Institutional Claim A 1 To 5010
This document was uploaded by user and they confirmed that they have the permission to share it. If you are author or own the copyright of this book, please report to us by using this DMCA report form. Report DMCA
Overview
Download & View Institutional Claim A 1 To 5010 as PDF for free.
More details
- Words: 40,237
- Pages: 93
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1
ISA01 ISA02
ID 2-2 AN 10-10
R R
00, 03
ISA03 ISA04
Security Information Qualifier Security Information
ID 2-2 AN 10-10
R R
00, 01
ISA05 ISA06
Interchange ID Qualifier Interchange Sender ID
ID 2-2 AN 15-15
R R
ISA07 ISA08 ISA09 ISA10
ID 2-2 AN 15-15 DT 6-6 TM 4-4
R R R R
ISA12
Interchange ID Qualifier Interchange Receiver ID Interchange Date Interchange Time Interchange Control Standards ID Interchange Control Version Number
ISA13
Interchange Control Number
ISA11
ISA14 ISA15 ISA16
GS GS01 GS02 GS03 GS04
GS05 GS06 GS07 GS08
1
R
___
1
ISA03 ISA04
Security Information Qualifier Security Information
ID 2-2 AN 10-10
R R
00, 01
01, 14, 20, 27, 28, 29, 30, 33, ZZ
ISA05 ISA06
Interchange ID Qualifier Interchange Sender ID
ID 2-2 AN 15-15
R R
01, 14, 20, 27, 28, 29, 30, 33, ZZ
ISA07 ISA08 ISA09 ISA10
ID 2-2 AN 15-15 DT 6-6 TM 4-4
R R R R
5-5
R
ISA12
N0
9-9
R
ISA13
Interchange Control Number
Acknowledgement Requested ID Usage Indicator ID Component Element Separator AN
1-1 1-1
R R
1-1
R
1 2-2 2-15 2-15 8-8
R R R R R
R R R R
1 00, 03
ID
4-8 1-9 1-2 1-12
___
Values
R R
ISA11
TM N0 ID AN
Loop Repeat
ID 2-2 AN 10-10
R
Time Group Control Number Responsible Agency Code Version Identifier Code
Loop
ISA01 ISA02
ISA
1-1
ID AN AN DT
Usage Reg.
INTERCHANGE CONTROL HEADER Authorization Information Qualifier Authorization Information
Interchange ID Qualifier Interchange Receiver ID Interchange Date Interchange Time Interchange Control Standards ID Interchange Control Version Number
FUNCTIONAL GROUP HEADER Functional Identifier Code Application Sender Code Application Receiver Code Date
Min. Max.
837-I 5010
INTERCHANGE CONTROL HEADER Authorization Information Qualifier Authorization Information
ISA
ID
YYMMDD HHMM
0, 1 P, T
ISA14 ISA15 ISA16
___
1
CCYYMMDD HHMM, HHMMSS, HHMMSSD, HHMMSSDD X 004010X096A1
GS GS01 GS02 GS03 GS04
GS05 GS06 GS07 GS08
1
R
1-1
R
ID
5-5
R
N0
9-9
R
Acknowledgement Requested ID Usage Indicator ID Component Element Separator AN
1-1 1-1
R R
1-1
R
1 2-2 2-15 2-15 8-8
R R R R R
FUNCTIONAL GROUP HEADER Functional Identifier Code Application Sender Code Application Receiver Code Date
Time Group Control Number Responsible Agency Code Version Identifier Code
Page 1 of 93
ID AN AN DT
TM N0 ID AN
4-8 1-9 1-2 1-12
R R R R
01, 14, 20, 27, 28, 29, 30, 33, ZZ
01, 14, 20, 27, 28, 29, 30, 33, ZZ YYMMDD HHMM
00501
0, 1 P, T
___
1
CCYYMMDD HHMM, HHMMSS, HHMMSSD, HHMMSSDD X 005010X223
Code Change
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1 ST ST01 ST02
TRANSACTION SET HEADER Transaction Set Identifier Code Transaction Set Control Number
1
R
ID
3-3
R
AN
4-9
R
BHT BHT01 BHT02 BHT03 BHT04
BHT05 BHT06
REF REF01 REF02 REF03 REF04 NM1 NM101 NM102 NM103 NM104 NM105 NM106 NM107 NM108 NM109 NM110 NM111
Transaction Set Creation Time Claim or Encounter ID
___
>1
ST 837
ST01 ST02
TRANSMISSION TYPE IDENTIFICATION Reference Identification Qualifier Reference Identification Description Reference Identifier SUBMITTER NAME Entity Identifier Code Entity Type Qualifier Submitter Last or Organization Name Submitter First Name Submitter Middle Name Name Prefix Name Suffix Identification Code Qualifier Submitter Identifier Entity Relationship Code Entity Identifier Code
ID
1 4-4
R R
ID
2-2
R
AN
1-30
R
DT
8-8
R
CCYYMMDD
4-8 2-2
R R
HHMM, HHMMSS, HHMMSSD, HHMMSSDD CH, RP
1
S
ID AN AN
2-3 1-30 1-80
R R N/U N/U
ID ID
1 2-3 1-1
R R R
AN AN AN AN AN ID AN ID ID
1-35 1-25 1-25 1-10 1-10 1-2 2-80 2-2 2-3
R S S N/U N/U R R N/U N/U
TM ID
Min. Max.
Usage Reg.
Loop
Loop Repeat
___
>1
Values
837-I 5010
ST03 BEGINNING OF HIERARCHICAL TRANSACTION Hierarchical Structure Code Transaction Set Purpose Code Originator Application Transaction ID Transaction Set Creation Date
ID
___
1 0019
BHT BHT01
00, 18
BHT02 BHT03 BHT04
BHT05 BHT06
TRANSACTION SET HEADER Transaction Set Identifier Code Transaction Set Control Number Implementation Convention Reference BEGINNING OF HIERARCHICAL TRANSACTION Hierarchical Structure Code Transaction Set Purpose Code Originator Application Transaction ID Transaction Set Creation Date Transaction Set Creation Time Claim or Encounter ID
1
R
ID
3-3
R
AN
4-9
R
AN
1-35
R
ID
1 4-4
R R
ID
2-2
R
AN
1-50
R
DT
8-8
R
837
New Element
___
1 0019 00, 18 Increase from 30 - 50
TM ID
4-8 2-2
CCYYMMDD HHMM, HHMMSS, HHMMSSD, HHMMSSDD 31, CH, RP Code Added
R R
Segment Deleted
87
1000A
1 41 1, 2
46
NM1 NM101 NM102 NM103 NM104 NM105 NM106 NM107 NM108 NM109 NM110 NM111 NM112
SUBMITTER NAME Entity Identifier Code Entity Type Qualifier Submitter Last or Organization Name Submitter First Name Submitter Middle Name Name Prefix Name Suffix Identification Code Qualifier Submitter Identifier Entity Relationship Code Entity Identifier Code Name Last or Organization Name
Page 2 of 93
ID ID
1 2-3 1-1
R R R
AN AN AN AN AN ID AN ID ID
1-60 1-35 1-25 1-10 1-10 1-2 2-80 2-2 2-3
R S S N/U N/U R R N/U N/U
AN
1-60
N/U
1000A
1 41 1, 2 Increase from 35 - 60 Increase from 25 - 35
46
New Element
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
PER PER01
SUBMITTER EDI CONTACT INFORMATION Contact Function Code
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
PER PER01
SUBMITTER EDI CONTACT INFORMATION Contact Function Code
837-I 4010A1 ID
2 2-2
R R
AN
1-60
R
ID AN
2-2 1-80
R R
PER07 PER08 PER09
Submitter Contact Name Communication Number Qualifier Communication Number Communication Number Qualifier Communication Number Communication Number Qualifier Communication Number Contact Inquiry Reference
ID AN AN
2-2 1-80 1-20
S S N/U
NM1 NM101 NM102 NM103 NM104 NM105 NM106 NM107 NM108 NM109 NM110 NM111
RECEIVER NAME Entity Identifier Code Entity Type Qualifier Receiver Name Name First Name Middle Name Prefix Name Suffix Identification Code Qualifier Receiver Primary Identifier Entity Relationship Code Entity Identifier Code
ID ID AN AN AN AN AN ID AN ID ID
1 2-3 1-1 1-35 1-25 1-25 1-10 1-10 1-2 2-80 2-2 2-3
R R R R N/U N/U N/U N/U R R N/U N/U
PER02 PER03 PER04 PER05 PER06
ID AN
2-2 1-80
HL HL01 HL02 HL03 HL04
PRV PRV01 PRV02 PRV03 PRV04
BILLING/PAY-TO PROVIDER SPECIALTY INFORMATION Provider Code Reference Identification Qualifier Provider Taxonomy Code State or Province Code
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010 1000A IC
PER02 ED, EM, FX. TE ED, EM, EX, FX, TE
S S
ED, EM, EX, FX, TE
1000B
1 40 2
46
PER03 PER04 PER05 PER06 PER07 PER08 PER09 NM1 NM101 NM102 NM103 NM104 NM105 NM106 NM107 NM108 NM109 NM110 NM111 NM112
BILLING/PAY-TO PROVIDER HIERARCHICAL LEVEL Hierarchical ID Number AN Hierarchical Parent ID Number AN Hierarchical Level Code ID Hierarchical Child Code ID
ID
Submitter Contact Name Communication Number Qualifier Communication Number Communication Number Qualifier Communication Number Communication Number Qualifier Communication Number Contact Inquiry Reference RECEIVER NAME Entity Identifier Code Entity Type Qualifier Receiver Name Name First Name Middle Name Prefix Name Suffix Identification Code Qualifier Receiver Primary Identifier Entity Relationship Code Entity Identifier Code Name Last or Organization Name
ID
2 2-2
R R
1000A
AN
1-60
S
ID 2-2 AN 1-256
R R
EM, FX. TE
ID 2-2 AN 1-256
S S
EM, EX, FX, TE
ID 2-2 AN 1-256 AN 1-20
S S N/U
EM, EX, FX, TE
ID ID AN AN AN AN AN ID AN ID ID
1 2-3 1-1 1-60 1-35 1-25 1-10 1-10 1-2 2-80 2-2 2-3
R R R R N/U N/U N/U N/U R R N/U N/U
AN
1-60
N/U
IC Usage change to Situational Code deleted Increase from 80 - 256 Code deleted Increase from 80 - 256 Code deleted Increase from 80 - 256
1000B
1 40 2 Increase from 35 - 60 Increase from 25 - 35
46
New Element
Name Change 1 1-12
R R
1-12 1-2 1-1
N/U R R
2000A
>1
HL HL01
20 1
HL02 HL03 HL04
BILLING PROVIDER HIERARCHICAL LEVEL Hierarchical ID Number Hierarchical Parent ID Number Hierarchical Level Code Hierarchical Child Code
AN
1 1-12
R R
AN ID ID
1-12 1-2 1-1
N/U R R
2000A
>1
20 1 Name Change
ID
1 1-3
S R
ID AN ID
2-3 1-30 2-2
R R N/U
2000A BI, PT ZZ
PRV PRV01 PRV02 PRV03 PRV04
BILLING PROVIDER SPECIALTY INFORMATION Provider Code ID Reference Identification Qualifier ID Provider Taxonomy Code AN State or Province Code ID
Page 3 of 93
1 1-3
S R
2-3 1-50 2-2
R R N/U
2000A BI
Code Deleted Code Change
PXC Increase from 30 - 50
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
PRV05
PROVIDER SPECIALTY INFORMATION
PRV06
Provider Organization Code
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1
CUR CUR01 CUR02 CUR03 CUR04 CUR05 CUR06 CUR07 CUR08 CUR09 CUR10 CUR11 CUR12 CUR13 CUR14 CUR15 CUR16 CUR17 CUR18 CUR19 CUR20 CUR21
FOREIGN CURRENCY INFORMATION Entity Identifier Code Currency Code Exchange Rate Entity Identifier Code Currency Code Currency Market/Exchange Code Date/Time Qualifier Date Time Date/Time Qualifier Date Time Date/Time Qualifier Date Time Date/Time Qualifier Date Time Date/Time Qualifier Date Time
N/U
PRV05
ID
3-3
N/U
PRV06
Provider Organization Code
ID ID R ID ID
1 2-3 3-3 4-10 2-3 3-3
S R R N/U N/U N/U
ID ID DT TM ID DT TM ID DT TM ID DT TM ID DT TM
3-3 3-3 8-8 4-8 3-3 8-8 4-8 3-3 8-8 4-8 3-3 8-8 4-8 3-3 8-8 4-8
N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U
ID ID
1 2-3 1-1
R R R
NM103 NM104
AN AN
1-35 1-25
R N/U
NM105 NM106
Name Middle Name Prefix
AN AN
1-25 1-10
NM107
Name Suffix
AN
1-10
NM108 NM109 NM110 NM111
Identification Code Qualifier Billing Provider Identifier Entity Relationship Code Entity Identifier Code
ID AN ID ID
1-2 2-80 2-2 2-3
Min. Max.
Usage Reg.
