Claim Status A To 5010

CLAIM STATUS

4010A1 Element Identifier

Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

276 4010A1

ISA01

INTERCHANGE CONTROL HEADER Authorization Information Qualifier

ISA02

Authorization Information

ISA

1

R

2-2

AN 10-10

Min. Max.

Usage Reg.

Loop

Loop Repeat

1

ISA01 ISA02

Authorization Information

ISA03

Security Information Qualifier

ISA04

Security Information

ISA

R R

1

R

2-2

R

1 00, 03

ID

AN 10-10

R

ID

R

00, 01 ISA03

Security Information Qualifier

ISA04

Security Information

ID

2-2

AN 10-10

R R

00, 01 2-2

AN 10-10

R

01, 14, 20, 27, 28, 29, 30, 33, ZZ ISA05

Interchange ID Qualifier

ID

ISA06

Interchange Sender ID

AN 15-15

2-2

Values

276 5010 INTERCHANGE CONTROL HEADER Authorization Information Qualifier

00, 03 ID

ID

01, 14, 20, 27, 28, 29, 30, 33, ZZ

R

ISA05

Interchange ID Qualifier

ID

R

ISA06

Interchange Sender ID

AN 15-15

2-2

R R

01, 14, 20, 27, 28, 29, 30, 33, ZZ

01, 14, 20, 27, 28, 29, 30, 33, ZZ

ISA07

Interchange ID Qualifier

ID

R

ISA07

Interchange ID Qualifier

ID

ISA08

Interchange Receiver ID

AN 15-15

R

ISA08

Interchange Receiver ID

AN 15-15

R

ISA09

Interchange Date

DT

6-6

R

YYMMDD

ISA09

Interchange Date

DT

6-6

R

YYMMDD

ISA10

TM

4-4

R

HHMM

ISA10

Interchange Time

TM

4-4

R

HHMM

ISA11

1-1

R

ISA12

Repetition Seperator Interchange Control Version Number

AN

ISA12

Interchange Time Interchange Control Standards ID Interchange Control Version Number

ID

5-5

R

ISA13

Interchange Control Number

ISA13

Interchange Control Number

N0

9-9

R

ISA14

Acknowledgement Requested

ID

1-1

R

ISA15

ID

1-1

R

ISA16

Usage Indicator Component Element Separator

AN

1-1

R

GS

FUNCTIONAL GROUP HEADER

1

R

GS01

Functional Identifier Code

ID

2-2

R

GS02

Application Sender Code

AN

2-15

R

ISA11

2-2

2-2

R

U ID

1-1

R

ID

5-5

R

N0

9-9

R

New usage for element

00401

00501

0, 1 ISA14

Acknowledgement Requested

ID

1-1

R

ISA15

ID

1-1

R

ISA16

Usage Indicator Component Element Separator

AN

1-1

R

GS

FUNCTIONAL GROUP HEADER

1

R

GS01

Functional Identifier Code

ID

2-2

R

GS02

Application Sender Code

AN

2-15

R

P, T

>1 HR

0, 1 P, T

>1 HR

GS03

Application Receiver Code

AN

2-15

R

GS03

Application Receiver Code

AN

2-15

R

GS04

Date

DT

8-8

R

CCYYMMDD

GS04

Date

DT

8-8

R

CCYYMMDD

GS05

Time

TM

4-8

R

HHMMSSDD

GS05

Time

TM

4-8

R

HHMMSSDD

GS06

Group Control Number

N0

1-9

R

GS06

Group Control Number

N0

1-9

R

GS07

Responsible Agency Code

ID

1-2

R

X

GS07

Responsible Agency Code

ID

1-2

R

X

GS08

Version Identifier Code

AN

1-12

R

004010X093

GS08

Version Identifier Code

AN

1-12

R

005010X212

Page 1 of 12

CLAIM STATUS

4010A1 Element Identifier

Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

276 4010A1 ST ST01 ST02

BHT

TRANSACTION SET HEADER Transaction Set Identifier Code Transaction Set Control Number

1

R

>1

ST03

BHT

BEGINNING OF HIERARCHICAL TRANSACTION

ST

ID

3-3

R

ST01

AN

4-9

R

ST02

1

Min. Max.

Usage Reg.

Loop

Loop Repeat

R

1

1

R

ID

3-3

R

AN

4-9

R

AN

1-35

R

1

R

ID

4-4

R

ID

2-2

R

>1 276

005010X212

BHT02

Hierarchical Structure Code Transaction Set Purpose Code

ID

4-4

R

ID

2-2

R

0010 BHT01

13

AN

BHT04

Reference Identification Transaction Set Creation Date

DT

8-8

R

BHT05

Time

TM

4-8

BHT06

Transaction Type Code

ID

HL

INFORMATION SOURCE LEVEL

BHT03

BHT02

Hierarchical Structure Code Transaction Set Purpose Code

13

AN

1-50

R

BHT04

Reference Identification Transaction Set Creation Date

DT

8-8

R

N/U

BHT05

Time

TM

4-8

R

2-2

N/U

BHT06

Transaction Type Code

ID

2-2

N/U

1

R

HL

INFORMATION SOURCE LEVEL

1

R

AN

1-12

R N/U

1-30

N/U

BHT03 CCYYMMDD

2000A

>1

Change from Not used to Required and Increase from 30 - 50 CCYYMMDD Change from Not used to Required

2000A

>1

AN

1-12

R

HL02

Hierarchical ID Number Hierarchical Parent ID Number

AN

1-12

N/U

HL02

Hierarchical ID Number Hierarchical Parent ID Number

AN

1-12

HL03

Hierarchical Level Code

ID

1-2

R

20

HL03

Hierarchical Level Code

ID

1-2

R

20

HL04

Hierarchical Child Code

ID

1-1

R

1

HL04

Hierarchical Child Code

ID

1-1

R

1

HL01

New Element

1

0010 BHT01

Values

276 5010 TRANSACTION SET HEADER Transaction Set Identifier Code Transaction Set Control Number Implementation Convention Reference

276

BEGINNING OF HIERARCHICAL TRANSACTION

ID

HL01

NM1

PAYER NAME

1

R

NM1

PAYER NAME

1

R

NM101

Entity Identifier Code

ID

2-3

R

PR

NM101

Entity Identifier Code

ID

2-3

R

PR

NM102

Entity Type Qualifier

ID

1-1

R

2

NM102

Entity Type Qualifier

ID

1-1

R

2

NM103

Payer Name

AN

1-35

R

NM103

Payer Name

AN

1-60

R

Increase from 35 - 60

NM104

Name First

AN

1-25

N/U

NM104

Name First

AN

1-35

N/U

Increase from 25 - 35

NM105

Name Middle

AN

1-25

N/U

NM105

Name Middle

AN

1-25

N/U

NM106

Name Prefix

AN

1-10

N/U

NM106

Name Prefix

AN

1-10

N/U

NM107

Name Suffix

AN

1-10

N/U

NM107

Name Suffix

AN

1-10

N/U

NM108

Identification Code Qualifier

ID

1-2

R

2100A

>1

21, AD, FI, NI, PI, PP, XV

ID

1-2

NM109

Payer Identifier

AN

2-80

R

NM109

Payer Identifier

AN

2-80

R

NM110

Entity Relationship Code

ID

2-2

N/U

NM110

Entity Relationship Code

ID

2-2

N/U

NM111

Entity Identifier Code

ID

2-3

N/U

NM111

Entity Identifier Code

ID

2-3

N/U

R

1

PI, XV

Identification Code Qualifier

NM108

2100A

Page 2 of 12

Codes Removed

CLAIM STATUS

4010A1 Element Identifier

Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

ID

NM112

Last Name

ID

276 4010A1

PER

PAYER CONTACT INFORMATION

PER01

Contact Function Code

PER02

Payer Contact Name Communication Number Qualifier

S

ID

2-2

R

AN

1-60

S

ID

2-2

R

Communication Number Communication Number Qualifier

AN

1-80

R

ID

2-2

S

Communication Number Communication Number Qualifier

AN

1-80

S

ID

2-2

S

PER08

Communication Number

AN

1-80

S

PER09

Contact Inquiry Reference

AN

1-20

N/U

HL

INFORMATION RECEIVER LEVEL

1

R

PER04 PER05 PER06 PER07

Loop

Loop Repeat

Values

276 5010 1-60

New Element

N/U

2100A IC ED, EM, TE

EX

EX, FX

2000B

>1

INFORMATION RECEIVER LEVEL

HL

1

R

AN

1-12

R

HL02

Hierarchical ID Number Hierarchical Parent ID Number

AN

1-12

R

HL03

Hierarchical Level Code

ID

1-2

R

21

HL04

Hierarchical Child Code

ID

1-1

R

1

NM1

INFORMATION RECEIVER NAME

1

R

41

NM101

Entity Identifier Code

ID

2-3

R

41

1, 2

NM102

Entity Type Qualifier

ID

1-1

R

1, 2

AN

1-12

R

HL02

Hierarchical ID Number Hierarchical Parent ID Number

AN

1-12

R

HL03

Hierarchical Level Code

ID

1-2

R

21

HL04

Hierarchical Child Code

ID

1-1

R

1

NM1

INFORMATION RECEIVER NAME

1

R

NM101

Entity Identifier Code

ID

2-3

R

NM102

Entity Type Qualifier

ID

1-1

R

HL01

Usage Reg.

Segment Removed 1

PER03

Min. Max.

HL01

2100B

>1

2000B

>1

Repeat Changed 2100B

1

Increase from 35 - 60 NM103 NM104 NM105

Information Receiver Last Name or Organization Name Information Receiver First Name Information Receiver Middle Name

AN

1-35

R

NM103

AN

1-25

S

NM104

AN

1-25

S

NM105

Name Prefix Information Receiver Name Suffix

AN

1-10

N/U

NM106

AN

1-10

S

NM107

ID

1-2

R

NM108

NM109

Identification Code Qualifier Information Receiver Identification Number

AN

2-80

R

NM110

Entity Relationship Code

ID

2-2

N/U

NM111

Entity Identifier Code

ID

2-3

N/U

NM106 NM107

Information Receiver Last Name or Organization Name Information Receiver First Name Information Receiver Middle Name

AN

1-60

S

AN

1-35

S

Increase from 25 - 35

AN

1-25

S

Name Prefix Information Receiver Name Suffix

AN

1-10

N/U

AN

1-10

N/U

ID

1-2

R

NM109

Identification Code Qualifier Information Receiver Identification Number

AN

2-80

R

NM110

Entity Relationship Code

ID

2-2

N/U

NM111

Entity Identifier Code

ID

2-3

N/U

NM112

Last Name

ID

1-60

N/U

Changed to Not Used

46, FI, XX NM108

46

Page 3 of 12

Codes Removed

New Element

CLAIM STATUS

4010A1 Element Identifier

Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

276 4010A1 HL

SERVICE PROVIDER LEVEL

1

R

AN

1-12

R

HL02

Hierarchical ID Number Hierarchical Parent ID Number

AN

1-12

R

HL03

Hierarchical Level Code

ID

1-2

R

19

HL04

Hierarchical Child Code

ID

1-1

R

1

R

ID

2-3

Entity Type Qualifier ID Provider Last or Organization Name AN Provider First Name AN

NM1

PROVIDER NAME Entity Identifier Code

NM102 NM103 NM104 NM105

Provider Middle Name

AN

Min. Max.

Usage Reg.

Loop

Loop Repeat

2000C

>1

HL

SERVICE PROVIDER LEVEL

1

R

HL01

AN

1-12

R

HL02

Hierarchical ID Number Hierarchical Parent ID Number

AN

1-12

R

HL03

Hierarchical Level Code

ID

1-2

R

19

1

HL04

Hierarchical Child Code

ID

1-1

R

1

NM1

PROVIDER NAME

1

R

R

1P

NM101

Entity Identifier Code

ID

2-3

R

1P

1-1

R

1, 2

NM102

1-1

R

1, 2

1-35

R

Entity Type Qualifier ID Provider Last or Organization Name AN Provider First Name AN

1-60

S

2000C

2100C

>1

>1

NM103

1-25

S

NM104

1-25

S

NM105

Provider Middle Name

AN

2100C

1-35

S

1-25

S

NM106

Provider Name Prefix

AN

1-10

S

NM106

Provider Name Prefix

AN

1-10

N/U

Provider Name Suffix

AN

1-10

S

NM107

Provider Name Suffix

AN

1-10

S

NM108

Identification Code Qualifier

ID

1-2

R

NM108

Identification Code Qualifier

ID

1-2

R

NM109

Provider Identifier

AN

2-80

R

NM109

Provider Identifier

AN

2-80

R

NM110

Entity Relationship Code

ID

2-2

N/U

NM110

Entity Relationship Code

ID

2-2

N/U

NM111

Entity Identifier Code

ID

2-3

N/U

NM111

Entity Identifier Code

ID

2-3

N/U

NM112

Last Name

ID

1-60

N/U

Increase from 25 - 35 Changed to Not Used

FI, SV, XX

HL

SUBSCRIBER LEVEL

1

R

HL01

AN

1-12

R

HL02

Hierarchical ID Number Hierarchical Parent ID Number

AN

1-12

R

HL03

Hierarchical Level Code

ID

1-2

R

22

HL04

Hierarchical Child Code

ID

1-1

R

0, 1

DMG

SUBSCRIBER DEMOGRAPHIC INFORMATION Date Time Period Format Qualifier

ID

2-3

R

DMG02

Subscriber Birth Date

AN

1-35

R

CCYYMMDD

DMG03

Subscriber Gender Code

ID

1-1

R

F, M, U

DMG04

Marital Status Code

ID

1-1

N/U

1

S

2000D

>1

2000D

Loop repeat changed

2

Increase from 35 - 60

NM107

DMG01

Values

276 5010

HL01

NM101

ID

FI, SV, XX

New Element

HL

SUBSCRIBER LEVEL

1

R

HL01

AN

1-12

R

HL02

Hierarchical ID Number Hierarchical Parent ID Number

AN

1-12

R

HL03

Hierarchical Level Code

ID

1-2

R

22

HL04

Hierarchical Child Code

ID

1-1

R

0, 1

DMG

SUBSCRIBER DEMOGRAPHIC INFORMATION Date Time Period Format Qualifier

1

S

ID

2-3

R

DMG02

Subscriber Birth Date

AN

1-35

R

CCYYMMDD

DMG03

Subscriber Gender Code

ID

1-1

S

F, M

DMG04

Marital Status Code

ID

1-1

N/U

D8 DMG01

>1

2000D D8

DMG05

Race or Ethnicity Code

ID

1-1

N/U

DMG05

Race or Ethnicity Code

ID

1-1

N/U

DMG06

Citizenship Status Code

ID

1-2

N/U

DMG06

Citizenship Status Code

ID

1-2

N/U

DMG07

Country Code

ID

2-3

N/U

DMG07

Country Code

ID

2-3

N/U

DMG08

Basis of Verification Code

ID

1-2

N/U

DMG08

Basis of Verification Code

ID

1-2

N/U

Page 4 of 12

2000D

Codes Removed

CLAIM STATUS

4010A1 Element Identifier

Description

DMG09

Quantity

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

ID

DMG09

Quantity

R

1-15

N/U

DMG10

Code List Qualifier Code

ID

1-3

N/U

New Element

DMG11

Industry Code

AN

1-30

N/U

New Element

276 4010A1 R

1-15

Min. Max.

