casualty
claims/encounters that are not covered under
HIPAA.
CODE SOURCE 513: Home Infusion EDI Coalition (HIEC)
Product/Service Code List
Original Page Number 491 Dated May 2000
45
004010X096A1 • 837
HEALTH CARE CLAIM: INSTITUTIONAL
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.
46
Original Page Number A.5 dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X096A1 • 837
HEALTH CARE CLAIM: INSTITUTIONAL
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.
OCTOBER 2002
Original Page Number A.6 dated May 2000
47
004010X096A1 • 837 • GS
FUNCTIONAL GROUP HEADER
FUNCTIONAL GROUP HEADER
GS
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X096A1GROUP
FUNCTIONAL
GS
• 002 • HEADER
IMPLEMENTATION
FUNCTIONAL GROUP HEADER
Example: GS✽HC✽SENDER CODE✽RECEIVER
CODE✽19940331✽0802✽1✽X✽004010X096A1~
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
48
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
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
REQUIRED
GS06
28
004010X096A1 • 837
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
1091
DEFINITION
004010X096A1 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:
Institutional Implementation Guide, originally
published May 2000 as 004010X096 and
incorporating the changes identified in the Addenda,
the value used in GS08 must be “004010X096A1".
004010X096A1 • 837
OCTOBER 2002
Original Page Number B.9 dated May 2000
49
004010X096A1 • 837
50
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
OCTOBER 2002
| File Type | application/pdf |
| File Modified | 2002-11-04 |
| File Created | 2001-08-31 |