Loop Repeat
Values
2000A 85
CUR CUR01 CUR02 CUR03 CUR04 CUR05 CUR06 CUR07 CUR08 CUR09 CUR10 CUR11 CUR12 CUR13 CUR14 CUR15 CUR16 CUR17 CUR18 CUR19 CUR20 CUR21
FOREIGN CURRENCY INFORMATION Entity Identifier Code Currency Code Exchange Rate Entity Identifier Code Currency Code Currency Market/Exchange Code Date/Time Qualifier Date Time Date/Time Qualifier Date Time Date/Time Qualifier Date Time Date/Time Qualifier Date Time Date/Time Qualifier Date Time
N/U ID
3-3
N/U
ID ID R ID ID
1 2-3 3-3 4-10 2-3 3-3
S R R N/U N/U N/U
ID ID DT TM ID DT TM ID DT TM ID DT TM ID DT TM
3-3 3-3 8-8 4-8 3-3 8-8 4-8 3-3 8-8 4-8 3-3 8-8 4-8 3-3 8-8 4-8
N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U
ID ID
1 2-3 1-1
R R R
NM103 NM104
Billing Provider Name Entity Identifier Code Entity Type Qualifier Billing Provider Last or Organizational Name Billing Provider First Name
AN AN
1-60 1-35
R N/U
N/U N/U
NM105 NM106
Billing Provider Middle Name Name Prefix
AN AN
1-25 1-10
N/U N/U
N/U
NM107
Billing Provider Name Suffix
AN
1-10
N/U
R S N/U N/U
Loop
837-I 5010 PROVIDER SPECIALTY INFORMATION
Billing Provider Name Entity Identifier Code Entity Type Qualifier Billing Provider Last or Organizational Name Name First
NM1 NM101 NM102
ID
2010AA
1 85 2
24, 34, XX
NM1 NM101 NM102
NM108 NM109 NM110 NM111 NM112
Identification Code Qualifier Billing Provider Identifier Entity Relationship Code Entity Identifier Code Name Last or Organization Name
Page 4 of 93
2000A 85
2010AA
1 85 2 Increase from 35 - 60
ID AN ID ID
1-2 2-80 2-2 2-3
S S N/U N/U
AN
1-60
N/U
Increase from 25 - 35
XX
Code Deleted Usage change to Situational
New Element
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
N3
BILLING PROVIDER ADDRESS
N301
Billing Provider Address Line
N302
Billing Provider Address Line
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
N3
BILLING PROVIDER ADDRESS
837-I 4010A1
N4 N401 N402 N403 N404 N405 N406
REF
REF01 REF02 REF03 REF04
BILLING PROVIDER CITY/STATE/ZIP CODE Billing Provider City Name Billing Provider State or Province Code Billing Provider Postal Zone or ZIP Code Country Code Location Qualifier Location Identifier
Reference Identification Qualifier Billing Provider Additional Identifier Description REFERENCE IDENTIFIER
REF02 REF03 REF04
CREDIT/DEBIT CARD BILLING INFORMATION Reference Identification Qualifier Billing Provider Additional Identifier Description REFERENCE IDENTIFIER
PER PER01
BILLING PROVIDER CONTACT INFORMATION Contact Function Code
REF REF01
PER02 PER03 PER04 PER05
R
AN
1-55
R
N301
Billing Provider Address Line
AN
1-55
S
N302
Billing Provider Address Line
AN
1 2-30
R R
ID
2-2
R
N402
ID ID ID AN
3-15 2-3 1-2 1-30
R S N/U N/U
N403 N404 N405 N406 N407
BILLING PROVIDER CITY/STATE/ZIP CODE Billing Provider City Name Billing Provider State or Province Code Billing Provider Postal Zone or ZIP Code Country Code Location Qualifier Location Identifier Country Subdivision Code
REF
BILLING PROVIDER TAX IDENTIFICATION
8
R
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010
1
BILLING PROVIDER TAX IDENTIFICATION
ID
2010AA
2010AA
N4 N401
2010AA 0B, 1A, 1B, 1C, 1D, 1G, 1H, 1J, B3, BQ, EI, FH, G2, G5, LU, SY, X5
ID
2-3
R
AN AN
1-30 1-80
R N/U N/U
8
S
ID
2-3
R
AN AN
1-30 1-80
R N/U N/U
ID
2 2-2
S R
1-60
R
2-2 1-80
R R
EM, FX, TE
2-2
S
EM, EX, FX, TE
1
R
AN
1-55
R
AN
1-55
S
AN
1 2-30
R R
ID
2-2
S
ID ID ID AN ID
3-15 2-3 1-2 1-30 1-3
S S N/U N/U S
1
R
2010AA
2010AA Usage change to Situational Usage change to Situational
New Element # Repeats change to 1 2010AA Code Deleted
REF01 REF02 REF03 REF04
Reference Identification Qualifier Billing Provider Additional Identifier Description REFERENCE IDENTIFIER
ID
2-3
R
AN AN
1-50 1-80
R N/U N/U
EI Increase from 30 - 50
Segment Deleted
Billing Provider Contact Name AN Communication Number Qualifier ID Communication Number AN Communication Number Qualifier ID
2010AA 06, 8U, EM, IJ, LU, RB, ST, TT
2010AA IC
PER PER01 PER02 PER03 PER04 PER05
BILLING PROVIDER CONTACT INFORMATION Contact Function Code
ID
2 2-2
Billing Provider Contact Name AN 1-60 Communication Number Qualifier ID 2-2 Communication Number AN 1-256 Communication Number Qualifier ID 2-2
Page 5 of 93
S R
2010AA IC Usage change to Situational
S R R
EM, FX, TE
S
EM, EX, FX, TE
Increase from 80 - 256
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1 PER06 PER07 PER08 PER09
Communication Number Communication Number Qualifier Communication Number Contact Inquiry Reference
AN
1-80
S
ID AN AN
2-2 1-80 1-20
S S N/U
ID ID
1 2-3 1-1
S R R
NM103
PAY-TO PROVIDER NAME Entity Identifier Code Entity Type Qualifier Pay-to Provider Last or Organization Name
AN
1-35
N/U
NM104
Name First
AN
1-25
NM105 NM106
Name Middle Name Prefix
AN AN
NM107
Name Suffix
NM108 NM109 NM110 NM111
Identification Code Qualifier Pay-to Provider Identifier Entity Relationship Code Entity Identifier Code
NM1 NM101 NM102
ID
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010 PER06 EM, EX, FX, TE
PER07 PER08 PER09
Communication Number Communication Number Qualifier Communication Number Contact Inquiry Reference
AN 1-256
S
ID 2-2 AN 1-256 AN 1-20
S S N/U
ID ID
1 2-3 1-1
S R R
NM103
PAY-TO ADDRESS NAME Entity Identifier Code Entity Type Qualifier Pay-to Provider Last or Organization Name
AN
1-60
N/U
N/U
NM104
Pay-to Provider First Name
AN
1-35
N/U
1-25 1-10
N/U N/U
NM105 NM106
Pay-to Provider Middle Name AN Name Prefix AN
1-25 1-10
N/U N/U
AN
1-10
N/U
NM107
Pay-to Provider Name Suffix
AN
1-10
N/U
ID AN ID ID
1-2 2-80 2-2 2-3
N/U N/U N/U N/U
NM108 NM109 NM110 NM111
ID AN ID ID
1-2 2-80 2-2 2-3
N/U N/U N/U N/U
NM112
Identification Code Qualifier Pay-to Provider Identifier Entity Relationship Code Entity Identifier Code Name Last or Organization Name
AN
1-60
N/U
N3
PAY-TO PROVIDER ADDRESS
1
R
2010AB
1 87 2
NM1 NM101 NM102
Increase from 80 - 256 EM, EX, FX, TE Increase from 80 - 256
2010AB
Name Change
1 87 2
Increase from 35 - 60 Increase from 25 - 35 Name Change Name Change
Name Change
N3
PAY-TO PROVIDER ADDRESS
1
R
24, 34, XX
2010AB
Code Deleted
New Element
2010AB
N301
Pay-to Provider Address Line AN
1-55
R
N301
Pay-to Provider Address Line AN
1-55
R
N302
Pay-to Provider Address Line AN
1-55
S
N302
Pay-to Provider Address Line AN
1-55
S
AN
1 2-30
R R
AN
1 2-30
R R
ID
2-2
R
N402
ID
2-2
S
Usage change to Situational Usage change to
ID
3-15
R
N403
ID
3-15
S
Situational
Pay-to Provider Country Code ID Location Qualifier ID Location Identifier AN
2-3 1-2 1-30
S N/U N/U
N404 N405 N406 N407
Pay-to Provider Country Code ID Location Qualifier ID Location Identifier AN Country Subdivision Code ID
2-3 1-2 1-30 1-3
S N/U N/U S
N4 N401 N402 N403 N404 N405 N406
REF
PAY-TO PROVIDER CITY/STATE/ZIP CODE Pay-to Provider City Name Pay-to Provider State Code Pay-to Provider Postal Zone or ZIP Code
PAY-TO PROVIDER SECONDARY IDENTIFICATION
5
S
2010AB
2010AB
N4 N401
PAY-TO PROVIDER CITY/STATE/ZIP CODE Pay-to Provider City Name Pay-to Provider State Code Pay-to Provider Postal Zone or ZIP Code
2010AB
New Element Segment Deleted
0B, 1A, 1B, 1C, 1D, 1G, 1H, 1J, B3, BQ, EI, FH, G2, G5, LU, SY, X5
Page 6 of 93
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1 REF01 REF02 REF03 REF04
Reference Identification Qualifier Billing Provider Additional Identifier Description REFERENCE IDENTIFIER
ID
2-3
R
AN AN
1-30 1-80
R N/U N/U
ID
Min. Max.
Usage Reg.
Loop
Loop Repeat
2010AC
1
Values
837-I 5010
NM1 NM101 NM102 NM103 NM104 NM105 NM106 NM107
PAY TO PLAN NAME Entity Identifier Code Entity Type Qualifier Pay to Plan Organizational Name Name First Name Middle Name Prefix Name Suffix
NM112
Identification Code Qualifier Identification Code Entity Relationship Code Entity Identifier Code Name Last or Organization Name
N3 N301 N302
PAY-TO PLAN ADDRESS Pay-to Plan Address Line Pay-to Plan Address Line
NM108 NM109 NM110 NM111
N4 N401 N402 N403 N404 N405 N406 N407
PAY-TO PLAN CITY/STATE/ZIP CODE Pay-to Plan City Name Pay-to Plan State Code Pay-to Plan Postal Zone or ZIP Code Pay-to Plan Country Code Location Qualifier Location Identifier Country Subdivision Code
REF01 REF02 REF03 REF04
SECONDARY IDENTIFICATION Reference Identification Qualifier Reference Identification Description REFERENCE IDENTIFIER
REF
PAY-TO PLAN TAX IDENTIFICATION
REF
Page 7 of 93
ID ID
1 2-3 1-1
S R R
AN AN AN AN AN
1-60 1-35 1-25 1-10 1-10
R N/U N/U N/U N/U
ID AN ID ID
1-2 2-80 2-2 2-3
R R N/U N/U
AN
1-60
N/U
1 1-55 1-55
R R S
2010AC
AN AN
R R S
2010AC
AN ID
1 2-30 2-2
ID ID ID AN ID
3-15 2-3 1-2 1-30 1-3
S S N/U N/U S
1
S
2-3 1-50 1-80
R R N/U N/U
1
R
New Segment PE 2
PI, XV
New Segment
New Segment
New Segment
ID AN AN
2010AC 2U, FY, NF
New Segment 2010AC
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
REF01 REF02 REF03 REF04
Reference Identification Qualifier Reference Identification Description REFERENCE IDENTIFIER
837-I 4010A1
HL HL01 HL02 HL03 HL04
SBR SBR01 SBR02 SBR03 SBR04 SBR05 SBR06 SBR07 SBR08
SUBSCRIBER HIERARCHICAL LEVEL Hierarchical ID Number Hierarchical Parent ID Number Hierarchical Level Code Hierarchical Child Code
AN
R R
AN ID ID
1-12 1-2 1-1
R R R
1
R
ID
1-1
R
P, S, T
SBR01
ID
2-2
S
18
SBR02
AN AN ID
1-30 1-60 1-3
S S N/U
SBR03 SBR04 SBR05
Coordination of Benefits Code ID Yes/No Condition or Response Code ID Employment Status Code ID
1-1
N/U
SBR06
1-1 2-2
N/U N/U
SBR07 SBR08
Individual Relationship Code Insured Group or Policy Number Insured Group Name Insurance Type Code
SBR09
Claim Filing Indicator Code
ID
1-2
S
NM1 NM101 NM102 NM103 NM104 NM105 NM106 NM107
SUBSCRIBER NAME Entity Identifier Code Entity Type Qualifier Subscriber Last Name Subscriber First Name Subscriber Middle Name Name Prefix Subscriber Name Suffix
ID ID AN AN AN AN AN
1 2-3 1-1 1-35 1-25 1-25 1-10 1-10
R R R R S S N/U S
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010
1 1-12
SUBSCRIBER INFORMATION Payer Responsibility Sequence Number Code
ID
2000B
>1
HL HL01
22 0, 1
2000B
SBR
09, 10, 11, 12, 13, 14, 15, 16, AM, BL, CH, CI, DS, HM, LI, LM, MA, MB, MC, OF, TV, VA, WC, ZZ 2010BA
HL02 HL03 HL04
1 IL 1, 2
ID AN AN
2-3 1-50 1-80
R R N/U N/U
AN
1 1-12
R R
AN ID ID
1-12 1-2 1-1
R R R
1
R
ID
1-1
R
ID
2-2
S
AN AN ID
1-50 1-60 1-3
S S N/U
Coordination of Benefits Code ID Yes/No Condition or Response Code ID Employment Status Code ID
1-1
N/U
1-1 2-2
N/U N/U
SUBSCRIBER HIERARCHICAL LEVEL Hierarchical ID Number Hierarchical Parent ID Number Hierarchical Level Code Hierarchical Child Code SUBSCRIBER INFORMATION Payer Responsibility Sequence Number Code Individual Relationship Code Insured Group or Policy Number Insured Group Name Insurance Type Code
EI
2000B
>1
22 0, 1
2000B A, B, C, D, E, F, Code Added G, H, P, S, T, U 18 Increase from 30 - 50
SBR09
Claim Filing Indicator Code
ID
1-2
S
NM1 NM101 NM102 NM103 NM104 NM105 NM106 NM107
SUBSCRIBER NAME Entity Identifier Code Entity Type Qualifier Subscriber Last Name Subscriber First Name Subscriber Middle Name Name Prefix Subscriber Name Suffix
ID ID AN AN AN AN AN
1 2-3 1-1 1-60 1-35 1-25 1-10 1-10
R R R R S S N/U S
11, 12, 13, 14, 15, Code Change 16, 17, AM, BL, CH, CI, DS, FI, HM, LM, MA, MB, MC, OF, TV, VA, WC, ZZ 2010BA
1 IL 1, 2 Increase from 35 - 60 Increase from 25 - 35
Code Change Usage change to Required NM108
Identification Code Qualifier
ID
1-2
S
NM109 NM110
Subscriber Primary Identifier Entity Relationship Code
AN ID
2-80 2-2
S N/U
MI, ZZ
NM108
Identification Code Qualifier
ID
1-2
R
NM109 NM110
Subscriber Primary Identifier Entity Relationship Code
AN ID
2-80 2-2
R N/U
II, MI Usage change to Required
Page 8 of 93
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
NM111
Entity Identifier Code
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
N3 N301 N302
SUBSCRIBER ADDRESS Subscriber Address Line Subscriber Address Line
N4 N401
SUBSCRIBER CITY/STATE/ZIP CODE Subscriber City Name
N402 N403 N404 N405 N406
Subscriber State Code Subscriber Postal Zone or ZIP Code Subscriber Country Code Location Qualifier Location Identifier
DMG01 DMG02 DMG03 DMG04 DMG05 DMG06
SUBSCRIBER DEMOGRAPHIC INFORMATION Date Time Period Format Qualifier Subscriber Birth Date Subscriber Gender Code Marital Status Code Race or Ethnicity Code Citizenship Status Code
DMG07 DMG08 DMG09
Country Code Basis of Verification Code Quantity
DMG
REF REF01 REF02 REF03 REF04
REF
ID
2-3
N/U
NM112
Entity Identifier Code Name Last or Organization Name
AN
1-60
N/U
N3 N301 N302
SUBSCRIBER ADDRESS Subscriber Address Line Subscriber Address Line
1 1-55 1-55
S R S
2010BA
AN AN
N4 N401
SUBSCRIBER CITY/STATE/ZIP CODE Subscriber City Name
1 2-30
S R
2010BA
AN ID
2-2
S
ID ID ID AN ID
3-15 2-3 1-2 1-30 1-3
S S N/U N/U S
1
S
REF01
NM111
1 1-55 1-55
S R S
2010BA
S R
2010BA
AN
1 2-30
ID
2-2
R
N402
ID ID ID AN
3-15 2-3 1-2 1-30
R S N/U N/U
N403 N404 N405 N406 N407
1
S
ID AN ID ID ID ID
2-3 1-35 1-1 1-1 1-1 1-2
R R R N/U N/U N/U
ID ID R
2-3 1-2 1-15
N/U N/U N/U
ID
4
S
2-3
R
1-30 1-80
R N/U N/U
1
S
2-3
R
Loop
Loop Repeat
Values
837-I 5010
N/U
AN AN
SUBSCRIBER SECONDARY IDENTIFICATION Reference Identification Qualifier ID Subscriber Supplemental Identifier AN Description AN REFERENCE IDENTIFIER CASUALTY CLAIM NUMBER Reference Identification Qualifier
2-3
Usage Reg.
ID
837-I 4010A1 ID
Min. Max.
Description
2010BA
DMG01 DMG02 DMG03 DMG04 DMG05 DMG06
SUBSCRIBER DEMOGRAPHIC INFORMATION Date Time Period Format Qualifier Subscriber Birth Date Subscriber Gender Code Marital Status Code Race or Ethnicity Code Citizenship Status Code
ID AN ID ID ID ID
2-3 1-35 1-1 1-1 1-1 1-2
R R R N/U N/U N/U
DMG07 DMG08 DMG09 DMG10 DMG11
Country Code Basis of Verification Code Quantity Code List Qualifier Code Industry Code
ID ID R ID AN
2-3 1-2 1-15 1-3 1-30
N/U N/U N/U N/U N/U
1
S
2-3
R
1-50 1-80
R N/U N/U
1
S
2-3
R
DMG D8 CCYYMMDD F, M, U
2010BA
REF 1W, 23, IG, SY
REF01 REF02 REF03 REF04
2010BA
REF Y4
Subscriber State Code Subscriber Postal Zone or ZIP Code Subscriber Country Code Location Qualifier Location Identifier Country Subdivision Code
New Element
REF01
SUBSCRIBER SECONDARY IDENTIFICATION Reference Identification Qualifier ID Subscriber Supplemental Identifier AN Description AN REFERENCE IDENTIFIER CASUALTY CLAIM NUMBER Reference Identification Qualifier
Page 9 of 93
ID
Usage change to Situational Usage change to Situational
New Element
2010BA D8 CCYYMMDD F, M, U
New Element New Element
2010BA Code Deleted SY Increase rom 30 - 50
2010BA Y4
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
REF02 REF03 REF04
Property Casualty Claim Number Description REFERENCE IDENTIFIER
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
REF02 REF03 REF04
Property Casualty Claim Number Description REFERENCE IDENTIFIER
837-I 4010A1
NM107
CREDIT/DEBIT CARD ACCOUNT HOLDER NAME Entity Identifier Code Entity Type Qualifier Credit or Debt Card Holder Last or Organization Name Credit or Debt Card Holder First Name Credit or Debt Card Holder Middle Name Name Prefix Credit or Debt Card Holder Name Suffix
NM108 NM109 NM110 NM111
Identification Code Qualifier Payer Identifier Entity Relationship Code Entity Identifier Code
NM1 NM101 NM102 NM103 NM104 NM105 NM106
AN AN
1-30 1-80
R N/U N/U
ID ID
1 2-3 1-1
S R R
AN
1-35
R
AN
1-25
S
AN AN
1-25 1-10
S N/U
AN
1-10
S
ID AN ID ID
1-2 2-80 2-2 2-3
R R N/U N/U
2
S
ID
2-3
R
AN AN
1-30 1-80
R N/U N/U
NM1 NM101 NM102 NM103 NM104 NM105 NM106 NM107
PAYER NAME Entity Identifier Code Entity Type Qualifier Payer Name Name First Name Middle Name Prefix Name Suffix
ID ID AN AN AN AN AN
1 2-3 1-1 1-35 1-25 1-25 1-10 1-10
R R R R N/U N/U N/U N/U
NM108 NM109 NM110 NM111
Identification Code Qualifier Payer Identifier Entity Relationship Code Entity Identifier Code
ID AN ID ID
1-2 2-80 2-2 2-3
R R N/U N/U
N3
PAYER ADDRESS
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010 Increase rom 30 - 50 AN AN
1-50 1-80
R N/U N/U
2010BB
1 AO 1, 2
MI
Segment Deleted
REF02 REF03 REF04
REF01
Min. Max.