Usage Reg.

Loop

Loop Repeat

Values

276 5010

N/U

NM1

SUBSCRIBER NAME

1

R

NM1

SUBSCRIBER NAME

1

R

NM101

Entity Identifier Code

ID

2-3

R

IL, QC

NM101

Entity Identifier Code

ID

2-3

R

IL

NM102

Entity Type Qualifier

ID

1-1

R

1, 2

NM102

Entity Type Qualifier

ID

1-1

R

1, 2

2100D

1

2100D

1 Code Removed

NM103

Subscriber Last Name

AN

1-35

R

NM103

Subscriber Last Name

AN

1-60

R

Increase from 35 - 60

NM104

Subscriber First Name

AN

1-25

S

NM104

Subscriber First Name

AN

1-35

S

Increase from 25 - 35

NM105

Subscriber Middle Name

AN

1-25

S

NM105

Subscriber Middle Name

AN

1-25

S

NM106

Subscriber Name Prefix

AN

1-10

S

NM106

Subscriber Name Prefix

AN

1-10

N/U

NM107

Subscriber Name Suffix

AN

1-10

S

NM107

Subscriber Name Suffix

AN

1-10

S

R

NM108

Identification Code Qualifier

ID

1-2

R

Change from Situational to Not Used

24, MI, ZZ

24, II, MI

Identification Code Qualifier

ID

1-2

NM109

Subscriber Identifier

AN

2-80

R

NM109

Subscriber Identifier

AN

2-80

R

NM110

Entity Relationship Code

ID

2-2

N/U

NM110

Entity Relationship Code

ID

2-2

N/U

NM111

Entity Identifier Code

ID

2-3

N/U

NM111

Entity Identifier Code

ID

2-3

N/U

NM112

Last Name

ID

1-60

N/U

TRN

CLAIM STATUS TRACKING NUMBER

1

S

NM108

TRN

CLAIM SUBMITTER TRACE NUMBER

TRN01

Trace Type Code

ID

1-2

R

TRN01

Trace Type Code

ID

1-2

R

TRN02

AN

1-30

R

TRN02

1-50

R

AN 10-10

N/U

TRN03

Trace Number Originating Company Identifier

AN

TRN03

Trace Number Originating Company Identifier

TRN04

Reference Identification

AN

N/U

TRN04

Reference Identifier

1

1-30

R

2200D

>1 1

Code Changes

New Element Name Change

AN 10-10

N/U

AN

N/U

1-50

2200D

>1 1 Increase from 30 - 50

Increase from 30 - 50 Name Change

REF01

PAYER CLAIM IDENTIFICATION NUMBER Reference Identification Qualifier

ID

2-3

R

REF02

Payer Claim Control Number

AN

1-30

REF03

Description

AN

1-80

REF04

REFERENCE IDENTIFIER

REF

1

REF01

PAYER CLAIM CONTROL NUMBER Reference Identification Qualifier

R

REF02

N/U N/U

S

2200D

REF

1

S

ID

2-3

R

Payer Claim Control Number

AN

1-50

R

REF03

Description

AN

1-80

N/U

REF04

Reference Identifier

1K

2200D 1K Increase from 30 - 50

REF01

INSTITUTIONAL BILL TYPE IDENTIFICATION Reference Identification Qualifier

REF02

Bill Type Identifier

AN

1-30

REF03

Description

AN

1-80

REF04

REFERENCE IDENTIFIER

N/U

REF

1

REF01

INSTITUTIONAL BILL TYPE IDENTIFICATION Reference Identification Qualifier

R

REF02

Bill Type Identifier

AN

1-50

R

N/U

REF03

Description

AN

1-80

N/U

REF04

Reference Identifier

S

2200D

REF BLT

ID

2-3

N/U

R

Page 5 of 12

1

S

2-3

R

2200D BLT

ID

N/U

Increase from 30 - 50

CLAIM STATUS

4010A1 Element Identifier

Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

276 4010A1

ID

Min. Max.

Usage Reg.

Loop

Loop Repeat

Values

276 5010 New Segment

REF02

APPLICATION OR LOCATION SYSTEM IDENTIFIER Reference Identification Qualifier Application or Location System Identifier

AN

1-50

R

REF03

Description

AN

1-80

N/U

REF04

Reference Identifier

REF REF01

REF01

MEDICAL RECORD IDENTIFICATION Reference Identification Qualifier

REF02

Medical Record Number

AN

1-30

R

REF03

Description

AN

1-80

N/U

REF04

REFERENCE IDENTIFIER

REF REF01

GROUP NUMBER Reference Identification Qualifier

REF02

Group Number

AN

1-30

REF03

Description

AN

1-80

REF04

REFERENCE IDENTIFIER

N/U

REF

1

S

2-3

R

2200D LU

ID

N/U Segment Deleted

1

S

2-3

R

2200D EA

ID

N/U Addenda 1

REF01

GROUP NUMBER Reference Identification Qualifier

R

REF02

Group Number

AN

1-50

R

N/U

REF03

Description

AN

1-80

N/U

REF04

Reference Identifier

S

2200D

REF LU

ID

2-3

R

REF01

PATIENT CONTROL NUMBER Reference Identification Qualifier

REF

1

S

2-3

R

6P ID

S

2-3

R

AN

1-50

R

Description

AN

1-80

N/U

REF04

Reference Identifier

REF02 REF04

PHARMACY PRESCRIPTION NUMBER Reference Identification Qualifier ID Pharmacy Prescription Number AN Description AN Reference Identifier

Page 6 of 12

2200D EJ

ID

Patient Control Number

REF03

Increase from 30 - 50

New Segment 1

REF02

REF01

Code Change

N/U

REF03

REF

2200D

N/U New Segment 1

S

2-3

R

2200D XZ

1-50

R

1-80

N/U N/U

CLAIM STATUS

4010A1 Element Identifier

Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

276 4010A1

REF01 REF02 REF03

CLAIM SUBMITTED CHARGES

1

S R

ID

1-3

AMT02

Amount Qualifier Code Total Claim Charge Amount S9(7)V99

R

1-18

R

AMT03

Credit/Debit Flag Code

ID

1-1

N/U

DTP

CLAIM SERVICE DATE

1

S

DTP01

Date Time Qualifier Date Time Period Format Qualifier

ID

3-3

R

AMT01

DTP02

2200D T3

2200D 232

2-3

R

CLAIM ID FOR CLEARINGHOUSES AND OTHER TRANSMISSION INTERMEDIARIES Reference Identification Qualifier

Usage Reg.

Loop

Loop Repeat

S

ID

2-3

R

Clearinghouse Trace Number AN Description AN

1-50

R

1-80

N/U

Reference Identifier

AMT

CLAIM SUBMITTED CHARGES

D9

N/U

1

S

ID

1-3

R

AMT02

Amount Qualifier Code Total Claim Charge Amount S9(7)V99

R

1-18

R

AMT03

Credit/Debit Flag Code

ID

1-1

N/U

DTP

CLAIM SERVICE DATE

1

S

DTP01

Date Time Qualifier Date Time Period Format Qualifier

ID

3-3

R

AMT01

DTP02

2200D

2200D T3

2200D 472 D8, RD8

ID

2-3

SVC SVC01

Claim Service Period

AN

SERVICE LINE INFORMATION Composite Medical Procedure Identifier

1-35

R

1

S

DTP03

2210D

>1

SVC

R

SVC01

Claim Service Period

AN

SERVICE LINE INFORMATION Composite Medical Procedure Identifier

Codes Added

R

CCYYMMDDCCYYMMDD DTP03

Values

New Segment

1

REF04

RD8 ID

Min. Max.

276 5010

REF

AMT

ID

1-35

R

1

S

CCYYMMDD, CCYYMMDDCCYYMMDD

2210D

New format allowed

>1

R AD, ER, HC, HP, Codes Removed IV, N4, NU, WK

AD, CI, HC, ID, IV, N1, N2, N3, N4, ND,NH, NU, RB SVC01-1

Product/Service ID Qualifier

ID

2-2

R

SVC01-1

Product Service ID

ID

2-2

R

SVC01-2

Service Identification Code

AN

1-48

R

SVC01-2

Service Identification Code

AN

1-48

R

SVC01-3

Procedure Modifier

AN

2-2

S

SVC01-3

Procedure Modifier

AN

2-2

S

SVC01-4

Procedure Modifier

AN

2-2

S

SVC01-4

Procedure Modifier

AN

2-2

S

SVC01-5

Procedure Modifier

AN

2-2

S

SVC01-5

Procedure Modifier

AN

2-2

S

SVC01-6

Procedure Modifier

AN

2-2

S

SVC01-6

Procedure Modifier

AN

2-2

S

SVC01-7

Description

AN

1-80

N/U

SVC01-7

Description

AN

1-80

N/U

SVC01-8

1-48

N/U

SVC02

R

1-18

R

SVC02

Product Service ID Line Item Charge Amount S9(7)V99

AN

Line Item Charge Amount S9(7)V99

R

1-18

R

SVC03

Monetary Amount

R

1-18

N/U

SVC03

Monetary Amount

R

1-18

N/U

SVC04

Revenue Code

AN

1-48

S

SVC04

Revenue Code

AN

1-48

S

SVC05

Quanity

R

1-15

N/U

SVC05

Quanity

R

1-15

N/U

Page 7 of 12

New Element

CLAIM STATUS

4010A1 Element Identifier

Description

SVC06

Composite Medical Procedure Identifier

SVC07

Quantity

ID

Min. Max.

Usage Reg.

5010 Element Identifier

Description

N/U

SVC06

Composite Medical Procedure Identifier

1-15

S

SVC07

Quantity

1

S

Loop

Loop Repeat

Values

276 4010A1

ID

Min. Max.

Usage Reg.

Loop

Loop Repeat

Values

276 5010 N/U Usage changed to required

R

REF01

SERVICE LINE ITEM IDENTIFICATION Reference Identification Qualifier

REF02

Line Item Control Number

AN

1-30

REF03

Description

AN

1-80

REF04

Reference Identifier

N/U

DTP

SERVICE LINE DATE

DTP01

Date Time Qualifier Date Time Period Format Qualifier

REF

DTP02

ID

2-3

1

S

2-3

R

R

REF02

Line Item Control Number

AN

1-50

R

N/U

REF03

Description

AN

1-80

N/U

REF04

Reference Identifier

DTP

SERVICE LINE DATE

DTP01

Date Time Qualifier Date Time Period Format Qualifier

R

1

R

3-3

R

2-3

R

REF01

REF

2210D 472 RD8

ID

1-15

SERVICE LINE ITEM IDENTIFICATION Reference Identification Qualifier

2210D FJ

ID

R

R

DTP02

2210D FJ

ID

Increase from 30 - 50

N/U

ID

1

R

3-3

R

2210D 472 D8, RD8

ID

2-3

CCYYMMDDCCYYMMDD DTP03

Service Line Date

AN

1-35

R

DTP03

HL

DEPENDENT LEVEL

1

S

HL01

AN

1-12

R

HL02

Hierarchical ID Number Hierarchical Parent ID Number

AN

1-12

R

HL03

Hierarchical Level Code

ID

1-2

R

HL04

Hierarchical Child Code

ID

1-1

N/U

DMG

DEPENDENT DEMOGRAPHIC INFORMATION Date Time Period Format Qualifier

ID

2-3

R

DMG02

Patient Birth Date

AN

1-35

R

CCYYMMDD

DMG03

Patient Gender Code

ID

1-1

R

F, M, U

DMG04

Marital Status Code

ID

1-1

N/U

DMG01

1

R

2000E

>1

23

2000E

Service Line Date

AN

1-35

CCYYMMDD, CCYYMMDDCCYYMMDD

R

HL

DEPENDENT LEVEL

1

S

HL01

AN

1-12

R

HL02

Hierarchical ID Number Hierarchical Parent ID Number

AN

1-12

R

HL03

Hierarchical Level Code

ID

1-2

R

HL04

Hierarchical Child Code

ID

1-1

N/U

DMG

DEPENDENT DEMOGRAPHIC INFORMATION Date Time Period Format Qualifier

1

R

ID

2-3

R

DMG02

Patient Birth Date

AN

1-35

R

CCYYMMDD

DMG03

Patient Gender Code

ID

1-1

S

F, M

DMG04

Marital Status Code

ID

1-1

N/U

D8 DMG01

Codes Added

R

2000E

New format allowed

>1

23

2000E D8

DMG05

Race or Ethnicity Code

ID

1-1

N/U

DMG05

Race or Ethnicity Code

ID

1-1

N/U

DMG06

Citizenship Status Code

ID

1-2

N/U

DMG06

Citizenship Status Code

ID

1-2

N/U

DMG07

Country Code

ID

2-3

N/U

DMG07

Country Code

ID

2-3

N/U

DMG08

Basis of Verification Code

ID

1-2

N/U

DMG08

Basis of Verification Code

ID

1-2

N/U

DMG09

Quantity

R

1-15

N/U

DMG09

Quantity

R

1-15

N/U

DMG09

Quantity

R

1-15

N/U

New Element

DMG10

Code List Qualifier Code

ID

1-3

N/U

New Element

DMG11

Industry Code

AN

1-30

N/U

New Element

Page 8 of 12

CLAIM STATUS

4010A1 Element Identifier

Description

NM1

DEPENDENT NAME

NM101

Entity Identifier Code

NM102 NM103

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

2100E

1

Values

Element Identifier

Description

NM1

DEPENDENT NAME

276 4010A1

ID

Min. Max.