Segment Deleted
CREDIT/DEBT CARD INFORMATION Reference Identification Qualifier Credit or Debt Card Authorization Number Description REFERENCE IDENTIFIER
REF
ID
1
S
2010BB AB, BB
2010BC
1 PR 2
PI, XV
2010BC
NM1 NM101 NM102 NM103 NM104 NM105 NM106 NM107
PAYER NAME Entity Identifier Code Entity Type Qualifier Payer Name Name First Name Middle Name Prefix Name Suffix
NM108 NM109 NM110 NM111 NM112
Identification Code Qualifier Payer Identifier Entity Relationship Code Entity Identifier Code Name Last or Organization Name
N3
PAYER ADDRESS
Page 10 of 93
ID ID AN AN AN AN AN
1 2-3 1-1 1-60 1-35 1-25 1-10 1-10
R R R R N/U N/U N/U N/U
ID AN ID ID
1-2 2-80 2-2 2-3
R R N/U N/U
AN
1-60
N/U
1
S
2010BB
Loop Change
1 PR 2
Increase from 35 - 60 Increase from 25 - 35
PI, XV
New Element
2010BB
Loop Change
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
N301 N302
Payer Address Line Payer Address Line
N4 N401
PAYER CITY/STATE/ZIP CODE Payer City Name
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Description
ID
N301 N302
Payer Address Line Payer Address Line
AN AN
1-55 1-55
R S
N4 N401
PAYER CITY/STATE/ZIP CODE Payer City Name
AN
1 2-30
R R
ID
2-2
S
ID ID ID AN ID
3-15 2-3 1-2 1-30 1-3
S S N/U N/U S
3
S
2-3 1-50 1-80
R R N/U N/U
837-I 4010A1
N402 N403 N404 N405 N406
REF REF01 REF02 REF03 REF04
Payer State Code Payer Postal Zone or ZIP Code Payer Country Code Location Qualifier Location Identifier
PAYER SECONDARY IDENTIFICATION Reference Identification Qualifier Payer Additional Identifier Description REFERENCE IDENTIFIER
1-55 1-55
R S
AN
1 2-30
R R
ID
2-2
R
N402
ID ID ID AN
3-15 2-3 1-2 1-30
R S N/U N/U
N403 N404 N405 N406 N407
ID AN AN
S
2-3 1-30 1-80
R R N/U N/U
2010BC
2010BC
REF 2U, FY, NF, TJ
REF01 REF02 REF03 REF04
REF REF01 REF02 REF03 REF04
NM1 NM101 NM102 NM103 NM104 NM105 NM106 NM107
RESPONSIBLE PARTY NAME Entity Identifier Code Entity Type Qualifier Payer Name Name First Name Middle Name Prefix Name Suffix
NM108 NM109 NM110 NM111
Identification Code Qualifier Identification Code Entity Relationship Code Entity Identifier Code
N3
RESPONSIBLE PARTY ADDRESS
Loop
Loop Repeat
Values
837-I 5010
AN AN
3
Min. Max.
Usage Reg.
Element Identifier
Payer State Code Payer Postal Zone or ZIP Code Payer Country Code Location Qualifier Location Identifier Country Subdivision Code PAYER SECONDARY IDENTIFICATION Reference Identification Qualifier Payer Additional Identifier Description REFERENCE IDENTIFIER BILLING PROVIDER SECONDARY IDENTIFICATION Reference Identification Qualifier Payer Additional Identifier Description REFERENCE IDENTIFIER
Loop Change 2010BB Usage change to Situational Usage change to Situational
New Element Loop Change 2010BB Code Change
ID AN AN
2U, EI, FY, NF Increase from 30 - 50
Segment Added
ID AN AN
1
S
2-3 1-50 1-80
R R N/U N/U
2010BB G2, LU
Segment Deleted ID ID AN AN AN AN AN
1 2-3 1-1 1-35 1-25 1-25 1-10 1-10
S R R R S S N/U S
ID AN ID ID
1-2 2-80 2-2 2-3
N/U N/U N/U N/U
1
S
2010BD
1 QD
Segment Deleted 2010BC
Page 11 of 93
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1
N302
Responsible Party Address Line Responsible Party Address Line
N4
RESPONSIBLE PARTY CITY/STATE/ZIP CODE
N301
AN
1-55
R
AN
1-55
S
1
R
Responsible Party City Name AN
2-30
R
N402
Responsible Party State Code ID
2-2
R
ID
3-15
R
ID ID AN
2-3 1-2 1-30
S N/U N/U
AN
1 1-12
S R
AN ID ID
1-12 1-2 1-1
R R R
1
R
N404 N405 N406
Responsible Party ZIP Code Responsible Party Country Code Location Qualifier Location Identifier
HL02 HL03 HL04
PATIENT HIERARCHICAL LEVEL Hierarchical ID Number Hierarchical Parent ID Number Hierarchical Level Code Hierarchical Child Code
PAT
PATIENT INFORMATION
HL HL01
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010
Segment Deleted
N401
N403
ID
2010BC
2000C
>1
HL02 HL03 HL04
PATIENT HIERARCHICAL LEVEL Hierarchical ID Number Hierarchical Parent ID Number Hierarchical Level Code Hierarchical Child Code
PAT
PATIENT INFORMATION
HL HL01
23 0 2000C
AN
1 1-12
S R
AN ID ID
1-12 1-2 1-1
R R R
1
R
2000C
>1
23 0 2000C Code Deleted
ID ID ID ID
2-2 1-1 2-2 1-1
R N/U N/U N/U
PAT05 PAT06
Individual Relationship Code Patient Location Code Employment Status Code Student Status Code Date Time Period Format Qualifier Patient Unit orDeath Basis Date for
ID AN
2-3 1-35
N/U N/U
PAT07 PAT08 PAT09
Measurement Code Patient Weight Pregnancy Indicator
ID R ID
2-2 1-10 1-1
N/U N/U N/U
NM1 NM101 NM102 NM103
PATIENT NAME Entity Identifier Code Entity Type Qualifier Patient Last Name
ID ID AN
1 2-3 1-1 1-35
R R R R
PAT01 PAT02 PAT03 PAT04
01, 04, 05, 07, 10, 15, 17, 19, 20, 21, 22, 23, 24, 29, 32, 33, 36, 39, 40, 41, 43, 53, G8
2010CA
1 QC 1
ID ID ID ID
2-2 1-1 2-2 1-1
R N/U N/U N/U
PAT05 PAT06
Individual Relationship Code Patient Location Code Employment Status Code Student Status Code Date Time Period Format Qualifier Patient Unit orDeath Basis Date for
ID AN
2-3 1-35
N/U N/U
PAT07 PAT08 PAT09
Measurement Code Patient Weight Pregnancy Indicator
ID R ID
2-2 1-10 1-1
N/U N/U N/U
NM1 NM101 NM102 NM103
PATIENT NAME Entity Identifier Code Entity Type Qualifier Patient Last Name
ID ID AN
1 2-3 1-1 1-60
R R R R
PAT01 PAT02 PAT03 PAT04
Page 12 of 93
01, 19, 20, 21, 39, 40, 53, G8
2010CA
1 QC 1 Increase from 35 - 60
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1 NM104 NM105 NM106 NM107
Patient First Name Patient Middle Name Name Prefix Patient Name Suffix
AN AN AN AN
1-25 1-25 1-10 1-10
ID
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010
R S N/U S
NM104 NM105 NM106 NM107
Patient First Name Patient Middle Name Name Prefix Patient Name Suffix
AN AN AN AN
1-35 1-25 1-10 1-10
Increase from 25 - 35 Usage change to Situational
S S N/U S
Code Deleted Usage change to Not Used NM108
Identification Code Qualifier
ID
1-2
S
NM109 NM110 NM111
Patient Primary Identifier Entity Relationship Code Entity Identifier Code
AN ID ID
2-80 2-2 2-3
S N/U N/U
MI, ZZ
NM108
Identification Code Qualifier
ID
1-2
N/U
NM109 NM110 NM111
AN ID ID
2-80 2-2 2-3
N/U N/U N/U
NM112
Patient Primary Identifier Entity Relationship Code Entity Identifier Code Name Last or Organization Name
AN
1-60
N/U
N3 N301 N302
PATIENT ADDRESS Patient Address Line Patient Address Line
1 1-55 1-55
R R S
2010CA
AN AN
N4 N401
PATIENT CITY/STATE/ZIP CODE Patient City Name
1 2-30
R R
2010CA
AN ID
2-2
S
ID ID ID AN ID
3-15 2-3 1-2 1-30 1-3
S S N/U N/U S
1
R
2-3 1-35 1-1 1-1 1-1 1-2 2-3 1-2 1-15 1-3 1-30
R R R N/U N/U N/U N/U N/U N/U N/U N/U
Usage change to Not Used
N3 N301 N302
PATIENT ADDRESS Patient Address Line Patient Address Line
N4 N401
PATIENT CITY/STATE/ZIP CODE Patient City Name
N402 N403 N404 N405 N406
DMG DMG01 DMG02 DMG03 DMG04 DMG05 DMG06 DMG07 DMG08 DMG09
Patient State Code Patient Postal Zone or ZIP Code Patient Country Code Location Qualifier Location Identifier
PATIENT DEMOGRAPHIC INFORMATION Date Time Period Format Qualifier Patient Birth Date Patient Gender Code Marital Status Code Race or Ethnicity Code Citizenship Status Code Country Code Basis of Verification Code Quantity
1 1-55 1-55
R R S
2010CA
AN AN
R R
2010CA
AN
1 2-30
ID
2-2
R
N402
ID ID ID AN
3-15 2-3 1-2 1-30
R S N/U N/U
N403 N404 N405 N406 N407
ID AN ID ID ID ID ID ID R
1
R
2-3 1-35 1-1 1-1 1-1 1-2 2-3 1-2 1-15
R R R N/U N/U N/U N/U N/U N/U
2010CA
DMG D8 CCYYMMDD F, M, U
DMG01 DMG02 DMG03 DMG04 DMG05 DMG06 DMG07 DMG08 DMG09 DMG10 DMG11
Patient State Code Patient Postal Zone or ZIP Code Patient Country Code Location Qualifier Location Identifier Country Subdivision Code PATIENT DEMOGRAPHIC INFORMATION Date Time Period Format Qualifier Patient Birth Date Patient Gender Code Marital Status Code Race or Ethnicity Code Citizenship Status Code Country Code Basis of Verification Code Quantity Code List Qualifier Code Industry Code
New Element
ID AN ID ID ID ID ID ID R ID AN
Usage change to Situational Usage change to Situational
New Element
2010CA D8 CCYYMMDD F, M, U
New Element New Element Segment Deleted
REF
PATIENT SECONDARY IDENTIFICATION NUMBER
5
S
2010CA
Page 13 of 93
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
REF01
Reference Identification Qualifier
REF02 REF03 REF04
Patient Secondary Identifier Description REFERENCE IDENTIFIER
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1
REF
PROPERTY AND CASUALTY CLAIM NUMBER Reference Identification Qualifier Property Casualty Claim Number Description REFERENCE IDENTIFIER
ID
2-3
R
AN AN
1-30 1-80
R N/U N/U
ID
2-3
R
AN AN
1-30 1-80
R N/U N/U
AN R ID
1 1-38 1-18 1-2
R R R N/U
ID
1-2
N/U R
CLM05
Facility Type Code Facility Code Qualifier Claim Frequency Code Provider or Supplier Signature Indicator
AN ID ID
1-2 1-2 1-1
R R R
A
CLM05-1 CLM05-2 CLM05-3
ID
1-1
N/U
N, Y
CLM06
ID
1-1
R
A, C
CLM07
CLM08
Medicare Assignment Code Benefits Assignment Certification Indicator
ID
1-1
R
N
CLM09
Release of Information Code
ID
1-1
R
A, I, M, N, O, Y
CLM CLM01 CLM02 CLM03 CLM04 CLM05 CLM05-1 CLM05-2 CLM05-3 CLM06
CLAIM INFORMATION Patient Account Number Total Claim Charge Amount Claim Filing Indicator Code Non-Institutional Claim Type Code HEALTH CARE SERVICE LOCATION INFORMATION
Usage Reg.
Loop
Loop Repeat
Values
1W, 23, IG, SY
S
REF02 REF03 REF04
Min. Max.
837-I 5010
1
REF01
ID
2010CA
REF Y4
1
S
ID
2-3
R
AN AN
1-50 1-80
R N/U N/U
AN R ID
1 1-38 1-18 1-2
R R R N/U
ID
1-2
N/U
Facility Type Code Facility Code Qualifier Claim Frequency Code Provider or Supplier Signature Indicator
AN ID ID
1-2 1-2 1-1
R R R
A
ID
1-1
N/U
N, Y
ID
1-1
R
A, B, C
CLM08
Medicare Assignment Code Benefits Assignment Certification Indicator
ID
1-1
R
N, W, Y
CLM09
Release of Information Code
ID
1-1
R
I, Y
REF01 REF02 REF03 REF04
2300
100
PROPERTY AND CASUALTY CLAIM NUMBER Reference Identification Qualifier Property Casualty Claim Number Description REFERENCE IDENTIFIER
CLM CLM01 CLM02 CLM03 CLM04
CLAIM INFORMATION Patient Account Number Total Claim Charge Amount Claim Filing Indicator Code Non-Institutional Claim Type Code HEALTH CARE SERVICE LOCATION INFORMATION
2010CA Y4 Increase from 30 - 50
2300
100
R
Code Added CLM07
Code Added Code Deleted
CLM10 CLM11
CLM12 CLM13 CLM14 CLM15
Patient Signature Source Code RELATED CAUSES INFORMATION
Special Program Indicator Yes/No Condition or Response Code Level of Service Code Yes/No Condition or Response Code
ID
1-1
N/U
CLM10
N/U
CLM11
ID
2-3
N/U
CLM12
ID ID
1-1 1-3
N/U N/U
CLM13 CLM14
ID
1-1
N/U
CLM15
Patient Signature Source Code RELATED CAUSES INFORMATION
Special Program Indicator Yes/No Condition or Response Code Level of Service Code Yes/No Condition or Response Code
Page 14 of 93
ID
1-1
S
P
Usage change to Situational Code Added
02, 03, 05, 09
Usage change to Situational Code Added
N/U
ID
2-3
S
ID ID
1-1 1-3
N/U N/U
ID
1-1
N/U
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
CLM18 CLM19
Participation Agreement Claim Status Code Yes/No Condition or Response Code Claim Submission Reason Code
CLM20
Delay Reason Code
DTP DTP01
DATE - DISCHARGE HOUR Date Time Qualifier Date Time Period Format Qualifier Discharge Hour
ID ID
1-1 1-2
N/U N/U
ID
1-1
R
ID
2-2
N/U
ID
1-2
S
ID
1 3-3
S R
ID AN
2-3 1-35
R R
ID
1 3-3
R R
DTP02
DATE - STATEMENT DATES Date Time Qualifier Date Time Period Format Qualifier
ID
2-3
R
DTP03
Statement From or To Date
AN
1-35
R
ID
1 3-3
S R
ID
2-3
DTP02 DTP03
DTP DTP01
DTP DTP01 DTP02
DTP03
DATE - ADMISSION DATE/HOUR Date Time Qualifier Date Time Period Format Qualifier
Admission Date and Hour
AN
1-35
ID ID
1-1 1-2
N/U N/U
ID
1-1
N/U
ID
2-2
N/U
ID
1-2
S
ID
1 3-3
S R
ID AN
2-3 1-35
R R
ID
1 3-3
S R
ID
2-3
R
Statement From and To Date AN
1-35
R
ID
1 3-3
S R
ID
2-3
R
INSTITUTIONAL CLAIM CODE Admission Type Code Admission Source Code
CLM19 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11
CLM20
Delay Reason Code
96
DTP DTP01
TM HHMM
DTP02 DTP03
DATE - DISCHARGE HOUR Date Time Qualifier Date Time Period Format Qualifier Discharge Time
434
DTP DTP01
N, Y
2300
2300
CLM18
D8, RD8 CCYYMMDDCCY YMMDD
DTP03
435
DTP DTP01
R
DT
DTP02
R
CCYYMMDDHHM M
CL103 CL104
Patient Status Code Nursing Home Code
PWK
CLAIM SUPPLEMENTAL INFORMATION
ID ID
1 1-1 1-1
S S S
ID ID
1-2 1-1
S NU
10
S
Loop
Loop Repeat
Values
837-I 5010 Participation Agreement Claim Status Code Yes/No Condition or Response Code Claim Submission Reason Code
CLM16 CLM17
2300
DTP02
DTP03
2300
DATE - STATEMENT DATES Date Time Qualifier Date Time Period Format Qualifier
DATE - ADMISSION DATE/HOUR Date Time Qualifier Date Time Period Format Qualifier
Admission Date and Hour
Usage change to Not Used
1, 2, 3, 4, 5, 6, 7, Code Added 8, 9, 10, 11, 15
2300 96 TM HHMM
Name Change Usage change to Situational
2300 434
Code Deleted RD8 CCYYMMDDCCY Name Change YMMDD
2300 435 Code Added
AN
1-35
R
S R
D8, DT CCYYMMDD, Code Added CCYYMMDDHHM M New Segment
ID
1 3-3
DTP02 DTP03
DATE - REPRICER RECEIVED DATE Date Time Qualifier Date Time Period Format Qualifier Order Date
ID AN
2-3 1-35
R R
CL1 CL101 CL102
INSTITUTIONAL CLAIM CODE Admission Type Code Admission Source Code
ID ID
1 1-1 1-1
S S S
CL103 CL104
Patient Status Code Nursing Home Code
ID ID
1-2 1-1
R NU
PWK
CLAIM SUPPLEMENTAL INFORMATION
10
S
DTP DTP01
CL1 CL101 CL102
Usage Reg.
ID
837-I 4010A1 CLM16 CLM17
Min. Max.
Description
2300 050 D8 CCYYMMDD
2300
Usage change to Required
2300
Page 15 of 93
2300
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1
ID
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010 Code Added
ID
2-2
R
PWK02 PWK03 PWK04
Attachment Report Type Code Attachment Transmission Code Report Copies Needed Entity Identifier Code
ID N0 ID
1-2 1-2 2-3
R N/U N/U
PWK05
Identification Code Qualifier
ID
1-2
S
PWK06
Attachment Control Number
AN
2-80
PWK07 PWK08 PWK09
Description ACTIONS INDICATED Request Category Code
AN
1-80
ID
CN1
CONTRACT INFORMATION
PWK01
AS, B2, B3, B4, CT, DA, DG, DS, EB, MT, NN, OB, OZ, PN, PO, PZ, RB, RR, RT AA, BM, EL, EM, FX
ID
2-2
R
PWK02 PWK03 PWK04
Attachment Report Type Code Attachment Transmission Code Report Copies Needed Entity Identifier Code
ID N0 ID
1-2 1-2 2-3
R N/U N/U
PWK05
Identification Code Qualifier
ID
1-2
S
S
PWK06
Attachment Control Number
AN
2-80
S
PWK07 PWK08 PWK09
Description ACTIONS INDICATED Request Category Code
AN
1-80
1-2
S N/U N/U
ID
1-2
N/U N/U N/U
1
S
CN1
CONTRACT INFORMATION
1
S
CN101 CN102 CN103 CN104 CN105 CN106
Contract Type Code Contract Amount Contract Percentage Contract Code Terms Discount Percent Contract Version Identifier
2-2 1-18 1-6 1-50 1-6 1-30
R S S S S S
AC
PWK01
03, 04, 05, 06, 07, 08, 09, 10, 11, 13, 15, 21, A3, A4, AM, AS, B2, B3, B4, BR, BS, BT, CB, CK, CT, D2, DA, DB, DG, DJ, DS, EB, HC, HR, I5, IR, LA, M1, MT, NN, OB, OC, OD, OE, OX, OZ, P4, P5, PE, PN, PO, PQ, PY, PZ, RB, RR, RT, RX, SG, V5, XP AA, BM, EL, EM, Code Added FT, FX
AC
Usage change to Not Used
CN101 CN102 CN103 CN104 CN105 CN106
Contract Type Code Contract Amount Contract Percentage Contract Code Terms Discount Percent Contract Version Identifier
AMT AMT01
ID R R AN R AN
2-2 1-18 1-6 1-30 1-6 1-30
R S S S S S
PAYER ESTIMATED AMOUNT DUE Amount Qualifier Code
ID
1 1-3
S R
AMT02 AMT03
Patient Responsibility Amount Credit/Debit Flag Code
R ID
1-18 1-1
R N/U
AMT AMT01
PATIENT ESTIMATED AMOUNT DUE Amount Qualifier Code
ID
1 1-3
S R
2300 01, 02, 03, 04, 05, 06, 09
ID R R AN R AN
2300 01, 02, 03, 04, 05, 06, 09
Increase from 30 - 50
Segment Deleted 2300 C5
2300 F3
AMT AMT01
PATIENT ESTIMATED AMOUNT DUE Amount Qualifier Code
Page 16 of 93
ID
1 1-3
S R
2300 F3
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1 Patient Responsibility Amount Credit/Debit Flag Code
R ID
1-18 1-1
R N/U
AMT AMT01 AMT02 AMT03
PATIENT PAID AMOUNT Amount Qualifier Code Patient Paid Amount Credit/Debit Flag Code
1 1-3 1-18 1-1
S R R N/U
2300
ID R ID
1 1-3
S R
2300
1-18 1-1
R N/U
1
S
2-3
R
4N
REF01
1-30 1-80
R N/U N/U
1, 2, 3, 4, 5, 6, 7
REF02 REF03 REF04
AMT02 AMT03
REF REF01 REF02 REF03 REF04
CREDIT/DEBIT CARD MAXIMUM AMOUNT Amount Qualifier Code ID Credit or Debit Card Maximum Amount R Credit/Debit Flag Code ID
SERVICE AUTHORIZATION EXCEPTION CODE Reference Identification Qualifier ID Service Authorization Exception Code AN Description AN REFERENCE IDENTIFIER
AMT02 AMT03
REF02 REF03 REF04
Prior Authorization Number Description REFERENCE IDENTIFIER
REF REF01 REF02 REF03
ORIGINAL REFERENCE NUMBER (ICN/DCN) Reference Identification Qualifier Claim Original Reference Number Description
Loop Repeat
Values
Patient Responsibility Amount Credit/Debit Flag Code
R ID
1-18 1-1
R N/U
Segment Deleted MA
2300
REF
REF02 REF03 REF04
REF01
Loop
Segment Deleted
REF01
PRIOR AUTHORIZATION Reference Identification Qualifier
Usage Reg.
F5
REF
REF
Min. Max.
837-I 5010
AMT02 AMT03
AMT AMT01
ID
2
S
ID
2-3
R
AN AN
1-30 1-80
R N/U N/U
1
S
ID
2-3
R
AN AN
1-30 1-80
R N/U
2300
REF 9F, G1
REF01 REF02 REF03 REF04
2300
REF F8
REF01 REF02 REF03
SERVICE AUTHORIZATION EXCEPTION CODE Reference Identification Qualifier ID Service Authorization Exception Code AN Description AN REFERENCE IDENTIFIER REFERRAL NUMBER Reference Identification Qualifier Prior Authorization or Referral Number Description REFERENCE IDENTIFIER
1
S
2-3
R
4N
1-50 1-80
R N/U N/U
1, 2, 3, 4, 5, 6, 7
1
S
ID
2-3
R
AN AN
1-50 1-80
R N/U N/U
1
S
2-3
R
1-50 1-80
R N/U N/U
1
S
ID
2-3
R
AN AN
1-50 1-80
R N/U
PRIOR AUTHORIZATION Reference Identification Qualifier ID Prior Authorization or Referral Number AN Description AN REFERENCE IDENTIFIER PAYER CLAIM CONTROL NUMBER Reference Identification Qualifier Claim Original Reference Number Description
Page 17 of 93
2300
Increase from 30 - 50
New Segment
2300 9F
# Repeats change to 1 Code Deleted
2300 G1
Increase from 30 - 50 Name Change
Name Change 2300 F8 Increase from 30 - 50
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
REF04
REFERENCE IDENTIFIER
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
REF04
REFERENCE IDENTIFIER
837-I 4010A1
REF REF01 REF02 REF03 REF04
REF REF01 REF02 REF03 REF04
REF REF01 REF02 REF03 REF04
REF REF01 REF02 REF03 REF04
REF REF01 REF02 REF03 REF04
ADJUSTED REPRICED CLAIM NUMBER Reference Identification Qualifier Adjusted Repriced Claim Reference Number Description REFERENCE IDENTIFIER
1
S
2-3
R
1-30 1-80
R N/U N/U
1
S
ID
2-3
R
AN AN
1-30 1-80
R N/U N/U
1
S
2-3
R
1-30 1-80
R N/U N/U
INVESTIGATIONAL DEVICE EXEMPTION NUMBER Reference Identification Qualifier ID Investigational Device Exemption Number AN Description AN REFERENCE IDENTIFIER CLAIM IDENTIFIER FOR TRANSMISSION INTERMEDIARIES Reference Identification Qualifier Value Added Network Trace Number Description REFERENCE IDENTIFIER DOCUMENT IDENTIFICATION CODE Reference Identification Qualifier Document ControlIdentifier Description REFERENCE IDENTIFIER
1
S
ID
2-3
R
AN AN
1-30 1-80
R N/U N/U
2
S
2-3 1-30 1-80
R R N/U N/U
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010
N/U
REPRICED CLAIM NUMBER Reference Identification Qualifier ID Repriced Claim Reference Number AN Description AN REFERENCE IDENTIFIER
ID
2300
REF 9A
REF01 REF02 REF03 REF04
2300
REF 9C
REF01 REF02 REF03 REF04
2300
REF LX
REF01 REF02 REF03 REF04
2300
REF D9
REF01 REF02 REF03 REF04
N/U
REPRICED CLAIM NUMBER Reference Identification Qualifier ID Repriced Claim Reference Number AN Description AN REFERENCE IDENTIFIER
1
S
2-3
R
1-50 1-80
R N/U N/U
1
S
ID
2-3
R
AN AN
1-50 1-80
R N/U N/U
5
S
2-3
R
1-50 1-80
R N/U N/U
1
S
ID
2-3
R
Clearinghouse Trace Number AN Description AN REFERENCE IDENTIFIER
1-50 1-80
R N/U N/U
ADJUSTED REPRICED CLAIM NUMBER Reference Identification Qualifier Adjusted Repriced Claim Reference Number Description REFERENCE IDENTIFIER
9A Increase from 30 - 50
2300 9C Increase from 30 - 50
INVESTIGATIONAL DEVICE EXEMPTION NUMBER Reference Identification Qualifier ID Investigational Device Exemption Number AN Description AN REFERENCE IDENTIFIER CLAIM IDENTIFIER FOR TRANSMISSION INTERMEDIARIES Reference Identification Qualifier
2300
2300 LX Increase from 30 - 50
2300 D9 Increase from 30 - 50 Name Change
Segment Deleted
ID AN AN
2300 DD
REF
AUTO ACCIDENT STATE
Page 18 of 93
1
S
2300
New Segment
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1
REF02 REF03 REF04
REF01 REF02 REF03 REF04
REF REF01 REF02 REF03 REF04
REF REF01 REF02 REF03 REF04
MEDICAL RECORD NUMBER Reference Identification Qualifier Medical Record Number Description REFERENCE IDENTIFIER DEMONSTRATION PROJECT IDENTIFIER Reference Identification Qualifier Demonstration Project Identifier Description REFERENCE IDENTIFIER PEER REVIEW ORGANIZARION (PRO) APPROVAL NUMBER Reference Identification Qualifier PRO Number Description REFERENCE IDENTIFIER
K303
FILE INFORMATION Fixed Format Information Record Format Code COMPOSITE UNIT OF MEASURE
NTE
CLAIM NOTE
K3 K301 K302
1
S
2-3 1-30 1-80
R R N/U N/U
1
S
ID
2-3
R
AN AN
1-30 1-80
R N/U N/U
ID AN AN
1
S
ID AN AN
2-3 1-30 1-80
R R N/U N/U
AN ID
10 1-80 1-2
S R N/U
2300
REF EA
2300
S
NTE01 NTE02
Note Reference Code Claim Note Text
ID AN
3-3 1-80
R R
NTE NTE01
BILLING NOTE Note Reference Code
ID
1 3-3
S R
REF01 REF02 REF03 REF04
REF P4
REF01 REF02 REF03 REF04
2300
REF G4
2300
REF01 REF02 REF03 REF04
2300 ALG, DCP, DGN, DME, MED, NTR, ODT, RHB, RLH, RNH, SET, SFM, SPT, UPI
2300 ADD
Reference Identification Qualifier Auto Accident State or Province Description REFERENCE IDENTIFIER MEDICAL RECORD NUMBER Reference Identification Qualifier Medical Record Number Description REFERENCE IDENTIFIER DEMONSTRATION PROJECT IDENTIFIER Reference Identification Qualifier Demonstration Project Identifier Description REFERENCE IDENTIFIER PEER REVIEW ORGANIZARION (PRO) APPROVAL NUMBER Reference Identification Qualifier PRO Number Description REFERENCE IDENTIFIER
K303
FILE INFORMATION Fixed Format Information Record Format Code COMPOSITE UNIT OF MEASURE
NTE
CLAIM NOTE
K3 K301 K302
N/U 10
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010 REF01
REF
ID
ID
2-3
R
AN AN
1-50 1-80
R N/U N/U
1
S
2-3 1-50 1-80
R R N/U N/U
1
S
ID
2-3
R
AN AN
1-50 1-80
R N/U N/U
1
S
ID AN AN
2-3 1-50 1-80
R R N/U N/U
AN ID
10 1-80 1-2
S R N/U
ID AN AN
2300 EA Increase from 30 - 50
2300 P4 Increase from 30 - 50
2300 G4 Increase from 30 - 50
2300
N/U 10
S
NTE01 NTE02
Note Reference Code Claim Note Text
ID AN
3-3 1-80
R R
NTE NTE01
BILLING NOTE Note Reference Code
ID
1 3-3
S R
Page 19 of 93
LU
2300 ALG, DCP, DGN, DME, MED, NTR, ODT, RHB, RLH, RNH, SET, SFM, SPT, UPI
2300 ADD
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
NTE02
Billing Note Text
CR6
HOME HEALTH CARE INFORMATION
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
ID
NTE02
Billing Note Text
AN
837-I 4010A1
CR601 CR602 CR603 CR604 CR605 CR606
Prognosis Indicator Service From Date Date Time Period Format Qualifier Home Health Certification Period Diagnosis Date Skilled Nursing Facility Indicator
CR615 CR616
Medicare Coverage Indicator Certification Type Indicator Surgery Date Product or Service ID Qualifier Surgical Procedure Code Physician Order Date Last Visit Date Physician Contact Date Date Time Period Format Qualifier Last Admission Period
CR617 CR618 CR619 CR620 CR621
Patient Discharge Facility Type Code Diagnosis Date Diagnosis Date Diagnosis Date Diagnosis Date
CR607 CR608 CR609 CR610 CR611 CR612 CR613 CR614
AN
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010
1-80
R
1
S
ID DT
1-1 8-8
R R
1, 2, 3, 4, 5, 6, 7, 8 CCYYMMDD
ID
2-3
S
RD8
AN DT
1-35 8-8
S R
CCYYMMDD
ID
1-1
R
N, U, Y
ID ID DT
1-1 1-1 8-8
R R
N, Y I, R, S CCYYMMDD
ID AN DT DT DT
2-2 1-15 8-8 8-8 8-8
S S S S S
HC, ID
ID AN
2-3 1-35
S S
1-80
R Segment Deleted
ID DT DT DT DT
1-1 8-8 8-8 8-8 8-8
2300
CCYYMMDD CCYYMMDD CCYYMMDD RD8 A, B, C, D, E, F, G, H, L, M, O, R, S, T CCYYMMDD CCYYMMDD CCYYMMDD CCYYMMDD
R S S S S
Segment Deleted CRC CRC01 CRC02
HOME HEALTH FUNCTIONAL LIMITATIONS Code Category Certification Condition Indicator
ID
3 2-2
S R
ID
1-1
R
N, Y AA, AL, BL, CO, DY, EL, HL, LB, OL, PA, SL
CRC03
Functional Limitations Code
ID
2-2
R
CRC04
Functional Limitations Code
ID
2-2
S
CRC05
Functional Limitations Code
ID
2-2
S
CRC06
Functional Limitations Code
ID
2-2
S
CRC07
Functional Limitations Code
ID
2-2
S
2300 75
Page 20 of 93
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1
ID
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010 Segment Deleted
CRC CRC01
HOME HEALTH FUNCTIONAL LIMITATIONS Code Category
ID
3 2-2
S R
CRC02
Functional Limitations Code
ID
1-1
R
N, Y BR, CA, CB, CR, EP, IH, NR, PW, TR, UT, WA, WR
CRC03
Activities Permitted Code
ID
2-2
R
CRC04
Activities Permitted Code
ID
2-2
S
CRC05
Activities Permitted Code
ID
2-2
S
CRC06
Activities Permitted Code
ID
2-2
S
CRC07
Activities Permitted Code
ID
2-2
S
2
S
2300 76
Segment Deleted
CRC01
HOME HEALTH MENTAL STATUS Certification Condition Indicator
ID
2-2
R
77
CRC02
Functional Limitations Code
ID
1-1
R
CRC03 CRC04 CRC05 CRC06 CRC07
Mental Status Code Mental Status Code Mental Status Code Mental Status Code Mental Status Code
ID ID ID ID ID
2-2 2-2 2-2 2-2 2-2
R S S S S
N, Y AG, CM, DI, DP, FO, LE, MC, OT
CRC
2300
CRC CRC01 CRC02 CRC03 CRC04 CRC05 CRC06 CRC07
EPSDT REFERRAL Code Category Certification Condition Indicator Condition Code Condition Code Condition Code Condition Indicator Condition Indicator
ID
1 2-2
S R
ID ID ID ID ID ID
1-1 2-3 2-3 2-3 2-3 2-3
R R S S N/U N/U
1
R
ID AN
1-3 1-30
R R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
New Segment
2300 ZZ N, Y AV, NU, S2, ST AV, NU, S2, ST AV, NU, S2, ST
Usage change to Required HI HI01 HI01-1 HI01-2 HI01-3 HI01-4 HI01-5 HI01-6 HI01-7
PRINCIPAL DIAGNOSIS HEALTH CARE CODE INFORMATION Code List Qualifier Code Industry Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
1
S
ID AN
1-3 1-30
R R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
2300
HI
BK
HI01 HI01-1 HI01-2 HI01-3 HI01-4 HI01-5 HI01-6 HI01-7
PRINCIPAL DIAGNOSIS HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
Page 21 of 93
2300
ABK, BK
Name Change Name Change
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION
AN
1-30
N/U
ID
1-1
S
Loop
Loop Repeat
Values
837-I 5010 HI01-8 HI01-9
HI02
Usage Reg.
ID
837-I 4010A1
HEALTH CARE CODE INFORMATION
Min. Max.