Usage Reg.

Loop

Loop Repeat

2100E

1

Values

276 5010

1

R

1

R

ID

2-3

R

QC

NM101

Entity Identifier Code

ID

2-3

R

QC

Entity Type Qualifier

ID

1-1

R

1

NM102

Entity Type Qualifier

ID

1-1

R

1

Patient Last Name

AN

1-35

R

NM103

Patient Last Name

AN

1-60

R

NM104

Patient First Name

AN

1-25

S

NM104

Patient First Name

AN

1-35

S

NM105

Patient Middle Name

AN

1-25

S

NM105

Patient Middle Name

AN

1-25

S

NM106

Patient Name Prefix

AN

1-10

S

NM106

Patient Name Prefix

AN

1-10

N/U

NM107

Patient Name Suffix

AN

1-10

S

NM107

Patient Name Suffix

AN

1-10

S

NM108

Identification Code Qualifier

ID

1-2

S

NM108

Identification Code Qualifier

ID

1-2

N/U

Changed to Not Used

MI, ZZ

Changed to Not Used

NM109

Patient Primary Identifier

AN

2-80

S

NM109

Patient Primary Identifier

AN

2-80

N/U

NM110

Entity Relationship Code

ID

2-2

N/U

NM110

Entity Relationship Code

ID

2-2

N/U

NM111

Entity Identifier Code

ID

2-3

N/U

NM111

Entity Identifier Code

ID

2-3

N/U

NM112

Last Name

ID

1-60

N/U

TRN

CLAIM STATUS TRACKING NUMBER

1

R

TRN

CLAIM SUBMITTER TRACE NUMBER

TRN01

Trace Type Code

ID

1-2

R

TRN01

Trace Type Code

ID

1-2

R

TRN02

AN

1-30

R

TRN02

1-50

R

AN 10-10

N/U

TRN03

Trace Number Originating Company Identifier

AN

TRN03

Trace Number Originating Company Identifier

TRN04

Reference Identification

AN

N/U

TRN04

Reference Identification

1

1-30

R

2200E

>1 1

Changed to Not Used

New Element Name Change

AN 10-10

N/U

AN

N/U

1-50

2200E

>1 1 Increase from 30 - 50

Increase from 30 - 50 Name Change

REF01

PAYER CLAIM IDENTIFICATION NUMBER Reference Identification Qualifier

ID

2-3

R

REF02

Payer Claim Control Number

AN

1-30

REF03

Description

AN

1-80

REF04

REFERENCE IDENTIFIER

REF

1

REF01

PAYER CLAIM CONTROL NUMBER Reference Identification Qualifier

R

REF02

N/U N/U

S

2200E

REF

1

S

ID

2-3

R

Payer Claim Control Number

AN

1-50

R

REF03

Description

AN

1-80

N/U

REF04

Reference Identifier

1K

2200E 1K Increase from 30 - 50

REF01

INSTITUTIONAL BILL TYPE IDENTIFICATION Reference Identification Qualifier

REF02

Bill Type Identifier

AN

1-30

REF03

Description

AN

1-80

REF04

REFERENCE IDENTIFIER

N/U

REF

1

REF01

INSTITUTIONAL BILL TYPE IDENTIFICATION Reference Identification Qualifier

R

REF02

Bill Type Identifier

AN

1-50

R

N/U

REF03

Description

AN

1-80

N/U

REF04

Reference Identifier

REF

APPLICATION OR LOCATION SYSTEM IDENTIFIER

S

2200E

REF BLT

ID

2-3

N/U

R

1

S

2-3

R

2200E BLT

ID

Increase from 30 - 50

N/U New Segment

Page 9 of 12

1

S

2200E

CLAIM STATUS

4010A1 Element Identifier

Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

276 4010A1

REF01

MEDICAL RECORD IDENTIFICATION Reference Identification Qualifier

REF02

Medical Record Number

AN

1-30

R

REF03

Description

AN

1-80

N/U

REF04

REFERENCE IDENTIFIER

Min. Max.

Usage Reg.

Loop

Loop Repeat

Values

276 5010 LU

REF02

Reference Identification Qualifier Application or Location System Identifier

AN

1-50

R

REF03

Description

AN

1-80

N/U

REF04

Reference Identifier

REF01

REF

ID

ID

2-3

R

N/U Segment Deleted

1

S

2-3

R

2200E EA

ID

N/U

REF01

GROUP NUMBER Reference Identification Qualifier

ID

2-3

R

REF02

Group Number

AN

1-50

R

REF03

Description

AN

1-80

N/U

REF04

Reference Identifier

REF

REF01

PATIENT CONTROL NUMBER Reference Identification Qualifier

REF

1

S

6P

N/U New Segment 1

S

2-3

R

REF02

Patient Control Number

AN

1-50

R

Description

AN

1-80

N/U

REF04

Reference Identifier

REF01 REF02

Description

REF04

Reference Identifier

REF REF01

N/U

PHARMACY PRESCRIPTION NUMBER Reference Identification Qualifier ID Pharmacy Prescription Number AN

REF03

CLAIM ID FOR CLEARINGHOUSES AND OTHER TRANSMISSION INTERMEDIARIES Reference Identification Qualifier

Page 10 of 12

2200E EJ

ID

REF03

REF

New Segment

2200E

AN

New Segment 1

S

2-3

R

2200E XZ

1-50

R

1-80

N/U N/U New Segment

1

S

2-3

R

2200E D9

ID

CLAIM STATUS

4010A1 Element Identifier

Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

276 4010A1

CLAIM SUBMITTED CHARGES

1

S R

ID

1-3

AMT02

Amount Qualifier Code Total Claim Charge Amount S9(7)V99

R

1-18

R

AMT03

Credit/Debit Flag Code

ID

1-1

N/U

DTP

CLAIM SERVICE DATE

1

S

DTP01

Date/Time Qualifier Date Time Period Format Qualifier

ID

3-3

R

AMT01

DTP02

2200E T3

2200E 232

2-3

R

Clearinghouse Trace Number AN

REF03

Description

REF04

Reference Identifier

AMT

CLAIM SUBMITTED CHARGES

Usage Reg.

AN

1-50

R

1-80

N/U

Loop

Loop Repeat

1

S

ID

1-3

R

AMT02

R

1-18

R

AMT03

Credit/Debit Flag Code

ID

1-1

N/U

DTP

CLAIM SERVICE DATE

1

S

DTP01

Date Time Qualifier Date Time Period Format Qualifier

ID

3-3

R

DTP02

2200E T3

2200E 472 D8, RD8

ID

2-3

SVC SVC01

Claim Service Period

AN

SERVICE LINE INFORMATION COMPOSITE MEDICAL PROCEDURE INDENTIFIER

1-35

R

1

S

DTP03

2210E

>1

SVC

R

SVC01

Claim Service Period

AN

SERVICE LINE INFORMATION Composite Medical Procedure Identifier

1-35

R

1

S

Codes Added

CCYYMMDD, CCYYMMDDCCYYMMDD

2210E

New format allowed

>1

R

AD, CI, HC, ID, IV, N1, N2, N3, N4, ND, NH, NU, RB

AD, ER, HC, HP, Code Changes IV, N4, NU, WK

SVC01-1

Product or Service ID Qualifier

ID

2-2

R

SVC01-1

Product Service ID

ID

2-2

R

SVC01-2

Service Identification Code

AN

1-48

R

SVC01-2

Service Identification Code

AN

1-48

R

SVC01-3

Procedure Modifier

AN

2-2

S

SVC01-3

Procedure Modifier

AN

2-2

S

SVC01-4

Procedure Modifier

AN

2-2

S

SVC01-4

Procedure Modifier

AN

2-2

S

SVC01-5

Procedure Modifier

AN

2-2

S

SVC01-5

Procedure Modifier

AN

2-2

S

SVC01-6

Procedure Modifier

AN

2-2

S

SVC01-6

Procedure Modifier

AN

2-2

S

SVC01-7

Description

AN

1-80

N/U

SVC01-7

Description

AN

1-80

N/U

SVC01-8

1-48

N/U

SVC02

R

1-18

R

SVC02

Product Service ID Line Item Charge Amount S9(7)V99

AN

Line Item Charge Amount S9(7)V99

R

1-18

R

SVC03

Monetary Amount

R

1-18

N/U

SVC03

Monetary Amount

R

1-18

N/U

SVC04

Revenue Code

AN

1-48

S

SVC04

Revenue Code

AN

1-48

S

SVC05

R

1-15

N/U

SVC05

1-15

N/U

N/U

SVC06

Quanity Composite Medical Procedure Identifier

R

SVC06

Quanity Composite Medical Procedure Identifier

SVC07

Quantity

R

S

SVC07

Quantity

R

1-15

Code Changed

R

CCYYMMDDCCYYMMDD DTP03

Values

N/U

Amount Qualifier Code Total Claim Charge Amount S9(7)V99

AMT01

RD8 ID

Min. Max.

276 5010 REF02

AMT

ID

Page 11 of 12

New Element

N/U 1-15

R

Usage Changed to Required

CLAIM STATUS

4010A1 Element Identifier

Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

276 4010A1

REF01

SERVICE LINE ITEM IDENTIFICATION Reference Identification Qualifier

REF02

Line Item Control Number

AN

1-30

REF03

Description

AN

1-80

REF04

REFERENCE IDENTIFIER

N/U

DTP

SERVICE LINE DATE

DTP01

Date Time Qualifier Date Time Period Format Qualifier

REF

DTP02

1

ID

2-3

REF01

R

REF02

Line Item Control Number

AN

1-50

R

N/U

REF03

Description

AN

1-80

N/U

REF04

Reference Identifier

DTP

SERVICE LINE DATE

DTP01

Date Time Qualifier Date Time Period Format Qualifier

S

2210E

REF

R

1

S

3-3

R

2-3

Usage Reg.

Loop

Loop Repeat

2210E 472

R

DTP02

1

S

2-3

R

2210E FJ

ID

Increase from 30 - 50

N/U

ID

1

R

3-3

R

2210E 472 D8, RD8

ID

2-3

Service Date

SE

TRANSACTION SET TRAILER

SE01 SE02

Transaction Segment Count Transaction Set Control Number

1-35

R

DTP03

Service Line Date

1

R

SE

TRANSACTION SET TRAILER

N0

1-10

R

SE01

AN

4-9

R

SE02

1

R

AN

GE01

FUNCTIONAL GROUP TRAILER Number of Transaction Sets Included

N0

1-6

R

GE02

Group Control Number

N0

1-9

R

1

R

GE

IEA01

INTERCHANGE CONTROL TRAILER Number of Included Functional Groups

N0

1-5

R

IEA02

Interchange Control Number

N0

9-9

R

IEA

1

1

1-35

R

1

R

N0

1-10

R

AN

4-9

R

1

R

GE01

FUNCTIONAL GROUP TRAILER Number of Transaction Sets Included

N0

1-6

R

GE02

Group Control Number

N0

1-9

R

1

R

GE

Must=GS06

Transaction Segment Count Transaction Set Control Number

AN

IEA01

INTERCHANGE CONTROL TRAILER Number of Included Functional Groups

N0

1-5

R

IEA02

Interchange Control Number

N0

9-9

R

IEA

Page 12 of 12

Codes Added

R

CCYYMMDDCCYYMMDD DTP03

Values

276 5010

RD8 ID

Min. Max.

SERVICE LINE ITEM IDENTIFICATION Reference Identification Qualifier

FJ ID

ID

CCYYMMDD, CCYYMMDDCCYYMMDD

1

1

New format allowed

CLAIM STATUS

4010A1 Element Identifier

Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

277 4010A1

ISA01

INTERCHANGE CONTROL HEADER Authorization Information Qualifier

ISA02

Authorization Information

ISA

1

R

2-2

AN 10-10

Min. Max.

Usage Reg.

Loop

Loop Repeat

1

ISA01 ISA02

Authorization Information

ISA03

Security Information Qualifier

ISA04

Security Information

ISA

R R

1

R

2-2

R

1 00, 03

ID

AN 10-10

R

ID

R

00, 01 ISA03

Security Information Qualifier

ISA04

Security Information

ID

2-2

AN 10-10

R R

00, 01 2-2

AN 10-10

R

01, 14, 20, 27, 28, 29, 30, 33, ZZ ISA05

Interchange ID Qualifier

ID

ISA06

Interchange Sender ID

AN 15-15

2-2

Values

277 5010 INTERCHANGE CONTROL HEADER Authorization Information Qualifier

00, 03 ID

ID

01, 14, 20, 27, 28, 29, 30, 33, ZZ

R

ISA05

Interchange ID Qualifier

ID

R

ISA06

Interchange Sender ID

AN 15-15

2-2

R R

01, 14, 20, 27, 28, 29, 30, 33, ZZ

01, 14, 20, 27, 28, 29, 30, 33, ZZ

ISA07

Interchange ID Qualifier

ID

R

ISA07

Interchange ID Qualifier

ID

ISA08

Interchange Receiver ID

AN 15-15

R

ISA08

Interchange Receiver ID

AN 15-15

R

ISA09

Interchange Date

DT

6-6

R

YYMMDD

ISA09

Interchange Date

DT

6-6

R

YYMMDD

ISA10

TM

4-4

R

HHMM

ISA10

Interchange Time

TM

4-4

R

HHMM

ISA11

1-1

R

ISA12

Repetition Seperator Interchange Control Version Number

AN

ISA12

Interchange Time Interchange Control Standards ID Interchange Control Version Number

ID

5-5

R

ISA13

Interchange Control Number

ISA13

Interchange Control Number

N0

9-9

R

ISA14

Acknowledgement Requested

ID

1-1

R

ISA15

ID

1-1

R

ISA16

Usage Indicator Component Element Separator

AN

1-1

R

GS

FUNCTIONAL GROUP HEADER

1

R

GS01

Functional Identifier Code

ID

2-2

R

GS02

Application Sender Code

AN

2-15

R

ISA11

2-2

2-2

R

U ID

1-1

R

ID

5-5

R

N0

9-9

R

New usage for element

00401

00501

0, 1 ISA14

Acknowledgement Requested

ID

1-1

R

ISA15

ID

1-1

R

ISA16

Usage Indicator Component Element Separator

AN

1-1

R

GS

FUNCTIONAL GROUP HEADER

1

R

GS01

Functional Identifier Code

ID

2-2

R

GS02

Application Sender Code

AN

2-15

R

P, T

>1 HN

0, 1 P, T

>1 HR

GS03

Application Receiver Code

AN

2-15

R

GS03

Application Receiver Code

AN

2-15

R

GS04

Date

DT

8-8

R

CCYYMMDD

GS04

Date

DT

8-8

R

CCYYMMDD

GS05

Time

TM

4-8

R

HHMMSSDD

GS05

Time

TM

4-8

R

HHMMSSDD

GS06

Group Control Number

N0

1-9

R

GS06

Group Control Number

N0

1-9

R

GS07

Responsible Agency Code

ID

1-2

R

X

GS07

Responsible Agency Code

ID

1-2

R

X

GS08

Version Identifier Code

AN

1-12

R

004010X093A1

GS08

Version Identifier Code

AN

1-12

R

005010X212

Page 1 of 24

CLAIM STATUS

4010A1 Element Identifier

Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

277 4010A1 ST ST01 ST02

BHT

TRANSACTION SET HEADER Transaction Set Identifier Code Transaction Set Control Number

1

R

>1

ST03

BHT

BEGINNING OF HIERARCHICAL TRANSACTION

ST

ID

3-3

R

ST01

AN

4-9

R

ST02

1

Min. Max.