Description
S
HI02
New Element New Element N, U, W, Y Usage change to Not Used
N/U Usage change to Not Used Name Change
HI02-1
Code List Qualifier Code
ID
1-3
R
BJ, ZZ
HI02-1
Diagnosis Type Code
ID
1-3
N/U Usage change to Not Used Name Change
HI02-2 HI02-3 HI02-4 HI02-5 HI02-6 HI02-7
Industry Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
AN
1-30
R
HI02-2
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
HI02-3 HI02-4 HI02-5 HI02-6 HI02-7 HI02-8 HI02-9
HI03
HEALTH CARE CODE INFORMATION
S
HI03
Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION
AN
1-30
N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
New Element New Element Usage change to Not Used
N/U Usage change to Not Used Name Change
HI03-1
Code List Qualifier Code
ID
1-3
R
BN
HI03-1
Diagnosis Type Code
ID
1-3
N/U Usage change to Not Used Name Change
HI03-2 HI03-3 HI03-4 HI03-5 HI03-6 HI03-7
Industry Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
AN
1-30
R
HI03-2
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
HI03-3 HI03-4 HI03-5 HI03-6 HI03-7 HI03-8 HI03-9
HI04
HEALTH CARE CODE INFORMATION
N/U
HI04 HI04-1 HI04-2 HI04-3 HI04-4 HI04-5 HI04-6 HI04-7 HI04-8 HI04-9
Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator
Page 22 of 93
AN
1-30
N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
New Element New Element
New Element New Element New Element New Element New Element New Element New Element New Element New Element
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
HI05
HEALTH CARE CODE INFORMATION
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1 N/U
HI05 HI05-1 HI05-2
HI05-9 HI06
N/U
HI06 HI06-1 HI06-2 HI06-3 HI06-4 HI06-5 HI06-6 HI06-7 HI06-8 HI06-9
HI07
HEALTH CARE CODE INFORMATION
N/U
HI07 HI07-1 HI07-2 HI07-3 HI07-4 HI07-5 HI07-6 HI07-7 HI07-8 HI07-9
HI08
HEALTH CARE CODE INFORMATION
N/U
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010
HI05-3 HI05-4 HI05-5 HI05-6 HI05-7 HI05-8
HEALTH CARE CODE INFORMATION
ID
HI08 HI08-1 HI08-2 HI08-3 HI08-4 HI08-5 HI08-6 HI08-7
HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
Page 23 of 93
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R
2-3 1-35 1-18 1-15
N/U N/U N/U N/U
AN AN
1-30 1-30
N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
New Element New Element New Element New Element New Element New Element New Element New Element New Element
New Element New Element New Element New Element New Element New Element New Element New Element New Element
New Element New Element New Element New Element New Element New Element New Element New Element New Element
New Element New Element New Element New Element New Element New Element New Element
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount
AN
1-30
N/U
ID
1-1
N/U
HI08-9 N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
HI09 HI09-1 HI09-2 HI09-3 HI09-4 HI09-5 HI09-6 HI09-7 HI09-8 HI09-9
HI10
HEALTH CARE CODE INFORMATION
ID
1-1
N/U
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
HI10 HI10-1 HI10-2 HI10-3 HI10-4 HI10-5 HI10-6 HI10-7 HI10-8 HI10-9
HI11
HEALTH CARE CODE INFORMATION
ID
1-1
N/U
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
HI11 HI11-1 HI11-2 HI11-3 HI11-4 HI11-5 HI11-6 HI11-7 HI11-8 HI11-9
HI12
HEALTH CARE CODE INFORMATION
ID
1-1
N/U
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R
2-3 1-35 1-18
N/U N/U N/U
Loop
Loop Repeat
Values
837-I 5010 HI08-8
HI09
Usage Reg.
ID
837-I 4010A1
HEALTH CARE CODE INFORMATION
Min. Max.
Description
HI12 HI12-1 HI12-2 HI12-3 HI12-4 HI12-5
Page 24 of 93
New Element New Element
New Element New Element New Element New Element New Element New Element New Element New Element New Element
New Element New Element New Element New Element New Element New Element New Element New Element New Element
New Element New Element New Element New Element New Element New Element New Element New Element New Element
New Element New Element New Element New Element New Element
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1
ID
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010 HI12-6 HI12-7 HI12-8 HI12-9 HI HI01 HI01-1 HI01-2 HI01-3 HI01-4 HI01-5 HI01-6 HI01-7 HI01-8 HI01-9 HI02 HI02-1 HI02-2 HI02-3 HI02-4 HI02-5 HI02-6 HI02-7 HI02-8 HI02-9 HI03 HI03-1 HI03-2 HI03-3 HI03-4 HI03-5 HI03-6 HI03-7 HI03-8 HI03-9 HI04 HI04-1 HI04-2
Quantity Version Identifier Industry code Present on Admission indicator ADMITTING DISGNOSIS HEALTH CARE CODE INFORMATION Diagnosis Type Code Admitting Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code
Page 25 of 93
R AN AN
1-15 1-30 1-30
N/U N/U N/U
ID
1-1
N/U
1
R
ID AN
1-3 1-30
R R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
N/U N/U N/U
New Element New Element New Element New Element
New Segment
2300
ABJ, BJ
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1
ID
Min. Max.
Usage Reg.
837-I 5010 HI04-3 HI04-4 HI04-5 HI04-6 HI04-7 HI04-8 HI04-9 HI05 HI05-1 HI05-2 HI05-3 HI05-4 HI05-5 HI05-6 HI05-7 HI05-8 HI05-9 HI06 HI06-1 HI06-2 HI06-3 HI06-4 HI06-5 HI06-6 HI06-7 HI06-8 HI06-9 HI07 HI07-1 HI07-2 HI07-3 HI07-4 HI07-5 HI07-6 HI07-7 HI07-8 HI07-9 HI08
Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION
Page 26 of 93
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U N/U
Loop
Loop Repeat
Values
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Min. Max.
Usage Reg.
Description
ID
Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator
ID AN
1-3 1-30
N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
837-I 4010A1
837-I 5010 HI08-1 HI08-2 HI08-3 HI08-4 HI08-5 HI08-6 HI08-7 HI08-8 HI08-9 HI09 HI09-1 HI09-2 HI09-3 HI09-4 HI09-5 HI09-6 HI09-7 HI09-8 HI09-9 HI10 HI10-1 HI10-2 HI10-3 HI10-4 HI10-5 HI10-6 HI10-7 HI10-8 HI10-9 HI11 HI11-1 HI11-2 HI11-3 HI11-4 HI11-5 HI11-6 HI11-7 HI11-8 HI11-9
Page 27 of 93
Loop
Loop Repeat
Values
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1
ID
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010 HI12 HI12-1 HI12-2 HI12-3 HI12-4 HI12-5 HI12-6 HI12-7 HI12-8 HI12-9
HI HI01 HI01-1 HI01-2 HI01-3 HI01-4 HI01-5 HI01-6 HI01-7 HI01-8 HI01-9 HI02 HI02-1 HI02-2 HI02-3 HI02-4 HI02-5 HI02-6 HI02-7 HI02-8 HI02-9 HI03 HI03-1 HI03-2 HI03-3 HI03-4 HI03-5
HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator PATIENT REASON FOR VISIT HEALTH CARE CODE INFORMATION Diagnosis Type Code Patient Reason For Visit Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Diagnosis Type Code Patient Reason For Visit Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Diagnosis Type Code Patient Reason For Visit Date Time Period Format Qualifier Date Time Period Monetary Amount
Page 28 of 93
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
1
R
ID AN
1-3 1-30
R R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN R
2-3 1-35 1-18
N/U N/U N/U
New Segment 2300
APR, PR
APR, PR
APR, PR
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1
ID
Min. Max.
Usage Reg.
837-I 5010 HI03-6 HI03-7 HI03-8 HI03-9 HI04 HI04-1 HI04-2 HI04-3 HI04-4 HI04-5 HI04-6 HI04-7 HI04-8 HI04-9 HI05 HI05-1 HI05-2 HI05-3 HI05-4 HI05-5 HI05-6 HI05-7 HI05-8 HI05-9 HI06 HI06-1 HI06-2 HI06-3 HI06-4 HI06-5 HI06-6 HI06-7 HI06-8 HI06-9 HI07 HI07-1 HI07-2 HI07-3
Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier
Page 29 of 93
R AN AN
1-15 1-30 1-30
N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID
2-3
N/U
Loop
Loop Repeat
Values
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Min. Max.
Usage Reg.
Description
ID
Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code
AN R R AN AN
1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
N/U N/U N/U
837-I 4010A1
837-I 5010 HI07-4 HI07-5 HI07-6 HI07-7 HI07-8 HI07-9 HI08 HI08-1 HI08-2 HI08-3 HI08-4 HI08-5 HI08-6 HI08-7 HI08-8 HI08-9 HI09 HI09-1 HI09-2 HI09-3 HI09-4 HI09-5 HI09-6 HI09-7 HI09-8 HI09-9 HI10 HI10-1 HI10-2 HI10-3 HI10-4 HI10-5 HI10-6 HI10-7 HI10-8 HI10-9 HI11 HI11-1 HI11-2
Page 30 of 93
Loop
Loop Repeat
Values
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1
ID
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010 HI11-3 HI11-4 HI11-5 HI11-6 HI11-7 HI11-8 HI11-9 HI12 HI12-1 HI12-2 HI12-3 HI12-4 HI12-5 HI12-6 HI12-7 HI12-8 HI12-9
HI HI01 HI01-1 HI01-2 HI01-3 HI01-4 HI01-5 HI01-6 HI01-7 HI01-8 HI01-9 HI02 HI02-1 HI02-2 HI02-3 HI02-4 HI02-5 HI02-6 HI02-7
Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator EXTERNAL CAUSE OF INJURY HEALTH CARE CODE INFORMATION Diagnosis Type Code External Cause of Injury Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code External Cause of Injury Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
Page 31 of 93
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
1
R
ID
1-3
R R
AN
1-30
R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
S
N, U, W, Y
ID
1-3
S R
ABN, BN
AN
1-30
R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
New Segment 2300
ABN, BN
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Min. Max.
Usage Reg.
Loop Repeat
Description
ID
Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code
AN
1-30
N/U
ID
1-1
S
N, U, W, Y
ID
1-3
S R
ABN, BN
External Cause of Injury Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code
AN
1-30
R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
S
N, U, W, Y
ID
1-3
S R
ABN, BN
AN
1-30
R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
N, U, W, Y
ID AN
1-3 1-30
S R R
ABN, BN
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
S
N, U, W, Y
ABN, BN
837-I 4010A1
Loop
Values
837-I 5010 HI02-8 HI02-9 HI03 HI03-1 HI03-2 HI03-3 HI03-4 HI03-5 HI03-6 HI03-7 HI03-8 HI03-9 HI04 HI04-1
HI06 HI06-1
External Cause of Injury Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code
ID
1-3
S R
HI06-2
External Cause of Injury Code AN
1-30
R
HI04-2 HI04-3 HI04-4 HI04-5 HI04-6 HI04-7 HI04-8 HI04-9 HI05 HI05-1 HI05-2 HI05-3 HI05-4 HI05-5 HI05-6 HI05-7 HI05-8 HI05-9
Page 32 of 93
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1
ID
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010 HI06-3 HI06-4 HI06-5 HI06-6 HI06-7 HI06-8 HI06-9 HI07 HI07-1 HI07-2 HI07-3 HI07-4 HI07-5 HI07-6 HI07-7 HI07-8 HI07-9 HI08 HI08-1 HI08-2 HI08-3 HI08-4 HI08-5 HI08-6 HI08-7 HI08-8 HI08-9 HI09 HI09-1 HI09-2 HI09-3 HI09-4 HI09-5 HI09-6 HI09-7 HI09-8
Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code External Cause of Injury Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code External Cause of Injury Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code External Cause of Injury Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code
Page 33 of 93
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
S
N, U, W, Y
ID
1-3
S R
ABN, BN
AN
1-30
R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
S
N, U, W, Y
ID
1-3
S R
ABN, BN
AN
1-30
R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
S
N, U, W, Y
ID
1-3
S R
ABN, BN
AN
1-30
R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1
HI10 HI10-1 HI10-2 HI10-3 HI10-4 HI10-5 HI10-6 HI10-7 HI10-8 HI10-9 HI11 HI11-1 HI11-2 HI11-3 HI11-4 HI11-5 HI11-6 HI11-7 HI11-8 HI11-9 HI12 HI12-1
R
2300
External Cause of Injury Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code External Cause of Injury Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code
HI12-9
HI
DIAGNOSIS RELATED GROUP (DRG) INFORMATION
HI12-3 HI12-4 HI12-5 HI12-6 HI12-7 HI12-8
1
Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code
External Cause of Injury Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator
HI12-2
HI
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010 HI09-9
DIAGNOSIS RELATED GROUP (DRG) INFORMATION
ID
Page 34 of 93
ID
1-1
S
N, U, W, Y
ID
1-3
S R
ABN, BN
AN
1-30
R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
S
N, U, W, Y
ID
1-3
S R
ABN, BN
AN
1-30
R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
S
N, U, W, Y
ID
1-3
S R
ABN, BN
AN
1-30
R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
S
1
R
N, U, W, Y
2300
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1 HI01 HI01-1 HI01-2 HI01-3 HI01-4 HI01-5 HI01-6 HI01-7
HEALTH CARE CODE INFORMATION Code List Qualifier Code DRG Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
ID AN
1-3 1-30
R R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
HI02
S
DR
HI01 HI01-1 HI01-2 HI01-3 HI01-4 HI01-5 HI01-6 HI01-7 HI01-8
HI02 HI02-1 HI02-2 HI02-3 HI02-4 HI02-5 HI02-6 HI02-7 HI02-8 HI02-9
HI03
HEALTH CARE CODE INFORMATION
N/U
HI03 HI03-1 HI03-2 HI03-3 HI03-4 HI03-5 HI03-6 HI03-7 HI03-8 HI03-9
HI04
HEALTH CARE CODE INFORMATION
N/U
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010
HI01-9 HEALTH CARE CODE INFORMATION
ID
HI04 HI04-1 HI04-2 HI04-3 HI04-4 HI04-5 HI04-6 HI04-7 HI04-8
HEALTH CARE CODE INFORMATION Qualifier DRG Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code
Page 35 of 93
ID AN
1-3 1-30
R R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
DR
Name Change
New Element New Element
New Element New Element New Element New Element New Element New Element New Element New Element New Element
New Element New Element New Element New Element New Element New Element New Element New Element New Element
New Element New Element New Element New Element New Element New Element New Element New Element
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1 HEALTH CARE CODE INFORMATION
N/U
HI05 HI05-1 HI05-2 HI05-3 HI05-4 HI05-5 HI05-6 HI05-7 HI05-8 HI05-9
HI06
HEALTH CARE CODE INFORMATION
N/U
HI06 HI06-1 HI06-2 HI06-3 HI06-4 HI06-5 HI06-6 HI06-7 HI06-8 HI06-9
HI07
HEALTH CARE CODE INFORMATION
N/U
HI07 HI07-1 HI07-2 HI07-3 HI07-4 HI07-5 HI07-6 HI07-7 HI07-8 HI07-9
HI08
HEALTH CARE CODE INFORMATION
N/U
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010 HI04-9
HI05
ID
HI08 HI08-1 HI08-2 HI08-3 HI08-4 HI08-5 HI08-6
Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity
Page 36 of 93
New Element ID
1-1
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R
2-3 1-35 1-18 1-15
N/U N/U N/U N/U
New Element New Element New Element New Element New Element New Element New Element New Element New Element
New Element New Element New Element New Element New Element New Element New Element New Element New Element
New Element New Element New Element New Element New Element New Element New Element New Element New Element
New Element New Element New Element New Element New Element New Element
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period
AN AN
1-30 1-30
N/U N/U
ID
1-1
N/U
HI08-9 N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
HI09 HI09-1 HI09-2 HI09-3 HI09-4 HI09-5 HI09-6 HI09-7 HI09-8 HI09-9
HI10
HEALTH CARE CODE INFORMATION
ID
1-1
N/U
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
HI10 HI10-1 HI10-2 HI10-3 HI10-4 HI10-5 HI10-6 HI10-7 HI10-8 HI10-9
HI11
HEALTH CARE CODE INFORMATION
ID
1-1
N/U
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
HI11 HI11-1 HI11-2 HI11-3 HI11-4 HI11-5 HI11-6 HI11-7 HI11-8 HI11-9
HI12
HEALTH CARE CODE INFORMATION
ID
1-1
N/U
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN
2-3 1-35
N/U N/U
Loop
Loop Repeat
Values
837-I 5010 HI08-7 HI08-8
HI09
Usage Reg.
ID
837-I 4010A1
HEALTH CARE CODE INFORMATION
Min. Max.