Usage Reg.

Loop

Loop Repeat

R

1

R

ID

3-3

R

AN

4-9

R

AN

1-35

R

1

R

ID

4-4

R

ID

2-2

R

AN

1-50

R

DT

8-8

R

>1 277

005010X212

0010 BHT01 BHT02

Hierarchical Structure Code Transaction Set Purpose Code

4-4

R

ID

2-2

R

BHT02

AN

1-30

R

BHT03

DT

8-8

R

BHT04

Originator Application Transaction Identifier Transaction Set Creation Date

BHT05

Time

TM

4-8

R

BHT06

Transaction Type Code

ID

2-2

R

HL

INFORMATION SOURCE LEVEL

1

R

AN

1-12

R N/U

08

BHT04 BHT05

Time

TM

4-8

N/U

BHT06

Transaction Type Code

ID

2-2

R

HL

INFORMATION SOURCE LEVEL

1

R

CCYYMMDD

DG

2000A

>1

08 Increase from 30 - 50 CCYYMMDD Change from Not used to Required DG

2000A

>1

AN

1-12

R

HL02

Hierarchical ID Number Hierarchical Parent ID Number

AN

1-12

N/U

HL02

Hierarchical ID Number Hierarchical Parent ID Number

AN

1-12

HL03

Hierarchical Level Code

ID

1-2

R

20

HL03

Hierarchical Level Code

ID

1-2

R

20

HL04

Hierarchical Child Code

ID

1-1

R

1

HL04

Hierarchical Child Code

ID

1-1

R

1

HL01

New Element

0010 BHT01

Hierarchical Structure Code Transaction Set Purpose Code

ID

Originator Application Transaction Identifier Transaction Set Creation Date

BHT03

Values

277 5010 TRANSACTION SET HEADER Transaction Set Identifier Code Transaction Set Control Number Implementation Convention Reference

277

BEGINNING OF HIERARCHICAL TRANSACTION

ID

HL01

NM1

PAYER NAME

1

R

NM1

PAYER NAME

1

R

NM101

Entity Identifier Code

ID

2-3

R

PR

NM101

Entity Identifier Code

ID

2-3

R

PR

NM102

Entity Type Qualifier

ID

1-1

R

2

NM102

Entity Type Qualifier

ID

1-1

R

2

NM103

Payer Name

AN

1-35

R

NM103

Payer Name

AN

1-60

R

Increase from 35 - 60

NM104

Name First

AN

1-25

N/U

NM104

Name First

AN

1-35

N/U

Increase from 25 - 35

NM105

Name Middle

AN

1-25

N/U

NM105

Name Middle

AN

1-25

N/U

NM106

Name Prefix

AN

1-10

N/U

NM106

Name Prefix

AN

1-10

N/U

NM107

Name Suffix

AN

1-10

N/U

NM107

Name Suffix

AN

1-10

N/U

NM108

Identification Code Qualifier

ID

1-2

R

2100A

>1

21, AD, FI, NI, PI, PP, XV

ID

1-2

NM109

Payer Identifier

AN

2-80

R

NM109

Payer Identifier

AN

2-80

R

NM110

Entity Relationship Code

ID

2-2

N/U

NM110

Entity Relationship Code

ID

2-2

N/U

NM111

Entity Identifier Code

ID

2-3

N/U

NM111

Entity Identifier Code

ID

2-3

N/U

NM112

Last Name

ID

1-60

N/U

R

1

PI, XV

Identification Code Qualifier

NM108

2100A

Page 2 of 24

Codes Removed

New Element

CLAIM STATUS

4010A1 Element Identifier

Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

277 4010A1 PER

PAYER CONTACT INFORMATION

PER01

Contact Function Code

PER02 PER03 PER04 PER05 PER06 PER07

Usage Reg.

2100A

PER

PAYER CONTACT INFORMATION

1

S

PER01

Contact Function Code

ID

2-2

R

PER02

Payer Contact Name Communication Number Qualifier

AN

1-60

S

ID

2-2

R

Communication Number Communication Number Qualifier

AN 1-256

Communication Number Communication Number Qualifier

AN 1-256

S

ID

S

S

ID

2-2

R

Payer Contact Name Communication Number Qualifier

AN

1-60

S

ID

2-2

R

Communication Number Communication Number Qualifier

AN

1-80

R

ID

2-2

S

PER05

Communication Number Communication Number Qualifier

AN

1-80

S

PER06

IC ED, EM, TE

PER03 PER04 EX

EX, FX 2-2

Min. Max.

Loop

Loop Repeat

Values

277 5010

1

ID

ID

S

PER07

PER08

Communication Number

AN

1-80

S

PER08

Communication Number

PER09

Contact Inquiry Reference

AN

1-20

N/U

PER09

Contact Inquiry Reference

HL

INFORMATION RECEIVER LEVEL

1

R

HL

INFORMATION RECEIVER LEVEL

2000B

>1

2100A IC ED, EM, TE, FX

ID

2-2

2-2

AN 1-256

R

Increase from 80 - 256

S

ED, EM, TE, FX, Code Changes EX Increase from 80 - 256 ED, EM, TE, FX, Code Changes EX Increase from 80 - 256

S

AN

1-20

N/U

1

R

AN

1-12

R

HL02

Hierarchical ID Number Hierarchical Parent ID Number

AN

1-12

R

HL03 HL04

Hierarchical Level Code Hierarchical Child Code

ID ID

1-2 1-1

R R

NM1

INFORMATION RECEIVER NAME

2000B

>1

AN

1-12

R

HL02

Hierarchical ID Number Hierarchical Parent ID Number

AN

1-12

R

HL03 HL04

Hierarchical Level Code Hierarchical Child Code

ID ID

1-2 1-1

R R

NM1

INFORMATION RECEIVER NAME

1

R

1

R

NM101

Entity Identifier Code

ID

2-3

R

41

NM101

Entity Identifier Code

ID

2-3

R

41

NM102

Entity Type Qualifier Information Receiver Last or Organization Name Information Receiver First Name Information Receiver Middle Name Information Receiver Name Prefix Information Receiver Name Suffix

ID

1-1

R

1, 2

NM102

ID

1-1

R

1, 2

AN

1-35

R

NM103

AN

1-60

S

AN

1-25

S

NM104

AN

1-35

S

AN

1-25

S

NM105

AN

1-25

S

AN

1-10

S

NM106

AN

1-10

N/U

AN

1-10

S

NM107

Entity Type Qualifier Information Receiver Last or Organization Name Information Receiver First Name Information Receiver Middle Name Information Receiver Name Prefix Information Receiver Name Suffix

AN

1-10

N/U

R

NM108

R

HL01

NM103 NM104 NM105 NM106 NM107

HL01

21 1

2100B

>1

ID

1-2

NM109

AN

2-80

R

NM110

Entity Relationship Code

ID

2-2

N/U

NM111

Entity Identifier Code

ID

2-3

N/U

21 0, 1

2100B

1

Increase from 25 - 35

Changed to Not Used 46 ID

1-2

NM109

Identification Code Qualifier Information Receiver Identification Number

AN

2-80

R

NM110

Entity Relationship Code

ID

2-2

N/U

NM111

Entity Identifier Code

ID

2-3

N/U

NM112

Last Name

ID

1-60

N/U

Page 3 of 24

Code Added

Increase from 35 - 60

46, FI, XX Identification Code Qualifier Information Receiver Identification Number

NM108

Code Added

Codes Removed

New Element

CLAIM STATUS

4010A1 Element Identifier

Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

277 4010A1

ID

Min. Max.

Usage Reg.

Loop

Loop Repeat

2200B

1

Values

277 5010

TRN03

INFORMATION RECEIVER TRACE IDENTIFIER Referenced Transaction Trace Number Claim Transaction Batch Number Originating Company Identifier

TRN04

Reference Identifier

TRN TRN01 TRN02

1

S

ID

1-2

R

AN

1-50

R

2

AN 10-10

N/U

AN

1-50

N/U

>1

R

AN

1-30

R

STC01-2

INFORMATION RECEIVER STATUS INFORMATION HEALTH CARE CLAIM STATUS Health Care Claim Status Category Code Health Care Claim Status Code

AN

1-30

R

STC01-3

Entity Identifier Code

ID

2-3

S

STC01-4

Code List Qualifier Code Status Information Effective Date

ID

1-3

N/U

DT

8-8

R

STC STC01 STC01-1

STC02

New Segment

D0, E

Action Code

ID

1-2

N/U

Monetary Amount

R

1-18

N/U

STC05

Monetary Amount

R

1-18

N/U

STC06

Date

DT

8-8

N/U

STC07

Payment Method Code

ID

3-3

N/U

STC08

Date

DT

8-8

N/U

STC09

AN

1-16

N/U

AN

1-30

R

STC10-2

Check Number HEALTH CARE CLAIM STATUS Health Care Claim Status Category Code Health Care Claim Status Code

AN

1-30

R

STC10-3

Entity Identifier Code

ID

2-3

S

STC10-4

ID

1-3

N/U

AN

1-30

R

STC11-2

Code List Qualifier Code HEALTH CARE CLAIM STATUS Health Care Claim Status Category Code Health Care Claim Status Code

AN

1-30

R

STC11-3

Entity Identifier Code

ID

2-3

S

STC11-4

Code List Qualifier Code

ID

1-3

N/U

STC12

Free-Form Message Text

AN 1-264

STC11 STC11-1

Page 4 of 24

41, AY, PR CCYYMMDD

STC04

STC10-1

2200B

R

STC03

STC10

New Loop and new segment

S D0, E

41, AY, PR

S D0, E

N/U

41, AY, PR

CLAIM STATUS

4010A1 Element Identifier

Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

277 4010A1 HL

SERVICE PROVIDER LEVEL

1

R

AN

1-12

R

HL02

Hierarchical ID Number Hierarchical Parent ID Number

AN

1-12

R

HL03

Hierarchical Level Code

ID

1-2

R

19

HL04

Hierarchical Child Code

ID

1-1

R

1

R

ID

2-3

Entity Type Qualifier ID Provider Last or Organization Name AN Provider First Name AN

NM1

PROVIDER NAME Entity Identifier Code

NM102 NM103 NM104 NM105

Provider Middle Name

AN

Min. Max.

Usage Reg.

Loop

Loop Repeat

2000C

>1

Values

277 5010

HL01

NM101

ID

HL

SERVICE PROVIDER LEVEL

1

R

HL01

AN

1-12

R

HL02

Hierarchical ID Number Hierarchical Parent ID Number

AN

1-12

R

HL03

Hierarchical Level Code

ID

1-2

R

19

1

HL04

Hierarchical Child Code

ID

1-1

R

0, 1

NM1

PROVIDER NAME

1

R

R

1P

NM101

Entity Identifier Code

ID

2-3

R

1P

1-1

R

1, 2

NM102

1-1

R

1, 2

1-35

R

Entity Type Qualifier ID Provider Last or Organization Name AN Provider First Name AN

1-60

S

2000C

2100C

>1

>1

NM103

1-25

S

NM104

1-25

S

NM105

Provider Middle Name

AN

2100C

New Code Loop repeat changed

2

Increase from 35 - 60 1-35

S

1-25

S

NM106

Provider Name Prefix

AN

1-10

S

NM106

Provider Name Prefix

AN

1-10

N/U

NM107

Provider Name Suffix

AN

1-10

S

NM107

Provider Name Suffix

AN

1-10

S

NM108

Identification Code Qualifier

ID

1-2

R

NM108

Identification Code Qualifier

ID

1-2

R

NM109

Provider Identifier

AN

2-80

R

NM109

Provider Identifier

AN

2-80

R

NM110

Entity Relationship Code

ID

2-2

N/U

NM110

Entity Relationship Code

ID

2-2

N/U

NM111

Entity Identifier Code

ID

2-3

N/U

NM111

Entity Identifier Code

ID

2-3

N/U

NM112

Last Name

ID

1-60

N/U

1

S

ID

1-2

R

AN

1-50

R

Increase from 25 - 35 Changed to Not Used

FI, SV, XX

FI, SV, XX

TRN03

PROVIDER OF SERVICE TRACE IDENTIFIER Current Transaction Trace Number Provider of Service Information Trace Identifier Originating Company Identifier

TRN04

Reference Identifier

TRN TRN01 TRN02

AN 10-10

N/U

AN

1-50

N/U

>1

R

AN

1-30

R

STC01-2

AN

1-30

R

STC01-3

Entity Identifier Code

ID

2-3

S

STC01-4

Code List Qualifier Code

ID

1-3

N/U

STC01 STC01-1

Page 5 of 24

2200C

New Loop and new segment

1 1

PROVIDER STATUS INFORMATION HEALTH CARE CLAIM STATUS Health Care Claim Status Category Code Health Care Claim Status Code

STC

New Element

New Segment 2200C

R D0, E

1P

CLAIM STATUS

4010A1 Element Identifier

Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

STC02

Status Information Effective Date

DT

277 4010A1

Min. Max.

Usage Reg.

Loop

Loop Repeat

Values

277 5010 ID

1-2

R

1-18

N/U

STC05

Monetary Amount

R

1-18

N/U

STC06

Date

DT

8-8

N/U

STC07

Payment Method Code

ID

3-3

N/U

STC08

Date

DT

8-8

N/U

STC09

AN

1-16

N/U

AN

1-30

R

STC10-2

Check Number HEALTH CARE CLAIM STATUS Health Care Claim Status Category Code Health Care Claim Status Code

AN

1-30

R

STC10-3

Entity Identifier Code

ID

2-3

S

STC10-4

ID

1-3

N/U

AN

1-30

R

STC11-2

Code List Qualifier Code HEALTH CARE CLAIM STATUS Health Care Claim Status Category Code Health Care Claim Status Code

AN

1-30

R

STC11-3

Entity Identifier Code

ID

2-3

S

STC11-4

Code List Qualifier Code

ID

1-3

N/U

STC12

Free-Form Message Text

AN 1-264

STC11-1

SUBSCRIBER LEVEL

1

R

AN

1-12

R

HL02

Hierarchical ID Number Hierarchical Parent ID Number

AN

1-12

R

HL03

Hierarchical Level Code

ID

1-2

R

22

HL04

Hierarchical Child Code

ID

1-1

R

0, 1

DMG

SUBSCRIBER DEMOGRAPHIC INFORMATION Date Time Period Format Qualifier

DMG02 DMG03 DMG04

Marital Status Code

2000D

>1

N/U

Action Code Monetary Amount

STC11

HL

R

STC03

STC10-1

HL01

CCYYMMDD 8-8

STC04

STC10

DMG01

ID

S D0, E

1P

S D0, E

1P

N/U

HL

SUBSCRIBER LEVEL

1

S

HL01

AN

1-12

R

HL02

Hierarchical ID Number Hierarchical Parent ID Number

AN

1-12

R

HL03

Hierarchical Level Code

ID

1-2

R

22

HL04

Hierarchical Child Code

ID

1-1

R

0, 1

2000D

>1

Segment Deleted 1

R

2000D

ID

2-3

R

Subscriber Birth Date

AN

1-35

R

CCYYMMDD

Subscriber Gender Code

ID

1-1

R

F, M, U

ID

1-1

N/U

D8

DMG05

Race or Ethnicity Code

ID

1-1

N/U

DMG06

Citizenship Status Code

ID

1-2

N/U

DMG07

Country Code

ID

2-3

N/U

Page 6 of 24

CLAIM STATUS

4010A1 Element Identifier

Description

DMG08

Basis of Verification Code

ID

1-2

N/U

DMG09

Quantity

R

1-15

N/U

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

277 4010A1

ID

Min. Max.

Usage Reg.

Loop

Loop Repeat

2100D

1

Values

277 5010

NM1

SUBSCRIBER NAME

1

R

NM1

SUBSCRIBER NAME

1

R

NM101

Entity Identifier Code

ID

2-3

R

IL, QC

NM101

Entity Identifier Code

ID

2-3

R

IL

NM102

Entity Type Qualifier

ID

1-1

R

1, 2

NM102

Entity Type Qualifier

ID

1-1

R

1, 2

2100D

1

Code change

NM103

Subscriber Last Name

AN

1-35

R

NM103

Subscriber Last Name

AN

1-60

R

Increase from 35 - 60

NM104

Subscriber First Name

AN

1-25

S

NM104

Subscriber First Name

AN

1-35

S

Increase from 25 - 35

NM105

Subscriber Middle Name

AN

1-25

S

NM105

Subscriber Middle Name

AN

1-25

S

NM106

Subscriber Name Prefix

AN

1-10

S

NM106

Subscriber Name Prefix

AN

1-10

N/U

NM107

Subscriber Name Suffix

AN

1-10

S

NM107

Subscriber Name Suffix

AN

1-10

S

NM108

Identification Code Qualifier

ID

1-2

R

NM108

Identification Code Qualifier

ID

1-2

R

NM109

Subscriber Identifier

AN

2-80

R

NM109

Subscriber Identifier

AN

2-80

R

NM110

Entity Relationship Code

ID

2-2

N/U

NM110

Entity Relationship Code

ID

2-2

N/U

NM111

Entity Identifier Code

ID

2-3

N/U

NM111

Entity Identifier Code

ID

2-3

N/U

NM112

Last Name

ID

1-60

N/U

1

S

ID

1-2

R

AN

1-50

R

Changed to Not Used

24, MI, ZZ

TRN

CLAIM SUBMITTER TRACE NUMBER

TRN01

Trace Type Code

TRN02 TRN03

Trace Number Originating Company Identifier

TRN04

Reference Identification

2200D

>1

24, II, MI

TRN

S

ID

1-2

R

TRN01

AN

1-30

R

TRN02

AN 10-10

N/U

TRN03

Trace Number Originating Company Identifier

AN

1-30

N/U

TRN04

Reference Identification

1

R

2

STC STC01 STC01-1 STC01-2

CLAIM LEVEL STATUS INFORMATION HEALTH CARE CLAIM STATUS Health Care Claim Status Category Code Health Care Claim Status Code

CLAIM STATUS TRACKING NUMBER Referenced Transaction Trace Number

1

2200D

STC

R

STC01

AN

1-30

R

STC01-1

AN

1-30

R

STC01-2

CLAIM LEVEL STATUS INFORMATION HEALTH CARE CLAIM STATUS Health Care Claim Status Category Code Health Care Claim Status Code

Page 7 of 24

New Element

2200D

Loop and segment name change

>1 2

AN 10-10

N/U

AN

1-50

N/U

>1

R R

AN

1-30

R

AN

1-30

R

Increase from 30 - 50

Increase from 30 - 50

2200D

CLAIM STATUS

4010A1 Element Identifier

Description

STC01-3

Entity Identifier Code

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

ID

STC01-3

Entity Identifier Code

ID

277 4010A1 ID

2-3

Min. Max.

Usage Reg.

Loop

Loop Repeat

Values

277 5010

S

13, 17, 1E, 1G, 1H, 1I, 1O, 1P, 1Q, 1R, 1S, 1T, 1U, 1V, 1W,1X, 1Y, 1Z, 28, 2A, 2B, 2E, 2I, 2K, 2P, 2Q, 2S, 2Z, 30, 36, 3A, 3C, 3D, 3E, 3F, 3G, 3H, 3I, 3J, 3K, 3L, 3M, 3N, 3O, 3P, 3Q, 3R, 3S, 3T, 3U, 3V, 3W, 3X, 3Y, 3Z, 40, 43, 44, 4A, 4B, 4C, 4D, 4E, 4F, 4G, 4H, 4I, 4J, 4L, 4M, 4N, 4O, 4P, 4Q, 4R, 4S, 4U, 4V, 4W, 4X, 4Y, 4Z, 5A, 5B, 5C, 5D, 5E, 5F, 5G, 5H, 5I, 5J, 5K, 5L, 5M, 5N, 5O, 5P, 5Q, 5R, 5S, 5T, 5U, 5V, 5W, 5X, 5Y, 5Z, 61, 6A, 6B, 6C, 6D, 6E, 6F, 6G, 6H, 6I, 6J, 6K, 6L, 6M, 6N, 6O, 6P, 6Q, 6R, 6S, 6U, 6V, 6W, 6X, 6Y, 71, 72, 73, 74, 77, 7C, 80, 82, 84, 85, 87, 95, continued on next row

Page 8 of 24

2-3

S

13, 17, 1E, 1G, 1H, Code changes 1I, 1O, 1P, 1Q, 1R, 1S, 1T, 1U, 1V, 1W,1X, 1Y, 1Z, 28, 2A, 2B, 2E, 2I, 2K, 2P, 2Q, 2S, 2Z, 30, 36, 3A, 3C, 3D, 3E, 3F, 3G, 3H, 3I, 3J, 3K, 3L, 3M, 3N, 3O, 3P, 3Q, 3R, 3S, 3T, 3U, 3V, 3W, 3X, 3Y, 3Z, 40, 43, 44, 4A, 4B, 4C, 4D, 4E, 4F, 4G, 4H, 4I, 4J, 4L, 4M, 4N, 4O, 4P, 4Q, 4R, 4S, 4U, 4V, 4W, 4X, 4Y, 4Z, 5A, 5B, 5C, 5D, 5E, 5F, 5G, 5H, 5I, 5J, 5K, 5L, 5M, 5N, 5O, 5P, 5Q, 5R, 5S, 5T, 5U, 5V, 5W, 5X, 5Y, 5Z, 61, 6A, 6B, 6C, 6D, 6E, 6F, 6G, 6H, 6I, 6J, 6K, 6L, 6M, 6N, 6O, 6P, 6Q, 6R, 6S, 6U, 6V, 6W, 6X, 6Y, 71, 72, 73, 74, 77, 7C, 80, 82, 84, 85, 87, 95, continued on next row

CLAIM STATUS

4010A1 Element Identifier

Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

277 4010A1

ID

Min. Max.

Usage Reg.

STC03 STC04 STC05

Action Code Total Claim Charge Amount S9(7)V99 Claim payment Amount S9(7)V99

CCYYMMDD DT

8-8

R

STC02

ID

1-2

N/U

STC03

R

1-18

R

STC04

R

1-18

R

STC05

Code List Qualifier Code Status Information Effective Date Action Code Total Claim Charge Amount S9(7)V99 Claim payment Amount S9(7)V99

ID

1-3

S

Adjudication or Payment Date DT

8-8

S

STC07

Payment Method Code Check Issue or EFT Effective Date

ID

3-3

S

DT

8-8

AN

1-16

STC10-2

Check or EFT Trace Number HEALTH CARE CLAIM STATUS Health Care Claim Status Category Code Health Care Claim Status Code

STC10-3

Entity Identifier Code

STC08 STC09 STC10 STC10-1

New element

DT

8-8

R

ID

1-2

N/U

R

1-18

S

R

1-18

S

8-8

S

CCYYMMDD STC06

ACH, BOP, CHK, FWT, NON CCYYMMDD

RX CCYYMMDD

CCYYMMDD STC06

Values

continued CK, CZ, D2, DD, DJ, DK, DN, DO, DQ, E1, E2, E7, E9, FA, FD, FE, G0, G3, GB, GD, GI, GJ, GK, GM, GY, HF, HH, I3, IJ, IL, IN, LI, LR, MR, OB, OD, OX, P0, P2, P3, P4, P6, P7, PT, PV, PW, QA, QB, QC, QD, QE, QH, QK, QL, QN, QO, QS, QV, QY, RC, RW, S4, SJ, SU, T4, TQ, TT, TU, UH, X3, X4, X5, ZZ, 03, 2D, MSC, PRP, SEP, TL, TTP end of list

STC01-4 STC02

Loop Repeat

277 5010

continued CK, CZ, D2, DD, DJ, DK, DN, DO, DQ, E1, E2, E7, E9, FA, FD, FE, G0, G3, GB, GD, GI, GJ, GK, GM, GY, HF, HH, I3, IJ, IL, IN, LI, LR, MR, OB, OD, OX, P0, P2, P3, P4, P6, P7, PT, PV, PW, QA, QB, QC, QD, QE, QH, QK, QL, QN, QO, QS, QV, QY, RC, RW, S4, SJ, SU, T4, TQ, TT, TU, UH, X3, X4, X5, ZZ end of list Status Information Effective Date

Loop

Adjudication or Payment Date DT

Usage changed to not used STC07

Payment Method Code

ID

3-3

N/U

S

STC08

Remittance Date

DT

8-8

S

S

STC09

AN

1-16

S

S

STC10

CCYYMMDD

AN

1-30

R

STC10-1

AN

1-30

R

STC10-2

Remittance Trace Number HEALTH CARE CLAIM STATUS Health Care Claim Status Category Code Health Care Claim Status Code

AN

2-3

S

STC10-3

Entity Identifier Code

STC10-4

Code List Qualifier Code

Page 9 of 24

S AN

1-30

R

AN

1-30

R

AN

2-3

S

ID

1-3

S

RX

New element

CLAIM STATUS

4010A1 Element Identifier

Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

277 4010A1

STC11-2

HEALTH CARE CLAIM STATUS Health Care Claim Status Category Code Health Care Claim Status Code

STC11-3

Entity Identifier Code

STC11 STC11-1

STC12

Free-Form Message Text

AN

1-30

R

STC11-1

AN

1-30

R

STC11-2

ID

2-3

S

STC11-3

Entity Identifier Code

STC11-4 STC12

S

STC11

N/U

REF01

PAYER CLAIM IDENTIFICATION NUMBER Reference Identification Qualifier

ID

2-3

R

REF02

Payer Claim Control Number

AN

1-30

REF03

Description

AN

1-80

REF04

REFERENCE IDENTIFIER

REF

1

Usage Reg.

Loop

Loop Repeat

Values

1-30

R

AN

1-30

R

ID

2-3

S

Code List Qualifier Code

ID

1-3

Free-Form Message Text

AN 1-264

REF01

R

REF02

N/U N/U

2200D

REF

S AN

PAYER CLAIM CONTROL NUMBER Reference Identification Qualifier

S

Min. Max.