Description
HI12 HI12-1 HI12-2 HI12-3 HI12-4
Page 37 of 93
New Element New Element New Element
New Element New Element New Element New Element New Element New Element New Element New Element New Element
New Element New Element New Element New Element New Element New Element New Element New Element New Element
New Element New Element New Element New Element New Element New Element New Element New Element New Element
New Element New Element New Element New Element
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1
HI12-9
HI01 HI01-1 HI01-2 HI01-3 HI01-4 HI01-5 HI01-6 HI01-7
OTHER DIAGNOSIS INFORMATION HEALTH CARE CODE INFORMATION Code List Qualifier Code Other Diagnosis Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
2
R
2300
HI
R ID AN
1-3 1-30
R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
HI01 BF
HI01-1 HI01-2 HI01-3 HI01-4 HI01-5 HI01-6 HI01-7 HI01-8 HI01-9
HI02 HI02-1 HI02-2 HI02-3 HI02-4 HI02-5 HI02-6 HI02-7
HEALTH CARE CODE INFORMATION Code List Qualifier Code Other Diagnosis Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
S ID AN
1-3 1-30
R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
HI02 BF
HI02-1 HI02-2 HI02-3 HI02-4 HI02-5 HI02-6 HI02-7 HI02-8 HI02-9
HI03 HI03-1 HI03-2 HI03-3 HI03-4 HI03-5 HI03-6 HI03-7
HEALTH CARE CODE INFORMATION Code List Qualifier Code Other Diagnosis Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
S ID AN
1-3 1-30
R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010 HI12-5 HI12-6 HI12-7 HI12-8
HI
ID
HI03 BF
HI03-1 HI03-2 HI03-3 HI03-4 HI03-5 HI03-6 HI03-7 HI03-8
Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator
R R AN AN
1-18 1-15 1-30 1-30
N/U N/U N/U N/U
ID
1-1
N/U
2
R
OTHER DIAGNOSIS INFORMATION HEALTH CARE CODE INFORMATION
2300
R
Diagnosis Type Code Other Diagnosis Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION
ID AN
1-3 1-30
R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
S
Diagnosis Type Code Other Diagnosis Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION
ID AN
1-3 1-30
R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
Diagnosis Type Code Other Diagnosis Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code
ID AN
1-3 1-30
R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
Page 38 of 93
New Element New Element New Element New Element New Element
ABF, BF
Name Change Code Added
New Element New Element N, U, W, Y
S ABF, BF
Name Change Code Added
New Element New Element N, U, W, Y
S ABF, BF
Name Change Code Added
New Element
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1
HI04-1 HI04-2 HI04-3 HI04-4 HI04-5 HI04-6 HI04-7
HEALTH CARE CODE INFORMATION Code List Qualifier Code Other Diagnosis Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
S ID AN
1-3 1-30
R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
HI04 BF
HI05 HI05-1 HI05-2 HI05-3 HI05-4 HI05-5 HI05-6 HI05-7
Code List Qualifier Code Other Diagnosis Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
1-3 1-30
R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
HI06 HI06-1 HI06-2 HI06-3 HI06-4 HI06-5 HI06-6 HI06-7
Code List Qualifier Code Other Diagnosis Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
ID AN
1-3 1-30
R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
Diagnosis Type Code Other Diagnosis Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION
ID AN
1-3 1-30
R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
HI07
Diagnosis Type Code Other Diagnosis Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION
HI07-1 HI07-2
Diagnosis Type Code Other Diagnosis
ID AN
HI05-1 HI05-2
HI06-1 HI06-2 HI06-3 HI06-4 HI06-5 HI06-6 HI06-7 HI06-8 HI06-9
HI07
HEALTH CARE CODE INFORMATION
HI07-1 HI07-2
Code List Qualifier Code Other Diagnosis
S ID AN
1-3 1-30
R R
Loop Repeat
Values
BF
Page 39 of 93
N, U, W, Y
S
2-3 1-35 1-18 1-15 1-30 1-30
HI06 BF
N/U
ID AN R R AN AN
HI05-3 HI05-4 HI05-5 HI05-6 HI05-7 HI05-8
S
1-1
R R
HI05-9 HEALTH CARE CODE INFORMATION
Loop
New Element ID
1-3 1-30
HI05 BF
Present on Admission indicator HEALTH CARE CODE INFORMATION
ID AN
HI04-3 HI04-4 HI04-5 HI04-6 HI04-7 HI04-8
S ID AN
Usage Reg.
Diagnosis Type Code Other Diagnosis Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION
HI04-1 HI04-2
HI04-9 HEALTH CARE CODE INFORMATION
Min. Max.
837-I 5010 HI03-9
HI04
ID
ABF, BF
Name Change Code Added
New Element New Element N, U, W, Y
S ABF, BF
Name Change Code Added
New Element New Element N, U, W, Y
S ABF, BF
Name Change Code Added
New Element New Element N, U, W, Y
S 1-3 1-30
R R
ABF, BF
Name Change Code Added
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
HI07-3 HI07-4 HI07-5 HI07-6 HI07-7
Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1 ID AN R R AN
2-3 1-35 1-18 1-15 1-30
HI08 HI08-1 HI08-2 HI08-3 HI08-4 HI08-5 HI08-6 HI08-7
Code List Qualifier Code Other Diagnosis Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
N/U N/U N/U N/U N/U
HI07-3 HI07-4 HI07-5 HI07-6 HI07-7 HI07-8
S ID AN
1-3 1-30
R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
HI08 BF
HI08-1 HI08-2 HI08-3 HI08-4 HI08-5 HI08-6 HI08-7 HI08-8 HI08-9
HI09 HI09-1 HI09-2 HI09-3 HI09-4 HI09-5 HI09-6 HI09-7
HEALTH CARE CODE INFORMATION Code List Qualifier Code Other Diagnosis Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
S ID AN
1-3 1-30
R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
HI09 BF
HI09-1 HI09-2 HI09-3 HI09-4 HI09-5 HI09-6 HI09-7 HI09-8 HI09-9
HI10 HI10-1 HI10-2 HI10-3 HI10-4 HI10-5 HI10-6 HI10-7
HEALTH CARE CODE INFORMATION Code List Qualifier Code Other Diagnosis Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
S ID AN
1-3 1-30
R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010
HI07-9 HEALTH CARE CODE INFORMATION
ID
HI10 BF
HI10-1 HI10-2 HI10-3 HI10-4 HI10-5 HI10-6 HI10-7 HI10-8
Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
N, U, W, Y
S
Diagnosis Type Code Other Diagnosis Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION
ID AN
1-3 1-30
R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
Diagnosis Type Code Other Diagnosis Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION
ID AN
1-3 1-30
R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
Diagnosis Type Code Other Diagnosis Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code
ID AN
1-3 1-30
R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
Page 40 of 93
New Element New Element
ABF, BF
Name Change Code Added
New Element New Element N, U, W, Y
S ABF, BF
Name Change Code Added
New Element New Element N, U, W, Y
S ABF, BF
Name Change Code Added
New Element
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1
HI11-1 HI11-2 HI11-3 HI11-4 HI11-5 HI11-6 HI11-7
HEALTH CARE CODE INFORMATION Code List Qualifier Code Other Diagnosis Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
S ID AN
1-3 1-30
R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
HI11 BF
HI11-1 HI11-2 HI11-3 HI11-4 HI11-5 HI11-6 HI11-7 HI11-8 HI11-9
HI12 HI12-1 HI12-2 HI12-3 HI12-4 HI12-5 HI12-6 HI12-7
HEALTH CARE CODE INFORMATION Code List Qualifier Code Other Diagnosis Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
S ID AN
1-3 1-30
R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
HI12 BF
HI12-1 HI12-2 HI12-3 HI12-4 HI12-5 HI12-6 HI12-7 HI12-8 HI12-9
HI HI01
PRINCIPAL PROCEDURE INFORMATION HEALTH CARE CODE INFORMATION
1
R
2300
HI
R
HI01
ID AN
1-3 1-30
R R
BP
HI01-1 HI01-2
HI01-3
Code List Qualifier Code Principal Procedure Code Date Time Period Format Qualifier
ID
2-3
S
D8
HI01-3
HI01-4 HI01-5 HI01-6 HI01-7
Date Time Period Monetary Amount Quantity Version Identifier
AN R R AN
1-35 1-18 1-15 1-30
S N/U N/U N/U
HI01-1 HI01-2
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010 HI10-9
HI11
ID
Present on Admission indicator HEALTH CARE CODE INFORMATION
New Element ID
1-1
N, U, W, Y
N/U S
Diagnosis Type Code Other Diagnosis Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION
ID AN
1-3 1-30
R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
Diagnosis Type Code Other Diagnosis Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator
ID AN
1-3 1-30
R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
1
R
ABF, BF
Name Change Code Added
New Element New Element N, U, W, Y
S
PRINCIPAL PROCEDURE INFORMATION HEALTH CARE CODE INFORMATION
ABF, BF
Name Change Code Added
New Element New Element N, U, W, Y
2300
R
Qualifier Principal Procedure Code Date Time Period Format Qualifier
ID AN
1-3 1-30
R R
ID
2-3
N/U
Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION
AN R R AN AN
1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U
ID
1-1
N/U
BBR, BR
Name Change Code Change Usage change to Not Used Usage change to Not Used
HI01-4 HI01-5 HI01-6 HI01-7 HI01-8 HI01-9
HI02
HEALTH CARE CODE INFORMATION
N/U
HI02
Page 41 of 93
N/U
New Element New Element
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator
ID AN
1-3 1-30
N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
HI02-3 HI02-4 HI02-5 HI02-6 HI02-7 HI02-8 HI02-9 N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
HI03 HI03-1 HI03-2 HI03-3 HI03-4 HI03-5 HI03-6 HI03-7 HI03-8 HI03-9
HI04
HEALTH CARE CODE INFORMATION
ID
1-1
N/U
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
HI04 HI04-1 HI04-2 HI04-3 HI04-4 HI04-5 HI04-6 HI04-7 HI04-8 HI04-9
HI05
HEALTH CARE CODE INFORMATION
ID
1-1
N/U
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
Loop
Loop Repeat
Values
837-I 5010 HI02-1 HI02-2
HI03
Usage Reg.
ID
837-I 4010A1
HEALTH CARE CODE INFORMATION
Min. Max.
Description
HI05 HI05-1 HI05-2 HI05-3 HI05-4 HI05-5 HI05-6 HI05-7 HI05-8 HI05-9
Page 42 of 93
New Element New Element New Element New Element New Element New Element New Element New Element New Element
New Element New Element New Element New Element New Element New Element New Element New Element New Element
New Element New Element New Element New Element New Element New Element New Element New Element New Element
New Element New Element New Element New Element New Element New Element New Element New Element New Element
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
HI06
HEALTH CARE CODE INFORMATION
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1 N/U
HI06 HI06-1 HI06-2
HI06-9 HI07
N/U
HI07 HI07-1 HI07-2 HI07-3 HI07-4 HI07-5 HI07-6 HI07-7 HI07-8 HI07-9
HI08
HEALTH CARE CODE INFORMATION
N/U
HI08 HI08-1 HI08-2 HI08-3 HI08-4 HI08-5 HI08-6 HI08-7 HI08-8 HI08-9
HI09
HEALTH CARE CODE INFORMATION
N/U
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010
HI06-3 HI06-4 HI06-5 HI06-6 HI06-7 HI06-8
HEALTH CARE CODE INFORMATION
ID
HI09 HI09-1 HI09-2 HI09-3 HI09-4 HI09-5 HI09-6 HI09-7 HI09-8
HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code
Page 43 of 93
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
New Element New Element New Element New Element New Element New Element New Element New Element New Element
New Element New Element New Element New Element New Element New Element New Element New Element New Element
New Element New Element New Element New Element New Element New Element New Element New Element New Element
New Element New Element New Element New Element New Element New Element New Element New Element
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1 HEALTH CARE CODE INFORMATION
N/U
HI10 HI10-1 HI10-2 HI10-3 HI10-4 HI10-5 HI10-6 HI10-7 HI10-8 HI10-9
HI11
HEALTH CARE CODE INFORMATION
N/U
HI11 HI11-1 HI11-2 HI11-3 HI11-4 HI11-5 HI11-6 HI11-7 HI11-8 HI11-9
HI12
HEALTH CARE CODE INFORMATION
N/U
HI12 HI12-1 HI12-2 HI12-3 HI12-4 HI12-5 HI12-6 HI12-7 HI12-8 HI12-9
HI01
OTHER PROCEDURE INFORMATION HEALTH CARE CODE INFORMATION
HI01-1 HI01-2
Code List Qualifier Code Procedure Code
HI
2
R
2300
1-3 1-30
R R
BO, BQ
Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator
HI01
OTHER PROCEDURE INFORMATION HEALTH CARE CODE INFORMATION
HI01-1 HI01-2
Qualifier Code Procedure Code
HI
R ID AN
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010 HI09-9
HI10
ID
Page 44 of 93
New Element ID
1-1
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
2
R
New Element New Element New Element New Element New Element New Element New Element New Element New Element
New Element New Element New Element New Element New Element New Element New Element New Element New Element
New Element New Element New Element New Element New Element New Element New Element New Element New Element
2300
R ID AN
1-3 1-30
R R
BBQ, BQ
Name Change Code Change
INSTITUTIONAL CLAIM
4010A1 Description
HI01-3
Date Time Period Format Qualifier
ID
2-3
S
HI01-4 HI01-5 HI01-6 HI01-7
Date Time Period Monetary Amount Quantity Version Identifier
AN R R AN
1-35 1-18 1-15 1-30
S N/U N/U N/U
ID
Min. Max.
Usage Reg.