277 5010 HEALTH CARE CLAIM STATUS Health Care Claim Status Category Code Health Care Claim Status Code

AN 1-264

ID

New element

Loop and segment name change 1

S

ID

2-3

R

Payer Claim Control Number

AN

1-50

R

REF03

Description

AN

1-80

N/U

REF04

REFERENCE IDENTIFIER

1K

RX

S N/U

2200D 1K Increase from 30 - 50

REF01

INSTITUTIONAL BILL TYPE IDENTIFICATION Reference Identification Qualifier

REF02

Bill Type Identifier

AN

1-30

REF03

Description

AN

1-80

REF04

REFERENCE IDENTIFIER

N/U

REF

REF01

MEDICAL RECORD IDENTIFICATION Reference Identification Qualifier

REF

1

REF01

INSTITUTIONAL BILL TYPE IDENTIFICATION Reference Identification Qualifier

R

REF02

Bill Type Identifier

AN

1-50

R

N/U

REF03

Description

AN

1-80

N/U

REF04

REFERENCE IDENTIFIER

S

2200D

REF BLT

ID

2-3

N/U

R

1

S

2-3

R

2200D BLT

ID

Increase from 30 - 50

N/U Segment Deleted

1

S

2-3

R

2200D EA

ID

REF02

Medical Record Number

AN

1-30

R

REF03

Description

AN

1-80

N/U

REF04

REFERENCE IDENTIFIER

N/U

REF01

PATIENT CONTROL NUMBER Reference Identification Qualifier

REF02

Patient Control Number

AN

1-50

R

REF03

Description

AN

1-80

N/U

REF04

REFERENCE IDENTIFIER

REF

PHARMACY PRESCRIPTION NUMBER

REF

Page 10 of 24

New Segment 1

S

2-3

R

2200D EJ

ID

N/U New Segment 1

S

2200D

CLAIM STATUS

4010A1 Element Identifier

Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

277 4010A1

ID

Min. Max.

Usage Reg.

Loop

Loop Repeat

Values

277 5010 XZ

REF02

Reference Identification Qualifier Pharmacy Prescription Number

AN

1-50

R

REF03

Description

AN

1-80

N/U

REF04

REFERENCE IDENTIFIER

REF REF01

VOUCHER IDENTIFIER Reference Identification Qualifier

REF02

Voucher Identifier

AN

1-50

R

REF03

Description

AN

1-80

N/U

REF04

REFERENCE IDENTIFIER

REF01

ID

2-3

R

N/U New Segment

REF REF01 REF02 REF03

DTP

CLAIM SERVICE DATE

DTP01

Date Time Qualifier Date Time Period Format Qualifier

DTP02

ID

1

S

3-3

R

2200D 232

2-3

R

2-3

R

N/U New Segment

ID

2-3

R

Clearinghouse Trace Number AN Description AN

1-50

R

1-80

N/U

DTP

CLAIM SERVICE DATE

DTP01

Date Time Qualifier Date Time Period Format Qualifier

2200D VV

ID

S

REFERENCE IDENTIFIER

DTP02

S

1

REF04

RD8 ID

CLAIM IDENTIFICATION NUMBER FOR CLEARINGHOUSES AND OTHER TRANSMISSION INTERMEDIARIES Reference Identification Qualifier

1

2200D D9

N/U

ID

1

S

3-3

R

2200D 472 D8, RD8

ID

2-3

SVC SVC01

Claim Service Period

AN

SERVICE LINE INFORMATION COMPOSITE MEDICAL PROCEDURE INDENTIFIER

1-35

R

1

S

DTP03

2220D

>1

SVC

R

SVC01

Claim Service Period

AN

SERVICE LINE INFORMATION COMPOSITE MEDICAL PROCEDURE INDENTIFIER

Codes Added

R

CCYYMMDDCCYYMMDD DTP03

Code Changed

1-35

R

1

S

CCYYMMDD, CCYYMMDDCCYYMMDD

2220D

New format allowed

>1

R

AD, CI, HC, ID, IV, N1, N2, N3, N4, ND,NH, NU, RB

AD, ER, HC, HP, Codes changed IV, N4, NU, WK

SVC01-1

Product/Service ID Qualifier

ID

2-2

R

SVC01-1

Product/Service ID Qualifier

ID

2-2

R

SVC01-2

Service Identification Code

AN

1-48

R

SVC01-2

Service Identification Code

AN

1-48

R

SVC01-3

Procedure Modifier

AN

2-2

S

SVC01-3

Procedure Modifier

AN

2-2

S

SVC01-4

Procedure Modifier

AN

2-2

S

SVC01-4

Procedure Modifier

AN

2-2

S

Page 11 of 24

CLAIM STATUS

4010A1 Element Identifier

Description

SVC01-5

Procedure Modifier

AN

2-2

SVC01-6

Procedure Modifier

AN

SVC01-7

SVC03

Description Line Item Charge Amount S9(7)V99 Line Item Provider Payment Amount S9(7)V99

SVC04

Revenue Code

SVC05

Quantity COMPOSITE MEDICAL PROCEDURE INDENTIFIER Original Units of Service Count S9(3)V9

R

Usage Reg.

5010 Element Identifier

Description

ID

S

SVC01-5

Procedure Modifier

AN

2-2

2-2

S

SVC01-6

Procedure Modifier

AN

2-2

S

AN

1-80

N/U

SVC01-7

AN

1-80

N/U

R

1-18

R

SVC02

R

1-18

R

R

1-18

R

SVC03

Description Line Item Charge Amount S9(7)V99 Line Item Payment Amount S9(7)V99

R

1-18

R

AN

1-48

S

SVC04

Revenue Code

AN

1-48

S

1-15

N/U

SVC05

R

1-15

N/U

N/U

SVC06

1-15

S

SVC07

Quantity COMPOSITE MEDICAL PROCEDURE INDENTIFIER Units of Service Count S9(3)V9

1

S

ID

Min. Max.

Loop

Loop Repeat

Values

277 4010A1

SVC02

SVC06 SVC07

STC STC01 STC01-1 STC01-2

SERVICE LINE STATUS INFORMATION HEALTH CARE CLAIM STATUS Health Care Claim Status Category Code Health Care Claim Status Code

R

Min. Max.

Usage Reg.

Loop

Loop Repeat

Values

277 5010

2220D

STC

R

STC01

AN

1-30

R

STC01-1

AN

1-30

R

STC01-2

CLAIM LEVEL STATUS INFORMATION HEALTH CARE CLAIM STATUS Health Care Claim Status Category Code Health Care Claim Status Code

Page 12 of 24

S

N/U R

1-15

S

>1

R R

AN

1-30

R

AN

1-30

R

2220D

Usage changed and repeat changed

CLAIM STATUS

4010A1 Element Identifier

Description

STC01-3

Entity Identifier Code

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

ID

STC01-3

Entity Identifier Code

ID

277 4010A1 ID

2-3

S

Min. Max.

Usage Reg.

Loop

Loop Repeat

Values

277 5010 13, 17, 1E, 1G, 1H, 1I, 1O, 1P, 1Q, 1R, 1S, 1T, 1U, 1V, 1W, 1X, 1Y, 1Z, 28, 2A, 2B, 2E, 2I, 2K, 2P, 2Q, 2S, 2Z, 30, 36, 3A, 3C, 3D, 3E, 3F, 3G, 3H, 3I, 3J, 3K, 3L, 3M, 3N, 3O, 3P, 3Q, 3R, 3S, 3T, 3U, 3V, 3W, 3X, 3Y, 3Z, 40, 43, 44, 4A, 4B, 4C, 4D, 4E, 4F, 4G, 4H, 4I, 4J, 4L, 4M, 4N, 4O, 4P, 4Q,4R, 4S, 4U, 4V, 4W, 4X, 4Y, 4Z, 5A, 5B, 5C, 5D, 5E, 5F, 5G, 5H, 5I, 5J, 5K, 5L, 5M, 5N, 5O, 5P, 5Q, 5R, 5S, 5T, 5U, 5V, 5W, 5X, 5Y, 5Z, 61, 6A, 6B, 6C, 6D, 6E, 6F, 6G, 6H, 6I, 6J, 6K, 6L, 6M, 6N, 6O, 6P, 6Q, 6R, 6S, 6U, 6V, 6W, 6X, 6Y, 71, 72, 73, 74, 77, 7C, 80, 82, 84, 85, 87, 95, continued on next row

Page 13 of 24

2-3

S

13, 17, 1E, 1G, 1H, Code changes 1I, 1O, 1P, 1Q, 1R, 1S, 1T, 1U, 1V, 1W,1X, 1Y, 1Z, 28, 2A, 2B, 2E, 2I, 2K, 2P, 2Q, 2S, 2Z, 30, 36, 3A, 3C, 3D, 3E, 3F, 3G, 3H, 3I, 3J, 3K, 3L, 3M, 3N, 3O, 3P, 3Q, 3R, 3S, 3T, 3U, 3V, 3W, 3X, 3Y, 3Z, 40, 43, 44, 4A, 4B, 4C, 4D, 4E, 4F, 4G, 4H, 4I, 4J, 4L, 4M, 4N, 4O, 4P, 4Q, 4R, 4S, 4U, 4V, 4W, 4X, 4Y, 4Z, 5A, 5B, 5C, 5D, 5E, 5F, 5G, 5H, 5I, 5J, 5K, 5L, 5M, 5N, 5O, 5P, 5Q, 5R, 5S, 5T, 5U, 5V, 5W, 5X, 5Y, 5Z, 61, 6A, 6B, 6C, 6D, 6E, 6F, 6G, 6H, 6I, 6J, 6K, 6L, 6M, 6N, 6O, 6P, 6Q, 6R, 6S, 6U, 6V, 6W, 6X, 6Y, 71, 72, 73, 74, 77, 7C, 80, 82, 84, 85, 87, 95, continued on next row

CLAIM STATUS

4010A1 Element Identifier

Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

277 4010A1

ID

Min. Max.

Usage Reg.

CCYYMMDD

Code List Qualifier Code Status Information Effective Date

DT

8-8

R

STC02

ID

1-2

N/U

STC03

R

1-18

S

STC04

R

1-18

S

STC05

Date

DT

8-8

N/U

STC06

Payment Method Code

ID

3-3

N/U

STC07

Date

DT

8-8

N/U

STC08

Remittance Date

AN

1-16

N/U

STC09

S

STC10

STC10-2

Check Number HEALTH CARE CLAIM STATUS Health Care Claim Status Category Code Health Care Claim Status Code

STC10-3

Entity Identifier Code

Action Code Line Item Charge Amount S9(7)V99 Line Item Provider Payment Amount S9(7)V99

STC06 STC07 STC08 STC09

STC03 STC04 STC05

STC10 STC10-1

STC11

HEALTH CARE CLAIM STATUS

Action Code Total Claim Charge Amount S9(7)V99 Claim payment Amount S9(7)V99

AN

1-30

R

STC10-1

AN

1-30

R

STC10-2

ID

2-3

S

STC10-3

Entity Identifier Code

STC10-4

Code List Qualifier Code HEALTH CARE CLAIM STATUS

STC11

ID

Page 14 of 24

1-3

Newe element

N/U CCYYMMDD

DT

8-8

R

ID

1-2

N/U

R

1-18

N/U

R

1-18

N/U

8-8

N/U

3-3

N/U

DT

8-8

N/U

AN

1-16

N/U

Usage changed Usage changed

Adjudication or Payment Date DT Payment Method Code ID Remittance Trace Number HEALTH CARE CLAIM STATUS Health Care Claim Status Category Code Health Care Claim Status Code

S

Values

continued CK, CZ, D2, DD, DJ, DK, DN, DO, DQ, E1, E2, E7, E9, FA, FD, FE, G0, G3, GB, GD, GI, GJ, GK, GM, GY, HF, HH, I3, IJ, IL, IN, LI, LR, MR, OB, OD, OX, P0, P2, P3, P4, P6, P7, PT, PV, PW, QA, QB, QC, QD, QE, QH, QK, QL, QN, QO, QS, QV, QY, RC, RW, S4, SJ, SU, T4, TQ, TT, TU, UH, X3, X4, X5, ZZ, 03, 2D, MSC, PRP, SEP, TL, TTP end of list

STC01-4 STC02

Loop Repeat

277 5010 continued CK, CZ, D2, DD, DJ, DK, DN, DO, DQ, E1, E2, E7, E9, FA, FD, FE, G0, G3, GB, GD, GI, GK, GM, GY, HF, HH, I3, IJ, IL, IN, LI, LR, MR, OB, OD, OX, P0, P2, P3, P4, P6, P7, PT, PV, PW, QA, QB, QC, QD, QE, QH, QK, QL, QN, QO, QS, QV, QY, RC, RW, S4, SJ, SU, T4, TQ, TT, TU, UH, X3, X4, X5, ZZ end of list

Status Information Effective Date

Loop

S AN

1-30

R

AN

1-30

R

AN

2-3

S

ID

1-3

N/U S

New element

CLAIM STATUS

4010A1 Element Identifier

Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

277 4010A1

STC11-2

Health Care Claim Status Category Code Health Care Claim Status Code

STC11-3

Entity Identifier Code

STC11-1

STC12

Free-Form Message Text

AN

1-30

R

STC11-1

AN

1-30

R

STC11-2

ID

2-3

S

STC11-3

Entity Identifier Code

STC11-4 STC12

N/U

REF01

SERVICE LINE ITEM IDENTIFICATION Reference Identification Qualifier

REF02

Line Item Control Number

AN

1-30

REF03

Description

AN

1-80

REF04

REFERENCE IDENTIFIER

N/U

DTP

SERVICE LINE DATE

DTP01

Date Time Qualifier Date Time Period Format Qualifier

REF

DTP02

1

ID

2-3

1-30

R

AN

1-30

R

ID

2-3

S

Code List Qualifier Code

ID

1-3

N/U

Free-Form Message Text

AN 1-264

R

REF02

Line Item Control Number

AN

1-50

R

REF03

Description

AN

1-80

N/U

REF04

REFERENCE IDENTIFIER

DTP

SERVICE LINE DATE

DTP01

Date Time Qualifier Date Time Period Format Qualifier

1

S R

Loop

Loop Repeat

2220D 472

R

DTP02

New element

1

S

2-3

R

2220D FJ

ID

Increase from 30 - 50

N/U

ID

1

R

3-3

R

2220D 472 R8, RD8

ID

2-3

Service Line Date

AN

1-35

R

HL

DEPENDENT LEVEL

1

S

HL01

AN

1-12

R

HL02

Hierarchical ID Number Hierarchical Parent ID Number

AN

1-12

R

HL03

Hierarchical Level Code

ID

1-2

R

HL04

Hierarchical Child Code

ID

1-1

N/U

DMG

DEPENDENT DEMOGRAPHIC INFORMATION Date Time Period Format Qualifier

DMG02 DMG03 DMG04

Marital Status Code

DMG01

DTP03 2000E

>1

23

Service Line Date

AN

1-35

Codes Added

R

CCYYMMDDCCYYMMDD DTP03

Values

N/U

N/U

REF

R

3-3 2-3

AN

REF01

2220D

RD8 ID

Usage Reg.

SERVICE LINE ITEM IDENTIFICATION Reference Identification Qualifier

S

FJ ID

Min. Max.

277 5010 Health Care Claim Status Category Code Health Care Claim Status Code

AN 1-264

ID

CCYYMMDD, CCYYMMDDCCYYMMDD

R

HL

DEPENDENT LEVEL

1

S

HL01

AN

1-12

R

HL02

Hierarchical ID Number Hierarchical Parent ID Number

AN

1-12

R

HL03

Hierarchical Level Code

ID

1-2

R

HL04

Hierarchical Child Code

ID

1-1

N/U

2000E

New format allowed

>1

23

Segment Deleted 1

R

2000E

ID

2-3

R

Patient Birth Date

AN

1-35

R

CCYYMMDD

Patient Gender Code

ID

1-1

R

F, M, U

ID

1-1

N/U

D8

DMG05

Race or Ethnicity Code

ID

1-1

N/U

DMG06

Citizenship Status Code

ID

1-2

N/U

DMG07

Country Code

ID

2-3

N/U

DMG08

Basis of Verification Code

ID

1-2

N/U

DMG09

Quantity

R

1-15

N/U

Page 15 of 24

CLAIM STATUS

4010A1 Element Identifier

Description

NM1

DEPENDENT NAME

NM101

Entity Identifier Code

NM102

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

2100E

1

Values

Element Identifier

Description

NM1

DEPENDENT NAME

277 4010A1

ID

Min. Max.

Usage Reg.

Loop

Loop Repeat

2100E

1

Values

277 5010

1

R

1

R

ID

2-3

R

QC

NM101

Entity Identifier Code

ID

2-3

R

QC

Entity Type Qualifier

ID

1-1

R

1

NM102

Entity Type Qualifier

ID

1-1

R

1

NM103

Patient Last Name

AN

1-35

R

NM103

Dependent Last Name

AN

1-60

R

Increase from 35 - 60

NM104

Patient First Name

AN

1-25

S

NM104

Dependent First Name

AN

1-35

S

Increase from 25 - 35

NM105

Patient Middle Name

AN

1-25

S

NM105

Dependent Middle Name

AN

1-25

S

NM106

Patient Name Prefix

AN

1-10

S

NM106

Dependent Name Prefix

AN

1-10

N/U

NM107

Patient Name Suffix

AN

1-10

S

NM107

Dependent Name Suffix

AN

1-10

S

NM108

Identification Code Qualifier

ID

1-2

S

NM108

Identification Code Qualifier

ID

1-2

N/U

Changed to Not Used

MI, ZZ

Changed to Not Used

NM109

Patient Primary Identifier

AN

2-80

S

NM109

Dependent Identifier

AN

2-80

N/U

NM110

Entity Relationship Code

ID

2-2

N/U

NM110

Entity Relationship Code

ID

2-2

N/U

NM111

Entity Identifier Code

ID

2-3

N/U

NM111

Entity Identifier Code

ID

2-3

N/U

NM112

Last Name

ID

1-60

N/U

1

R

ID

1-2

R

AN

1-50

R

TRN

CLAIM SUBMITTER TRACE NUMBER

TRN01

Trace Type Code

TRN02 TRN03

Trace Number Originating Company Identifier

TRN04

Reference Identification

2200E

>1

TRN

R

ID

1-2

R

TRN01

AN

1-30

R

TRN02

AN 10-10

N/U

TRN03

Trace Number Originating Company Identifier

AN

1-30

N/U

TRN04

Reference Identification

1

R

2

STC STC01 STC01-1 STC01-2

CLAIM LEVEL STATUS INFORMATION HEALTH CARE CLAIM STATUS Health Care Claim Status Category Code Health Care Claim Status Code

CLAIM STATUS TRACKING NUMBER Referenced Transaction Trace Number

1

2200E

STC

R

STC01

AN

1-30

R

STC01-1

AN

1-30

R

STC01-2

CLAIM LEVEL STATUS INFORMATION HEALTH CARE CLAIM STATUS Health Care Claim Status Category Code Health Care Claim Status Code

Page 16 of 24

Changed to Not Used

New element Name Change 2200E

>1 2

AN 10-10

N/U

AN

1-50

N/U

>1

R

Increase from 30 - 50

Increase from 30 - 50

2200E

R <> R AN

1-30

R

AN

1-30

R

CLAIM STATUS

4010A1 Element Identifier

Description

STC01-3

Entity Identifier Code

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

ID

STC01-3

Entity Identifier Code

ID

277 4010A1 ID

2-3

S

Min. Max.

Usage Reg.

Loop

Loop Repeat

Values

277 5010 13, 17, 1E, 1G, 1H, 1I, 1O, 1P, 1Q, 1R, 1S, 1T, 1U, 1V, 1W, 1X, 1Y, 1Z, 28, 2A, 2B, 2D, 2E, 2I, 2K, 2P, 2Q, 2S, 2Z, 30, 36, 3A, 3C, 3D, 3E, 3F, 3G, 3H, 3I, 3J, 3K, 3L, 3M, 3N, 3O, 3P, 3Q, 3R, 3S, 3T, 3U, 3V, 3W, 3X, 3Y, 3Z, 40, 43, 44, 4A, 4B, 4C, 4D, 4E, 4F, 4G, 4H, 4I, 4J, 4L, 4M, 4N, 4O, 4P, 4Q, 4R, 4S, 4U, 4V, 4W, 4X, 4Y, 4Z, 5A, 5B, 5C, 5D, 5E, 5F, 5G, 5H, 5I, 5J, 5K, 5L, 5M, 5N, 5O, 5P, 5Q, 5R, 5S, 5T, 5U, 5V, 5W, 5X, 5Y, 5Z, 61, 6A, 6B, 6C, 6D, 6E, 6F, 6G, 6H, 6I, 6J, 6K, 6L, 6M, 6N, 6O, 6P, 6Q, 6R, 6S, 6U, 6V, 6W, 6X, 6Y, 71, 72, 73, 74, 77, 7C, 80, 82, 84, 85, 87, 95, continued on next row

Page 17 of 24

2-3

S

13, 17, 1E, 1G, 1H, 1I, 1O, 1P, 1Q, 1R, 1S, 1T, 1U, 1V, 1W,1X, 1Y, 1Z, 28, 2A, 2B, 2E, 2I, 2K, 2P, 2Q, 2S, 2Z, 30, 36, 3A, 3C, 3D, 3E, 3F, 3G, 3H, 3I, 3J, 3K, 3L, 3M, 3N, 3O, 3P, 3Q, 3R, 3S, 3T, 3U, 3V, 3W, 3X, 3Y, 3Z, 40, 43, 44, 4A, 4B, 4C, 4D, 4E, 4F, 4G, 4H, 4I, 4J, 4L, 4M, 4N, 4O, 4P, 4Q, 4R, 4S, 4U, 4V, 4W, 4X, 4Y, 4Z, 5A, 5B, 5C, 5D, 5E, 5F, 5G, 5H, 5I, 5J, 5K, 5L, 5M, 5N, 5O, 5P, 5Q, 5R, 5S, 5T, 5U, 5V, 5W, 5X, 5Y, 5Z, 61, 6A, 6B, 6C, 6D, 6E, 6F, 6G, 6H, 6I, 6J, 6K, 6L, 6M, 6N, 6O, 6P, 6Q, 6R, 6S, 6U, 6V, 6W, 6X, 6Y, 71, 72, 73, 74, 77, 7C, 80, 82, 84, 85, 87, 95, continued on next row

CLAIM STATUS

4010A1 Element Identifier

Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

277 4010A1

ID

Min. Max.

Usage Reg.

STC03 STC04 STC05

Action Code Total Claim Charge Amount S9(7)V99 Claim Payment Amount S9(7)V99

CCYYMMDD DT

8-8

R

STC02

ID

1-2

N/U

STC03

R

1-18

R

STC04

R

1-18

R

STC05

Code List Qualifier Code Status Information Effective Date Action Code Total Claim Charge Amount S9(7)V99 Claim payment Amount S9(7)V99

ID

1-3

Adjudication or Payment Date DT

8-8

S

STC07

Payment Method Code Check Issue or EFT Effective Date

ID

3-3

S

CCYYMMDD DT

8-8

R

ID

1-2

N/U

R

1-18

S

R

1-18

S

8-8

S

DT

8-8

AN

1-16

STC10-2

Check or EFT TraceNumber HEALTH CARE CLAIM STATUS Health Care Claim Status Category Code Health Care Claim Status Code

STC10-3

Entity Identifier Code

STC08 STC09 STC10 STC10-1

CCYYMMDD STC06

ACH, BOP, CHK, FWT, NON CCYYMMDD

New element

N/U

CCYYMMDD STC06

Values

continued CK, CZ, D2, DD, DJ, DK, DN, DO, DQ, E1, E2, E7, E9, FA, FD, FE, G0, G3, GB, GD, GI, GJ, GK, GM, GY, HF, HH, I3, IJ, IL, IN, LI, LR, MR, OB, OD, OX, P0, P2, P3, P4, P6, P7, PT, PV, PW, QA, QB, QC, QD, QE, QH, QK, QL, QN, QO, QS, QV, QY, RC, RW, S4, SJ, SU, T4, TQ, TT, TU, UH, X3, X4, X5, ZZ, 03, 2D, MSC, PRP, SEP, TL, TTP end of list

STC01-4 STC02

Loop Repeat

277 5010 continued CK, CZ, D2, DD, DJ, DK, DN, DO, DQ, E1, E2, E7, E9, FA, FD, FE, G0, G3, GB, GD, GI, GJ, GK, GM, GY, HF, HH, I3, IJ, IL, IN, LI, LR, MR, OB, OD, OX, P0, P2, P3, P4, P6, P7, PT, PV, PW, QA, QB, QC, QD, QE, QH, QK, QL, QN, QO, QS, QV, QY, RC, RW, S4, SJ, SU, T4, TQ, TT, TU, UH, X3, X4, X5, ZZ end of list

Status Information Effective Date

Loop

Adjudication or Payment Date DT

Usage changed to not used STC07

Payment Method Code

ID

3-3

N/U

S

STC08

Remittance Date

DT

8-8

S

S

STC09

AN

1-16

S

S

STC10

CCYYMMDD

AN

1-30

R

STC10-1

AN

1-30

R

STC10-2

Remittance Trace Number HEALTH CARE CLAIM STATUS Health Care Claim Status Category Code Health Care Claim Status Code

ID

2-3

S

STC10-3

Entity Identifier Code

STC10-4

Code List Qualifier Code

Page 18 of 24

S AN

1-30

R

AN

1-30

R

AN

2-3

S

ID

1-3

N/U

New element

CLAIM STATUS

4010A1 Element Identifier

Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

277 4010A1

STC11-2

HEALTH CARE CLAIM STATUS Health Care Claim Status Category Code Health Care Claim Status Code

STC11-3

Entity Identifier Code

STC11 STC11-1

STC12

Free-Form Message Text

AN

1-30

R

STC11-1

AN

1-30

R

STC11-2

ID

2-3

S

STC11-3

Entity Identifier Code

STC11-4 STC12

S

STC11

N/U

REF01

PAYER CLAIM IDENTIFICATION NUMBER Reference Identification Qualifier

ID

2-3

R

REF02

Payer Claim Control Number

AN

1-30

REF03

Description

AN

1-80

REF04

REFERENCE IDENTIFIER

REF

1

Usage Reg.

Loop

Loop Repeat

Values

1-30

R

AN

1-30

R

ID

2-3

S

Code List Qualifier Code

ID

1-3

N/U

Free-Form Message Text

AN 1-264

REF01

R

REF02

N/U N/U

2200E

REF

S AN

PAYER CLAIM CONTROL NUMBER Reference Identification Qualifier

R

Min. Max.

277 5010 HEALTH CARE CLAIM STATUS Health Care Claim Status Category Code Health Care Claim Status Code

AN 1-264

ID

1

S

ID

2-3

R

Payer Claim Control Number

AN

1-50

R

REF03

Description

AN

1-80

N/U

REF04

REFERENCE IDENTIFIER

1K

New element

N/U Usage changed to situational and name change

2200E 1K

Increase from 30 - 50

REF01

INSTITUTIONAL BILL TYPE IDENTIFICATION Reference Identification Qualifier

REF02

Bill Type Identifier

AN

1-30

REF03

Description

AN

1-80

REF04

REFERENCE IDENTIFIER

N/U

REF

REF01

MEDICAL RECORD IDENTIFICATION Reference Identification Qualifier

REF

1

REF01

INSTITUTIONAL BILL TYPE IDENTIFICATION Reference Identification Qualifier

R

REF02

Bill Type Identifier

AN

1-50

R

N/U

REF03

Description

AN

1-80

N/U

REF04

REFERENCE IDENTIFIER

S

2200E

REF BLT

ID

2-3

N/U

R

1

S

2-3

R

2200E BLT

ID

Increase from 30 - 50

N/U Segment deleted

1

S

2-3

R

2200E EA

ID

REF02

Medical Record Number

AN

1-30

R

REF03

Description

AN

1-80

N/U

REF04

REFERENCE IDENTIFIER

N/U

REF01

PATIENT CONTROL NUMBER Reference Identification Qualifier

REF02

Patient Control Number

AN

1-50

R

REF03

Description

AN

1-80

N/U

REF04

REFERENCE IDENTIFIER

REF

PHARMACY PRESCRIPTION NUMBER

REF

Page 19 of 24

New segment 1

S

2-3

R

2200E EJ

ID

N/U New segment 1

S

2200E

CLAIM STATUS

4010A1 Element Identifier

Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

277 4010A1

REF02

AN

1-50

R

Description

AN

1-80

N/U

REF04

REFERENCE IDENTIFIER

REF REF01

VOUCHER IDENTIFIER Reference Identification Qualifier

ID

2-3

REF02

Voucher Identifier

AN

1-50

R

REF03

Description

AN

1-80

N/U

REF04

REFERENCE IDENTIFIER

REF02 REF03

Date/Time Qualifier Date Time Period Format Qualifier

DTP02

ID

1

S

3-3

R

2200E 232

2-3

R

CLAIM IDENTIFICATION NUMBER FOR CLEARINGHOUSES AND OTHER TRANSMISSION INTERMEDIARIES Reference Identification Qualifier

2-3

Loop Repeat

N/U 1

S

VV R

N/U New segment

ID

2-3

R

Clearinghouse Trace Number AN Description AN

1-50

R

1-80

N/U

DTP

CLAIM SERVICE DATE

DTP01

Date Time Qualifier Date Time Period Format Qualifier

New segment

2200E

2200E D9

N/U

ID ID

1

S

3-3

R

2-3

2200E

SVC SVC01

Claim Service Period

AN

SERVICE LINE INFORMATION COMPOSITE MEDICAL PROCEDURE INDENTIFIER

1-35

R

1

S

DTP03

2220E

>1

SVC

R

SVC01

Claim Service Period

AN

SERVICE LINE INFORMATION COMPOSITE MEDICAL PROCEDURE INDENTIFIER

472

Code Changed

D8, RD8

Code Changed

R

CCYYMMDDCCYYMMDD DTP03

Values

R

S

REFERENCE IDENTIFIER

DTP02

ID

1

REF04

RD8 ID

Loop

XZ

REF03

REF01

CLAIM SERVICE DATE

Usage Reg.