Element Identifier
5010 Loop
Loop Repeat
Element Identifier
Description
D8
HI01-3
Date Time Period Format Qualifier
CCYYMMDD
HI01-4 HI01-5 HI01-6 HI01-7 HI01-8
Values
837-I 4010A1
ID
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010 Usage change to Required ID
2-3
R
D8
Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION
AN R R AN AN
1-35 1-18 1-15 1-30 1-30
R N/U N/U N/U N/U
CCYYMMDD
ID
1-1
N/U
Qualifier Code Procedure Code Date Time Period Format Qualifier
ID AN
1-3 1-30
R R
BBQ, BQ
ID
2-3
R
D8
Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION
AN R R AN AN
1-35 1-18 1-15 1-30 1-30
R N/U N/U N/U N/U
CCYYMMDD
ID
1-1
N/U
Qualifier Code Procedure Code Date Time Period Format Qualifier
ID AN
1-3 1-30
R R
BBQ, BQ
ID
2-3
R
D8
Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION
AN R R AN AN
1-35 1-18 1-15 1-30 1-30
R N/U N/U N/U N/U
CCYYMMDD
ID
1-1
N/U
ID AN
1-3 1-30
R R
BBQ, BQ
ID
2-3
R
D8
AN R
1-35 1-18
R N/U
CCYYMMDD
Usage change to Required
HI01-9 HI02
HEALTH CARE CODE INFORMATION
S
HI02
ID AN
1-3 1-30
R R
BO, BQ
HI02-1 HI02-2
HI02-3
Code List Qualifier Code Procedure Code Date Time Period Format Qualifier
ID
2-3
S
D8
HI02-3
HI02-4 HI02-5 HI02-6 HI02-7
Date Time Period Monetary Amount Quantity Version Identifier
AN R R AN
1-35 1-18 1-15 1-30
S N/U N/U N/U
CCYYMMDD
HI02-4 HI02-5 HI02-6 HI02-7 HI02-8
HI02-1 HI02-2
New Element New Element
S Name Change Code Change Usage change to Required Usage change to Required
HI02-9 HI03
HEALTH CARE CODE INFORMATION
S
HI03
ID AN
1-3 1-30
R R
BO, BQ
HI03-1 HI03-2
HI03-3
Code List Qualifier Code Procedure Code Date Time Period Format Qualifier
ID
2-3
S
D8
HI03-3
HI03-4 HI03-5 HI03-6 HI03-7
Date Time Period Monetary Amount Quantity Version Identifier
AN R R AN
1-35 1-18 1-15 1-30
S N/U N/U N/U
CCYYMMDD
HI03-4 HI03-5 HI03-6 HI03-7 HI03-8
HI03-1 HI03-2
New Element New Element
S Name Change Code Change Usage change to Required Usage change to Required
HI03-9 HI04
HEALTH CARE CODE INFORMATION
S
HI04
ID AN
1-3 1-30
R R
BO, BQ
HI04-1 HI04-2
HI04-3
Code List Qualifier Code Procedure Code Date Time Period Format Qualifier
ID
2-3
S
D8
HI04-3
Qualifier Code Procedure Code Date Time Period Format Qualifier
HI04-4 HI04-5
Date Time Period Monetary Amount
AN R
1-35 1-18
S N/U
CCYYMMDD
HI04-4 HI04-5
Date Time Period Monetary Amount
HI04-1 HI04-2
New Element New Element
S Name Change Code Change Usage change to Required Usage change to Required
Page 45 of 93
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
HI04-6 HI04-7
Quantity Version Identifier
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1 R AN
1-15 1-30
HI05
HI04-6 HI04-7 HI04-8
S
HI05
ID AN
1-3 1-30
R R
BO, BQ
HI05-1 HI05-2
HI05-3
Code List Qualifier Code Procedure Code Date Time Period Format Qualifier
ID
2-3
S
D8
HI05-3
HI05-4 HI05-5 HI05-6 HI05-7
Date Time Period Monetary Amount Quantity Version Identifier
AN R R AN
1-35 1-18 1-15 1-30
S N/U N/U N/U
CCYYMMDD
HI05-4 HI05-5 HI05-6 HI05-7 HI05-8
HI05-1 HI05-2
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010
N/U N/U
HI04-9 HEALTH CARE CODE INFORMATION
ID
Quantity R Version Identifier AN Industry code AN Yes/No Condition or response Code ID HEALTH CARE CODE INFORMATION
1-15 1-30 1-30
N/U N/U N/U
1-1
N/U
New Element New Element
S
Qualifier Code Procedure Code Date Time Period Format Qualifier
ID AN
1-3 1-30
R R
BBQ, BQ
ID
2-3
R
D8
Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION
AN R R AN AN
1-35 1-18 1-15 1-30 1-30
R N/U N/U N/U N/U
CCYYMMDD
ID
1-1
N/U
Qualifier Code Procedure Code Date Time Period Format Qualifier
ID AN
1-3 1-30
R R
BBQ, BQ
ID
2-3
R
D8
Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION
AN R R AN AN
1-35 1-18 1-15 1-30 1-30
R N/U N/U N/U N/U
CCYYMMDD
ID
1-1
N/U
Qualifier Code Procedure Code Date Time Period Format Qualifier
ID AN
1-3 1-30
R R
BBQ, BQ
ID
2-3
R
D8
Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code
AN R R AN AN
1-35 1-18 1-15 1-30 1-30
R N/U N/U N/U N/U
CCYYMMDD
ID
1-1
N/U
Name Change Code Change Usage change to Required Usage change to Required
HI05-9 HI06
HEALTH CARE CODE INFORMATION
S
HI06
ID AN
1-3 1-30
R R
BO, BQ
HI06-1 HI06-2
HI06-3
Code List Qualifier Code Procedure Code Date Time Period Format Qualifier
ID
2-3
S
D8
HI06-3
HI06-4 HI06-5 HI06-6 HI06-7
Date Time Period Monetary Amount Quantity Version Identifier
AN R R AN
1-35 1-18 1-15 1-30
S N/U N/U N/U
CCYYMMDD
HI06-4 HI06-5 HI06-6 HI06-7 HI06-8
HI06-1 HI06-2
New Element New Element
S Name Change Code Change Usage change to Required Usage change to Required
HI06-9 HI07
HEALTH CARE CODE INFORMATION
S
HI07
ID AN
1-3 1-30
R R
BO, BQ
HI07-1 HI07-2
HI07-3
Code List Qualifier Code Procedure Code Date Time Period Format Qualifier
ID
2-3
S
D8
HI07-3
HI07-4 HI07-5 HI07-6 HI07-7
Date Time Period Monetary Amount Quantity Version Identifier
AN R R AN
1-35 1-18 1-15 1-30
S N/U N/U N/U
CCYYMMDD
HI07-4 HI07-5 HI07-6 HI07-7 HI07-8
HI07-1 HI07-2
New Element New Element
S Name Change Code Change Usage change to Required Usage change to Required
HI07-9
Page 46 of 93
New Element New Element
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
HI08
HEALTH CARE CODE INFORMATION
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
HI08
HEALTH CARE CODE INFORMATION
837-I 4010A1
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010
S ID AN
1-3 1-30
R R
BO, BQ
HI08-1 HI08-2
HI08-3
Code List Qualifier Code Procedure Code Date Time Period Format Qualifier
ID
2-3
S
D8
HI08-3
HI08-4 HI08-5 HI08-6 HI08-7
Date Time Period Monetary Amount Quantity Version Identifier
AN R R AN
1-35 1-18 1-15 1-30
S N/U N/U N/U
CCYYMMDD
HI08-4 HI08-5 HI08-6 HI08-7 HI08-8
HI08-1 HI08-2
ID
S
Qualifier Code Procedure Code Date Time Period Format Qualifier
ID AN
1-3 1-30
R R
BBQ, BQ
ID
2-3
R
D8
Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION
AN R R AN AN
1-35 1-18 1-15 1-30 1-30
R N/U N/U N/U N/U
CCYYMMDD
ID
1-1
N/U
Qualifier Code Procedure Code Date Time Period Format Qualifier
ID AN
1-3 1-30
R R
BBQ, BQ
ID
2-3
R
D8
Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION
AN R R AN AN
1-35 1-18 1-15 1-30 1-30
R N/U N/U N/U N/U
CCYYMMDD
ID
1-1
N/U
Qualifier Code Procedure Code Date Time Period Format Qualifier
ID AN
1-3 1-30
R R
BBQ, BQ
ID
2-3
R
D8
AN R R AN AN
1-35 1-18 1-15 1-30 1-30
R N/U N/U N/U N/U
CCYYMMDD
ID
1-1
N/U
HI11
Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION
HI11-1 HI11-2
Qualifier Code Procedure Code
ID AN
Name Change Code Change Usage change to Required Usage change to Required
HI08-9 HI09
HEALTH CARE CODE INFORMATION
S
HI09
ID AN
1-3 1-30
R R
BO, BQ
HI09-1 HI09-2
HI09-3
Code List Qualifier Code Procedure Code Date Time Period Format Qualifier
ID
2-3
S
D8
HI09-3
HI09-4 HI09-5 HI09-6 HI09-7
Date Time Period Monetary Amount Quantity Version Identifier
AN R R AN
1-35 1-18 1-15 1-30
S N/U N/U N/U
CCYYMMDD
HI09-4 HI09-5 HI09-6 HI09-7 HI09-8
HI09-1 HI09-2
New Element New Element
S Name Change Code Change Usage change to Required Usage change to Required
HI09-9 HI10
HEALTH CARE CODE INFORMATION
S
HI10
ID AN
1-3 1-30
R R
BO, BQ
HI10-1 HI10-2
HI10-3
Code List Qualifier Code Procedure Code Date Time Period Format Qualifier
ID
2-3
S
D8
HI10-3
HI10-4 HI10-5 HI10-6 HI10-7
Date Time Period Monetary Amount Quantity Version Identifier
AN R R AN
1-35 1-18 1-15 1-30
S N/U N/U N/U
CCYYMMDD
HI10-4 HI10-5 HI10-6 HI10-7 HI10-8
HI10-1 HI10-2
New Element New Element
S Name Change Code Change Usage change to Required Usage change to Required
HI10-9 HI11
HEALTH CARE CODE INFORMATION
HI11-1 HI11-2
Code List Qualifier Code Procedure Code
S ID AN
1-3 1-30
R R
BO, BQ
Page 47 of 93
New Element New Element
S 1-3 1-30
R R
BBQ, BQ
Name Change Code Change
INSTITUTIONAL CLAIM
4010A1 Description
HI11-3
Date Time Period Format Qualifier
ID
2-3
S
HI11-4 HI11-5 HI11-6 HI11-7
Date Time Period Monetary Amount Quantity Version Identifier
AN R R AN
1-35 1-18 1-15 1-30
S N/U N/U N/U
ID
Min. Max.
Usage Reg.
Element Identifier
5010 Loop
Loop Repeat
Element Identifier
Description
D8
HI11-3
Date Time Period Format Qualifier
CCYYMMDD
HI11-4 HI11-5 HI11-6 HI11-7 HI11-8
Values
837-I 4010A1
ID
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010 Usage change to Required ID
2-3
R
D8
Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION
AN R R AN AN
1-35 1-18 1-15 1-30 1-30
R N/U N/U N/U N/U
CCYYMMDD
ID
1-1
N/U
Qualifier Code Procedure Code Date Time Period Format Qualifier
ID AN
1-3 1-30
R R
BBQ, BQ
ID
2-3
R
D8
Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code
AN R R AN AN
1-35 1-18 1-15 1-30 1-30
R N/U N/U N/U N/U
CCYYMMDD
ID
1-1
N/U
2
R
ID AN
1-3 1-30
R R R
ID
2-3
R
AN R R AN AN
1-35 1-18 1-15 1-30 1-30
R N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
HI02-3
Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Occurrence Span Code Date Time Period Format Qualifier
ID
2-3
R
HI02-4
Date Time Period
AN
1-35
R
Usage change to Required
HI11-9 HI12
HEALTH CARE CODE INFORMATION
S
HI12
ID AN
1-3 1-30
R R
BO, BQ
HI12-1 HI12-2
HI12-3
Code List Qualifier Code Procedure Code Date Time Period Format Qualifier
ID
2-3
S
D8
HI12-3
HI12-4 HI12-5 HI12-6 HI12-7
Date Time Period Monetary Amount Quantity Version Identifier
AN R R AN
1-35 1-18 1-15 1-30
S N/U N/U N/U
CCYYMMDD
HI12-4 HI12-5 HI12-6 HI12-7 HI12-8
HI12-1 HI12-2
New Element New Element
S Name Change Code Change Usage change to Required Usage change to Required
HI12-9
HI01-3
OCCURRENCE SPAN INFORMATION HEALTH CARE CODE INFORMATION Code List Qualifier Code Occurrence Span Code Date Time Period Format Qualifier
HI01-4 HI01-5 HI01-6 HI01-7
Date Time Period Monetary Amount Quantity Version Identifier
HI HI01 HI01-1 HI01-2
2
S
ID AN
1-3 1-30
R R R
ID
2-3
R
AN R R AN
1-35 1-18 1-15 1-30
R N/U N/U N/U
2300
HI
BI
RD8 CCYYMMDDCCYYMMDD
HI01 HI01-1 HI01-2 HI01-3 HI01-4 HI01-5 HI01-6 HI01-7 HI01-8 HI01-9
ID AN
1-3 1-30
S R R
HI02-3
HEALTH CARE CODE INFORMATION Code List Qualifier Code Occurrence Span Code Date Time Period Format Qualifier
ID
2-3
R
HI02-4
Date Time Period
AN
1-35
R
HI02 HI02-1 HI02-2
BI
RD8 CCYYMMDDCCYYMMDD
HI02 HI02-1 HI02-2
OCCURRENCE SPAN INFORMATION HEALTH CARE CODE INFORMATION Qualifier Occurrence Span Code Date Time Period Format Qualifier
Page 48 of 93
New Element New Element
Usage change to Required 2300
BI
Name Change
RD8 CCYYMMDDCCYYMMDD
New Element New Element
BI
RD8 CCYYMMDDCCYYMMDD
Name Change
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
HI02-5 HI02-6 HI02-7
Monetary Amount Quantity Version Identifier
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1 R R AN
1-18 1-15 1-30
HI03 HI03-1 HI03-2
ID AN
1-3 1-30
S R R
ID
2-3
R
AN R R AN AN
1-35 1-18 1-15 1-30 1-30
R N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
HI04-3
Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Code List Qualifier Code Occurrence Span Code Date Time Period Format Qualifier
ID
2-3
R
HI04-4 HI04-5 HI04-6 HI04-7
Date Time Period Monetary Amount Quantity Version Identifier
AN R R AN
1-35 1-18 1-15 1-30
R N/U N/U N/U
HI03-3 HI03-4 HI03-5 HI03-6 HI03-7 HI03-8 HI03-9 HI04 HI04-1 HI04-2
HI02-5 HI02-6 HI02-7 HI02-8
BI
RD8 CCYYMMDDCCYYMMDD
HI03 HI03-1 HI03-2 HI03-3 HI03-4 HI03-5 HI03-6 HI03-7 HI03-8 HI03-9
BI
RD8 CCYYMMDDCCYYMMDD
HI04 HI04-1 HI04-2 HI04-3 HI04-4 HI04-5 HI04-6 HI04-7 HI04-8 HI04-9
ID AN
1-3 1-30
S R R
HI05-3
HEALTH CARE CODE INFORMATION Code List Qualifier Code Occurrence Span Code Date Time Period Format Qualifier
ID
2-3
R
HI05-4 HI05-5 HI05-6 HI05-7
Date Time Period Monetary Amount Quantity Version Identifier
AN R R AN
1-35 1-18 1-15 1-30
R N/U N/U N/U
HI05 HI05-1 HI05-2
BI
RD8 CCYYMMDDCCYYMMDD
HI05 HI05-1 HI05-2 HI05-3 HI05-4 HI05-5 HI05-6 HI05-7 HI05-8 HI05-9
HI06
HEALTH CARE CODE INFORMATION
S
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010
N/U N/U N/U
HI02-9 HEALTH CARE CODE INFORMATION Code List Qualifier Code Occurrence Span Code Date Time Period Format Qualifier
ID
HI06
Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Occurrence Span Code Date Time Period Format Qualifier
R R AN AN
1-18 1-15 1-30 1-30
N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID
2-3
R
Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Occurrence Span Code Date Time Period Format Qualifier
AN R R AN AN
1-35 1-18 1-15 1-30 1-30
R N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID
2-3
R
Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Occurrence Span Code Date Time Period Format Qualifier
AN R R AN AN
1-35 1-18 1-15 1-30 1-30
R N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID
2-3
R
Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION
AN R R AN AN
1-35 1-18 1-15 1-30 1-30
R N/U N/U N/U N/U
ID
1-1
N/U
Page 49 of 93
S
New Element New Element
BI
Name Change
RD8 CCYYMMDDCCYYMMDD
New Element New Element
BI
Name Change
RD8 CCYYMMDDCCY YMMDD
New Element New Element
BI
Name Change
RD8 CCYYMMDDCCYYMMDD
New Element New Element
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
ID AN
1-3 1-30
R R
BI
ID
2-3
R
Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Occurrence Span Code Date Time Period Format Qualifier
AN R R AN AN
1-35 1-18 1-15 1-30 1-30
R N/U N/U N/U N/U
RD8 CCYYMMDDCCYYMMDD
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID
2-3
R
Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Occurrence Span Code Date Time Period Format Qualifier
AN R R AN AN
1-35 1-18 1-15 1-30 1-30
R N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID
2-3
R
AN R R AN AN
1-35 1-18 1-15 1-30 1-30
R N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
HI09-3
Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Occurrence Span Code Date Time Period Format Qualifier
ID
2-3
R
HI09-4 HI09-5 HI09-6
Date Time Period Monetary Amount Quantity
AN R R
1-35 1-18 1-15
R N/U N/U
1-3 1-30
R R
BI
HI06-1 HI06-2
HI06-3
ID
2-3
R
HI06-3
HI06-4 HI06-5 HI06-6 HI06-7
Date Time Period Monetary Amount Quantity Version Identifier
AN R R AN
1-35 1-18 1-15 1-30
R N/U N/U N/U
RD8 CCYYMMDDCCYYMMDD
HI06-4 HI06-5 HI06-6 HI06-7 HI06-8 HI06-9
ID AN
1-3 1-30
S R R
HI07-3
ID
2-3
R
HI07-4 HI07-5 HI07-6 HI07-7
Date Time Period Monetary Amount Quantity Version Identifier
AN R R AN
1-35 1-18 1-15 1-30
R N/U N/U N/U
BI
RD8 CCYYMMDDCCYYMMDD
HI07 HI07-1 HI07-2 HI07-3 HI07-4 HI07-5 HI07-6 HI07-7 HI07-8 HI07-9
ID AN
1-3 1-30
S R R
HI08-3
HEALTH CARE CODE INFORMATION Code List Qualifier Code Occurrence Span Code Date Time Period Format Qualifier
ID
2-3
R
HI08-4 HI08-5 HI08-6 HI08-7
Date Time Period Monetary Amount Quantity Version Identifier
AN R R AN
1-35 1-18 1-15 1-30
R N/U N/U N/U
HI08 HI08-1 HI08-2
BI
RD8 CCYYMMDDCCYYMMDD
HI08 HI08-1 HI08-2 HI08-3 HI08-4 HI08-5 HI08-6 HI08-7 HI08-8 HI08-9
ID AN
1-3 1-30
S R R
HI09-3
HEALTH CARE CODE INFORMATION Code List Qualifier Code Occurrence Span Code Date Time Period Format Qualifier
ID
2-3
R
HI09-4 HI09-5 HI09-6
Date Time Period Monetary Amount Quantity
AN R R
1-35 1-18 1-15
R N/U N/U
HI09 HI09-1 HI09-2
Loop
Values
837-I 5010
ID AN
HI07 HI07-1 HI07-2
Loop Repeat
Qualifier Occurrence Span Code Date Time Period Format Qualifier
837-I 4010A1
HEALTH CARE CODE INFORMATION Code List Qualifier Code Occurrence Span Code Date Time Period Format Qualifier
Usage Reg.
ID
Code List Qualifier Code Occurrence Span Code Date Time Period Format Qualifier
HI06-1 HI06-2
Min. Max.
Description
BI
RD8 CCYYMMDDCCYYMMDD
HI09 HI09-1 HI09-2
Page 50 of 93
Name Change
New Element New Element
BI
Name Change
RD8 CCYYMMDDCCYYMMDD
New Element New Element
BI
Name Change
RD8 CCYYMMDDCCYYMMDD
New Element New Element
BI
RD8 CCYYMMDDCCYYMMDD
Name Change
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
HI09-7
Version Identifier
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
1-30
Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Occurrence Span Code Date Time Period Format Qualifier
AN AN
1-30 1-30
N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID
2-3
R
Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Occurrence Span Code Date Time Period Format Qualifier
AN R R AN AN
1-35 1-18 1-15 1-30 1-30
R N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID
2-3
R
Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Occurrence Span Code Date Time Period Format Qualifier
AN R R AN AN
1-35 1-18 1-15 1-30 1-30
R N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID
2-3
R
AN R R AN AN
1-35 1-18 1-15 1-30 1-30
R N/U N/U N/U N/U
HI12-9
Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code
ID
1-1
N/U
HI
OCCURRENCE INFORMATION
2
R
HI09-7 HI09-8 HI09-9
ID AN
1-3 1-30
S R R
HI10-3
ID
2-3
R
HI10-4 HI10-5 HI10-6 HI10-7
Date Time Period Monetary Amount Quantity Version Identifier
AN R R AN
1-35 1-18 1-15 1-30
R N/U N/U N/U
HI10 HI10-1 HI10-2
BI
RD8 CCYYMMDDCCYYMMDD
HI10 HI10-1 HI10-2 HI10-3 HI10-4 HI10-5 HI10-6 HI10-7 HI10-8 HI10-9
ID AN
1-3 1-30
S R R
HI11-3
HEALTH CARE CODE INFORMATION Code List Qualifier Code Occurrence Span Code Date Time Period Format Qualifier
ID
2-3
R
HI11-4 HI11-5 HI11-6 HI11-7
Date Time Period Monetary Amount Quantity Version Identifier
AN R R AN
1-35 1-18 1-15 1-30
R N/U N/U N/U
HI11 HI11-1 HI11-2
BI
RD8 CCYYMMDDCCYYMMDD
HI11 HI11-1 HI11-2 HI11-3 HI11-4 HI11-5 HI11-6 HI11-7 HI11-8 HI11-9
ID AN
1-3 1-30
S R R
HI12-3
HEALTH CARE CODE INFORMATION Code List Qualifier Code Occurrence Span Code Date Time Period Format Qualifier
ID
2-3
R
HI12-4 HI12-5 HI12-6 HI12-7
Date Time Period Monetary Amount Quantity Version Identifier
AN R R AN
1-35 1-18 1-15 1-30
R N/U N/U N/U
HI12 HI12-1 HI12-2
HI
OCCURRENCE INFORMATION
2
R
Loop
Loop Repeat
Values
837-I 5010
N/U
HEALTH CARE CODE INFORMATION Code List Qualifier Code Occurrence Span Code Date Time Period Format Qualifier
Usage Reg.