277 5010

REF

DTP

Min. Max.

Reference Identification Qualifier Pharmacy Prescription Number

REF01

DTP01

ID

1-35

R

1

S

CCYYMMDD, CCYYMMDDCCYYMMDD

2200E

New format allowed

>1

R

AD, CI, HC, ID, IV, N1, N2, N3, N4, ND, NH, NU, RB

AD, ER, HC, HP, Code changes IV, N4, NU, WK

SVC01-1

Product/Service ID Qualifier

ID

2-2

R

SVC01-1

Product/Service ID Qualifier

ID

2-2

R

SVC01-2

Service Identification Code

AN

1-48

R

SVC01-2

Service Identification Code

AN

1-48

R

SVC01-3

Procedure Modifier

AN

2-2

S

SVC01-3

Procedure Modifier

AN

2-2

S

SVC01-4

Procedure Modifier

AN

2-2

S

SVC01-4

Procedure Modifier

AN

2-2

S

SVC01-5

Procedure Modifier

AN

2-2

S

SVC01-5

Procedure Modifier

AN

2-2

S

Page 20 of 24

CLAIM STATUS

4010A1 Element Identifier

Description

SVC01-6

Procedure Modifier

AN

2-2

SVC01-7

Description

AN

1-80

ID

Min. Max.

Usage Reg.

5010 Element Identifier

Description

ID

S

SVC01-6

Procedure Modifier

AN

2-2

S

N/U

SVC01-7

Description

AN

1-80

N/U

SVC01-8

AN

1-80

N/U

R

1-18

R R

Loop

Loop Repeat

Values

277 4010A1

R

R

1-18

R

SVC03

R

1-18

AN

1-48

S

SVC04

Revenue Code

AN

1-48

S

1-15

N/U

SVC05

R

1-15

N/U

N/U

SVC06

1-15

S

SVC07

Quantity COMPOSITE MEDICAL PROCEDURE INDENTIFIER Units of Service Count S9(3)V9

1

S

SVC03

Revenue Code

SVC05

Quantity COMPOSITE MEDICAL PROCEDURE INDENTIFIER Original Units of Service Count S9(3)V9

R

SVC07

STC STC01 STC01-1 STC01-2

SERVICE LINE STATUS INFORMATION HEALTH CARE CLAIM STATUS Health Care Claim Status Category Code Health Care Claim Status Code

R

R

Loop

Loop Repeat

Values

277 5010

1-18

SVC04

SVC06

Usage Reg.

Product Service ID Line Item Charge Amount S9(7)V99 Line Item Payment Amount S9(7)V99

Line Item Charge Amount S9(7)V99 Line Item Provider Payment Amount S9(7)V99

SVC02

Min. Max.

SVC02

2220E

STC

R

STC01

AN

1-30

R

STC01-1

AN

1-30

R

STC01-2

CLAIM LEVEL STATUS INFORMATION HEALTH CARE CLAIM STATUS Health Care Claim Status Category Code Health Care Claim Status Code

Page 21 of 24

New element

N/U R

1-15

S

>1

R

Repeat and usage changed

R AN

1-30

R

AN

1-30

R

2200E

CLAIM STATUS

4010A1 Element Identifier

Description

STC01-3

Entity Identifier Code

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

ID

STC01-3

Entity Identifier Code

ID

277 4010A1 ID

2-3

S

Min. Max.

Usage Reg.

Loop

Loop Repeat

Values

277 5010 13, 17, 1E, 1G, 1H, 1I, 1O, 1P, 1Q, 1R, 1S, 1T, 1U, 1V, 1W, 1X, 1Y, 1Z, 28, 2A, 2B, 2D, 2E, 2I, 2K, 2P, 2Q, 2S, 2Z, 30, 36, 3A, 3C, 3D, 3E, 3F, 3G, 3H, 3I, 3J, 3K, 3L, 3M, 3N, 3O, 3P, 3Q, 3R, 3S, 3T, 3U, 3V, 3W, 3X, 3Y, 3Z, 40, 43, 44, 4A, 4B, 4C, 4D, 4E, 4F, 4G, 4H, 4I, 4J, 4L, 4M, 4N, 4O, 4P, 4Q, 4R, 4S, 4U, 4V, 4W, 4X, 4Y, 4Z, 5A, 5B, 5C, 5D, 5E, 5F, 5G, 5H, 5I, 5J, 5K, 5L, 5M, 5N, 5O, 5P, 5Q, 5R, 5S, 5T, 5U, 5V, 5W, 5X, 5Y, 5Z, 61, 6A, 6B, 6C, 6D, 6E, 6F, 6G, 6H, 6I, 6J, 6K, 6L, 6M, 6N, 6O, 6P, 6Q, 6R, 6S, 6U, 6V, 6W, 6X, 6Y, 71, 72, 73, 74, 77, 7C, 80, 82, 84, 85, 87, 95, continued on next row

Page 22 of 24

2-3

S

13, 17, 1E, 1G, 1H, 1I, 1O, 1P, 1Q, 1R, 1S, 1T, 1U, 1V, 1W,1X, 1Y, 1Z, 28, 2A, 2B, 2E, 2I, 2K, 2P, 2Q, 2S, 2Z, 30, 36, 3A, 3C, 3D, 3E, 3F, 3G, 3H, 3I, 3J, 3K, 3L, 3M, 3N, 3O, 3P, 3Q, 3R, 3S, 3T, 3U, 3V, 3W, 3X, 3Y, 3Z, 40, 43, 44, 4A, 4B, 4C, 4D, 4E, 4F, 4G, 4H, 4I, 4J, 4L, 4M, 4N, 4O, 4P, 4Q, 4R, 4S, 4U, 4V, 4W, 4X, 4Y, 4Z, 5A, 5B, 5C, 5D, 5E, 5F, 5G, 5H, 5I, 5J, 5K, 5L, 5M, 5N, 5O, 5P, 5Q, 5R, 5S, 5T, 5U, 5V, 5W, 5X, 5Y, 5Z, 61, 6A, 6B, 6C, 6D, 6E, 6F, 6G, 6H, 6I, 6J, 6K, 6L, 6M, 6N, 6O, 6P, 6Q, 6R, 6S, 6U, 6V, 6W, 6X, 6Y, 71, 72, 73, 74, 77, 7C, 80, 82, 84, 85, 87, 95, continued on next row

CLAIM STATUS

4010A1 Element Identifier

Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

277 4010A1

ID

Min. Max.

Usage Reg.

CCYYMMDD

Code List Qualifier Code Status Information Effective Date

DT

8-8

R

STC02

ID

1-2

N/U

STC03

R

1-18

S

STC04

R

1-18

S

STC05

Date

DT

8-8

N/U

STC06

Payment Method Code

ID

3-3

N/U

STC07

Date

DT

8-8

N/U

STC08

Remittance Date

AN

1-16

N/U

STC09

S

STC10

STC10-2

Check Number HEALTH CARE CLAIM STATUS Health Care Claim Status Category Code Health Care Claim Status Code

STC10-3

Entity Identifier Code

Action Code Line Item Charge Amount S9(7)V99 Line Item Provider Payment Amount S9(7)V99

STC06 STC07 STC08 STC09

STC03 STC04 STC05

STC10 STC10-1

STC11

HEALTH CARE CLAIM STATUS

Action Code Total Claim Charge Amount S9(7)V99 Claim payment Amount S9(7)V99

AN

1-30

R

STC10-1

AN

1-30

R

STC10-2

ID

2-3

S

STC10-3

Entity Identifier Code

STC10-4

Code List Qualifier Code HEALTH CARE CLAIM STATUS

STC11

ID

Page 23 of 24

1-3

New element

N/U CCYYMMDD

DT

8-8

R

ID

1-2

N/U

R

1-18

N/U

R

1-18

N/U

8-8

N/U

3-3

N/U

DT

8-8

N/U

AN

1-16

N/U

Usage changed Usage changed

Adjudication or Payment Date DT Payment Method Code ID Remittance Trace Number HEALTH CARE CLAIM STATUS Health Care Claim Status Category Code Health Care Claim Status Code

S

Values

continued CK, CZ, D2, DD, DJ, DK, DN, DO, DQ, E1, E2, E7, E9, FA, FD, FE, G0, G3, GB, GD, GI, GJ, GK, GM, GY, HF, HH, I3, IJ, IL, IN, LI, LR, MR, OB, OD, OX, P0, P2, P3, P4, P6, P7, PT, PV, PW, QA, QB, QC, QD, QE, QH, QK, QL, QN, QO, QS, QV, QY, RC, RW, S4, SJ, SU, T4, TQ, TT, TU, UH, X3, X4, X5, ZZ, 03, 2D, MSC, PRP, SEP, TL, TTP end of list

STC01-4 STC02

Loop Repeat

277 5010 continued CK, CZ, D2, DD, DJ, DK, DN, DO, DQ, E1, E2, E7, E9, FA, FD, FE, G0, G3, GB, GD, GI, GJ, GK, GM, GY, HF, HH, I3, IJ, IL, IN, LI, LR, MR, OB, OD, OX, P0, P2, P3, P4, P6, P7, PT, PV, PW, QA, QB, QC, QD, QE, QH, QK, QL, QN, QO, QS, QV, QY, RC, RW, S4, SJ, SU, T4, TQ, TT, TU, UH, X3, X4, X5, ZZ end of list

Status Information Effective Date

Loop

S AN

1-30

R

AN

1-30

R

AN

2-3

S

ID

1-3

N/U S

New element

CLAIM STATUS

4010A1 Element Identifier

Description

ID

Min. Max.

Usage Reg.

5010 Loop

Loop Repeat

Values

Element Identifier

Description

277 4010A1

STC11-2

Health Care Claim Status Category Code Health Care Claim Status Code

STC11-3

Entity Identifier Code

STC11-1

STC12

Free-Form Message Text

AN

1-30

R

STC11-1

AN

1-30

R

STC11-2

ID

2-3

S

STC11-3

Entity Identifier Code

STC11-4 STC12

N/U

REF01

SERVICE LINE ITEM IDENTIFICATION Reference Identification Qualifier

REF02

Line Item Control Number

AN

1-30

REF03

Description

AN

1-80

REF04

REFERENCE IDENTIFIER

N/U

DTP

SERVICE LINE DATE

DTP01

Date Time Qualifier Date Time Period Format Qualifier

REF

DTP02

1

ID

2-3

1-30

R

AN

1-30

R

ID

2-3

S

Code List Qualifier Code

ID

1-3

N/U

Free-Form Message Text

AN 1-264

R

REF02

Line Item Control Number

AN

1-50

R

REF03

Description

AN

1-80

N/U

REF04

REFERENCE IDENTIFIER

DTP

SERVICE LINE DATE

DTP01

Date Time Qualifier Date Time Period Format Qualifier

1

S R

Loop

Loop Repeat

2220E 472

R

DTP02

New element

1

S

2-3

R

2200E FJ

ID

Increase from 30 - 50

N/U

ID

1

R

3-3

R

2200E 472 R8, RD8

ID

2-3

Service Date

SE

TRANSACTION SET TRAILER

SE01 SE02

Transaction Segment Count Transaction Set Control Number

1-35

R

DTP03

Service Line Date

1

R

SE

TRANSACTION SET TRAILER

N0

1-10

R

SE01

AN

4-9

R

SE02

1

R

AN

GE01

FUNCTIONAL GROUP TRAILER Number of Transaction Sets Included

N0

1-6

R

GE02

Group Control Number

N0

1-9

R

1

R

GE

IEA01

INTERCHANGE CONTROL TRAILER Number of Included Functional Groups

N0

1-5

R

IEA02

Interchange Control Number

N0

9-9

R

IEA

1

1

Transaction Segment Count Transaction Set Control Number

AN

1-35

R

1

R

N0

1-10

R

AN

4-9

R

1

R

GE01

FUNCTIONAL GROUP TRAILER Number of Transaction Sets Included

N0

1-6

R

GE02

Group Control Number

N0

1-9

R

1

R

GE

IEA01

INTERCHANGE CONTROL TRAILER Number of Included Functional Groups

N0

1-5

R

IEA02

Interchange Control Number

N0

9-9

R

IEA

Page 24 of 24

Codes Added

R

CCYYMMDDCCYYMMDD DTP03

Values

N/U

N/U

REF

R

3-3 2-3

AN

REF01

2220E

RD8 ID

Usage Reg.

SERVICE LINE ITEM IDENTIFICATION Reference Identification Qualifier

S

FJ ID

Min. Max.

277 5010 Health Care Claim Status Category Code Health Care Claim Status Code

AN 1-264

ID

CCYYMMDD, CCYYMMDDCCYYMMDD

1

1

New format allowed