ID
837-I 4010A1 AN
Min. Max.
Description
BI
RD8 CCYYMMDDCCYYMMDD
2300
HI12 HI12-1 HI12-2 HI12-3 HI12-4 HI12-5 HI12-6 HI12-7 HI12-8
Page 51 of 93
New Element New Element
BI
Name Change
RD8 CCYYMMDDCCYYMMDD
New Element New Element
BI
Name Change
RD8 CCYYMMDDCCYYMMDD
New Element New Element
BI
Name Change
RD8 CCYYMMDDCCYYMMDD
New Element New Element
2300
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1 HI01 HI01-1 HI01-2 HI01-3 HI01-4 HI01-5 HI01-6 HI01-7
HEALTH CARE CODE INFORMATION Code List Qualifier Code Occurrence Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
ID AN
1-3 1-30
R R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
R R N/U N/U N/U
HI02 HI02-1 HI02-2 HI02-3 HI02-4 HI02-5 HI02-6 HI02-7
ID AN
1-3 1-30
S R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
R R N/U N/U N/U
BH
D8 CCYYMMDD
HI01 HI01-1 HI01-2 HI01-3 HI01-4 HI01-5 HI01-6 HI01-7 HI01-8
BH
D8 CCYYMMDD
HI02 HI02-1 HI02-2 HI02-3 HI02-4 HI02-5 HI02-6 HI02-7 HI02-8 HI02-9
HI03 HI03-1 HI03-2 HI03-3 HI03-4 HI03-5 HI03-6 HI03-7
HEALTH CARE CODE INFORMATION Code List Qualifier Code Occurrence Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
ID AN
1-3 1-30
S R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
R R N/U N/U N/U
BH
D8 CCYYMMDD
HI03 HI03-1 HI03-2 HI03-3 HI03-4 HI03-5 HI03-6 HI03-7 HI03-8 HI03-9
HI04 HI04-1 HI04-2 HI04-3 HI04-4 HI04-5 HI04-6 HI04-7
HEALTH CARE CODE INFORMATION Code List Qualifier Code Occurrence Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
ID AN
1-3 1-30
S R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
R R N/U N/U N/U
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010
HI01-9 HEALTH CARE CODE INFORMATION Code List Qualifier Code Occurrence Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
ID
BH
D8 CCYYMMDD
HI04 HI04-1 HI04-2 HI04-3 HI04-4 HI04-5 HI04-6 HI04-7 HI04-8
HEALTH CARE CODE INFORMATION Qualifier Occurrence Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Occurrence Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Occurrence Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Occurrence Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code
Page 52 of 93
ID AN
1-3 1-30
R R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
R R N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
R R N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
R R N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
R R N/U N/U N/U N/U
BH
Name Change
D8 CCYYMMDD
New Element New Element
BH
Name Change
D8 CCYYMMDD
New Element New Element
BH
Name Change
D8 CCYYMMDD
New Element New Element
BH
Name Change
D8 CCYYMMDD
New Element
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1
HI05-3 HI05-4 HI05-5 HI05-6 HI05-7
HEALTH CARE CODE INFORMATION Code List Qualifier Code Occurrence Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
ID AN
1-3 1-30
S R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
R R N/U N/U N/U
BH
D8 CCYYMMDD
HI05 HI05-1 HI05-2 HI05-3 HI05-4 HI05-5 HI05-6 HI05-7 HI05-8 HI05-9
HI06 HI06-1 HI06-2 HI06-3 HI06-4 HI06-5 HI06-6 HI06-7
HEALTH CARE CODE INFORMATION Code List Qualifier Code Occurrence Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
ID AN
1-3 1-30
S R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
R R N/U N/U N/U
BH
D8 CCYYMMDD
HI06 HI06-1 HI06-2 HI06-3 HI06-4 HI06-5 HI06-6 HI06-7 HI06-8 HI06-9
HI07 HI07-1 HI07-2 HI07-3 HI07-4 HI07-5 HI07-6 HI07-7
HEALTH CARE CODE INFORMATION Code List Qualifier Code Occurrence Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
ID AN
1-3 1-30
S R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
R R N/U N/U N/U
BH
D8 CCYYMMDD
HI07 HI07-1 HI07-2 HI07-3 HI07-4 HI07-5 HI07-6 HI07-7 HI07-8 HI07-9
HI08 HI08-1 HI08-2 HI08-3 HI08-4 HI08-5 HI08-6
HEALTH CARE CODE INFORMATION Code List Qualifier Code Occurrence Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity
ID AN
1-3 1-30
S R R
ID AN R R
2-3 1-35 1-18 1-15
R R N/U N/U
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010 HI04-9
HI05 HI05-1 HI05-2
ID
BH
D8 CCYYMMDD
HI08 HI08-1 HI08-2 HI08-3 HI08-4 HI08-5 HI08-6
Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Occurrence Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Occurrence Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Occurrence Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Occurrence Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity
Page 53 of 93
New Element ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
R R N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
R R N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
R R N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN R R
2-3 1-35 1-18 1-15
R R N/U N/U
BH
Name Change
D8 CCYYMMDD
New Element New Element
BH
Name Change
D8 CCYYMMDD
New Element New Element
BH
Name Change
D8 CCYYMMDD
New Element New Element
BH
D8 CCYYMMDD
Name Change
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
HI08-7
Version Identifier
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
1-30
HI09 HI09-1 HI09-2 HI09-3 HI09-4 HI09-5 HI09-6 HI09-7
ID AN
1-3 1-30
S R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
R R N/U N/U N/U
HI08-7 HI08-8
BH
D8 CCYYMMDD
HI09 HI09-1 HI09-2 HI09-3 HI09-4 HI09-5 HI09-6 HI09-7 HI09-8 HI09-9
HI10 HI10-1 HI10-2 HI10-3 HI10-4 HI10-5 HI10-6 HI10-7
HEALTH CARE CODE INFORMATION Code List Qualifier Code Occurrence Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
ID AN
1-3 1-30
S R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
R R N/U N/U N/U
BH
D8 CCYYMMDD
HI10 HI10-1 HI10-2 HI10-3 HI10-4 HI10-5 HI10-6 HI10-7 HI10-8 HI10-9
HI11 HI11-1 HI11-2 HI11-3 HI11-4 HI11-5 HI11-6 HI11-7
HEALTH CARE CODE INFORMATION Code List Qualifier Code Occurrence Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
ID AN
1-3 1-30
S R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
R R N/U N/U N/U
BH
D8 CCYYMMDD
HI11 HI11-1 HI11-2 HI11-3 HI11-4 HI11-5 HI11-6 HI11-7 HI11-8 HI11-9
HI12 HI12-1 HI12-2 HI12-3 HI12-4
HEALTH CARE CODE INFORMATION Code List Qualifier Code Occurrence Code Date Time Period Format Qualifier Date Time Period
Loop Repeat
Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Occurrence Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Occurrence Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Occurrence Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Occurrence Code Date Time Period Format Qualifier Date Time Period
AN AN
1-30 1-30
N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
R R N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
R R N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
R R N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
BH
ID AN
2-3 1-35
R R
D8 CCYYMMDD
Loop
Values
837-I 5010
N/U
HI08-9 HEALTH CARE CODE INFORMATION Code List Qualifier Code Occurrence Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
Usage Reg.
ID
837-I 4010A1 AN
Min. Max.
Description
ID AN
1-3 1-30
S R R
BH
HI12 HI12-1 HI12-2
ID AN
2-3 1-35
R R
D8 CCYYMMDD
HI12-3 HI12-4
Page 54 of 93
New Element New Element
BH
Name Change
D8 CCYYMMDD
New Element New Element
BH
Name Change
D8 CCYYMMDD
New Element New Element
BH
Name Change
D8 CCYYMMDD
New Element New Element
Name Change
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
HI12-5 HI12-6 HI12-7
Monetary Amount Quantity Version Identifier
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1 R R AN
1-18 1-15 1-30
HI01 HI01-1 HI01-2 HI01-3 HI01-4 HI01-5 HI01-6 HI01-7
VALUE INFORMATION HEALTH CARE CODE INFORMATION Code List Qualifier Code Value Code Date Time Period Format Qualifier Date Time Period Value Code Associated Amount Quantity Version Identifier
HI12-5 HI12-6 HI12-7 HI12-8
2
R
2300
HI
ID AN
1-3 1-30
R R R
ID AN
2-3 1-35
N/U N/U
HI01-3 HI01-4
R R AN
1-18 1-15 1-30
R N/U N/U
HI01-5 HI01-6 HI01-7 HI01-8
BE
HI01 HI01-1 HI01-2
HI02 HI02-1 HI02-2 HI02-3 HI02-4 HI02-5 HI02-6 HI02-7
ID AN
1-3 1-30
S R R
ID AN
2-3 1-35
N/U N/U
HI02-3 HI02-4
R R AN
1-18 1-15 1-30
R N/U N/U
HI02-5 HI02-6 HI02-7 HI02-8
BE
HI02 HI02-1 HI02-2
HI03 HI03-1 HI03-2 HI03-3 HI03-4 HI03-5 HI03-6 HI03-7
Loop
Loop Repeat
Values
Monetary Amount R Quantity R Version Identifier AN Industry code AN Yes/No Condition or response Code ID
1-18 1-15 1-30 1-30
N/U N/U N/U N/U
1-1
N/U
2
R
ID AN
1-3 1-30
R R R
ID AN
2-3 1-35
N/U N/U
R R AN AN
1-18 1-15 1-30 1-30
R N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN
2-3 1-35
N/U N/U
R R AN AN
1-18 1-15 1-30 1-30
R N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN
2-3 1-35
N/U N/U
Value Code Amount R Quantity R Version Identifier AN Industry code AN Yes/No Condition or response Code ID
1-18 1-15 1-30 1-30
R N/U N/U N/U
1-1
N/U
VALUE INFORMATION HEALTH CARE CODE INFORMATION Qualifier Value Code Date Time Period Format Qualifier Date Time Period
New Element New Element
2300
BE
Name Change
Value Code Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Value Code Date Time Period Format Qualifier Date Time Period
New Element New Element
BE
Name Change
Name Change
HI02-9 HEALTH CARE CODE INFORMATION Code List Qualifier Code Value Code Date Time Period Format Qualifier Date Time Period Value Code Associated Amount Quantity Version Identifier
Usage Reg.
Name Change
HI01-9 HEALTH CARE CODE INFORMATION Code List Qualifier Code Value Code Date Time Period Format Qualifier Date Time Period Value Code Associated Amount Quantity Version Identifier
Min. Max.
837-I 5010
N/U N/U N/U
HI12-9 HI
ID
ID AN
1-3 1-30
S R R
ID AN
2-3 1-35
N/U N/U
HI03-3 HI03-4
R R AN
1-18 1-15 1-30
R N/U N/U
HI03-5 HI03-6 HI03-7 HI03-8
BE
HI03 HI03-1 HI03-2
Value Code Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Value Code Date Time Period Format Qualifier Date Time Period
New Element New Element
BE
Name Change
Name Change
HI03-9
Page 55 of 93
New Element New Element
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1 HI04 HI04-1 HI04-2 HI04-3 HI04-4 HI04-5 HI04-6 HI04-7
HEALTH CARE CODE INFORMATION Code List Qualifier Code Value Code Date Time Period Format Qualifier Date Time Period Value Code Associated Amount Quantity Version Identifier
HI05 HI05-1 HI05-2 HI05-3 HI05-4 HI05-5 HI05-6 HI05-7
ID AN
1-3 1-30
S R R
ID AN
2-3 1-35
N/U N/U
HI04-3 HI04-4
R R AN
1-18 1-15 1-30
R N/U N/U
HI04-5 HI04-6 HI04-7 HI04-8
BE
HI04 HI04-1 HI04-2
HI06 HI06-1 HI06-2 HI06-3 HI06-4 HI06-5 HI06-6 HI06-7
ID AN
1-3 1-30
S R R
ID AN
2-3 1-35
N/U N/U
HI05-3 HI05-4
R R AN
1-18 1-15 1-30
R N/U N/U
HI05-5 HI05-6 HI05-7 HI05-8
BE
HI05 HI05-1 HI05-2
HI07 HI07-1 HI07-2 HI07-3 HI07-4
Loop
Loop Repeat
Values
HEALTH CARE CODE INFORMATION Qualifier Value Code Date Time Period Format Qualifier Date Time Period
ID AN
1-3 1-30
S R R
ID AN
2-3 1-35
N/U N/U
R R AN AN
1-18 1-15 1-30 1-30
R N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN
2-3 1-35
N/U N/U
R R AN AN
1-18 1-15 1-30 1-30
R N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN
2-3 1-35
N/U N/U
R R AN AN
1-18 1-15 1-30 1-30
R N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN
2-3 1-35
N/U N/U
BE
Name Change
Value Code Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Value Code Date Time Period Format Qualifier Date Time Period
New Element New Element
BE
Name Change
Name Change
ID AN
1-3 1-30
S R R
ID AN
2-3 1-35
N/U N/U
HI06-3 HI06-4
R R AN
1-18 1-15 1-30
R N/U N/U
HI06-5 HI06-6 HI06-7 HI06-8
BE
HI06 HI06-1 HI06-2
Value Code Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Value Code Date Time Period Format Qualifier Date Time Period
New Element New Element
BE
Name Change
Name Change
HI06-9 HEALTH CARE CODE INFORMATION Code List Qualifier Code Value Code Date Time Period Format Qualifier Date Time Period
Usage Reg.
Name Change
HI05-9 HEALTH CARE CODE INFORMATION Code List Qualifier Code Value Code Date Time Period Format Qualifier Date Time Period Value Code Associated Amount Quantity Version Identifier
Min. Max.
837-I 5010
HI04-9 HEALTH CARE CODE INFORMATION Code List Qualifier Code Value Code Date Time Period Format Qualifier Date Time Period Value Code Associated Amount Quantity Version Identifier
ID
ID AN
1-3 1-30
S R R
ID AN
2-3 1-35
N/U N/U
BE
HI07 HI07-1 HI07-2 HI07-3 HI07-4
Value Code Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Value Code Date Time Period Format Qualifier Date Time Period
Page 56 of 93
New Element New Element
BE
Name Change
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
HI07-5 HI07-6 HI07-7
Value Code Associated Amount Quantity Version Identifier
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1
HI08 HI08-1 HI08-2 HI08-3 HI08-4 HI08-5 HI08-6 HI08-7
HI09 HI09-1 HI09-2 HI09-3 HI09-4 HI09-5 HI09-6 HI09-7
1-18 1-15 1-30
R N/U N/U
HI07-5 HI07-6 HI07-7 HI07-8
ID AN
1-3 1-30
S R R
ID AN
2-3 1-35
N/U N/U
HI08-3 HI08-4
R R AN
1-18 1-15 1-30
R N/U N/U
HI08-5 HI08-6 HI08-7 HI08-8
BE
HI08 HI08-1 HI08-2
HI10 HI10-1 HI10-2 HI10-3 HI10-4 HI10-5 HI10-6 HI10-7
Loop
Loop Repeat
Values
Value Code Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Value Code Date Time Period Format Qualifier Date Time Period
R R AN AN
1-18 1-15 1-30 1-30
R N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN
2-3 1-35
N/U N/U
Value Code Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Value Code Date Time Period Format Qualifier Date Time Period
R R AN AN
1-18 1-15 1-30 1-30
R N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN
2-3 1-35
N/U N/U
R R AN AN
1-18 1-15 1-30 1-30
R N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN
2-3 1-35
N/U N/U
Value Code Amount R Quantity R Version Identifier AN Industry code AN Yes/No Condition or response Code ID
1-18 1-15 1-30 1-30
R N/U N/U N/U
1-1
N/U
New Element New Element
BE
Name Change
Name Change
ID AN
1-3 1-30
S R R
ID AN
2-3 1-35
N/U N/U
HI09-3 HI09-4
R R AN
1-18 1-15 1-30
R N/U N/U
HI09-5 HI09-6 HI09-7 HI09-8
BE
HI09 HI09-1 HI09-2
New Element New Element
BE
Name Change
Name Change
HI09-9 HEALTH CARE CODE INFORMATION Code List Qualifier Code Value Code Date Time Period Format Qualifier Date Time Period Value Code Associated Amount Quantity Version Identifier
Usage Reg.
Name Change R R AN
HI08-9 HEALTH CARE CODE INFORMATION Code List Qualifier Code Value Code Date Time Period Format Qualifier Date Time Period Value Code Associated Amount Quantity Version Identifier
Min. Max.
837-I 5010
HI07-9 HEALTH CARE CODE INFORMATION Code List Qualifier Code Value Code Date Time Period Format Qualifier Date Time Period Value Code Associated Amount Quantity Version Identifier
ID
ID AN
1-3 1-30
S R R
ID AN
2-3 1-35
N/U N/U
HI10-3 HI10-4
R R AN
1-18 1-15 1-30
R N/U N/U
HI10-5 HI10-6 HI10-7 HI10-8
BE
HI10 HI10-1 HI10-2
Value Code Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Value Code Date Time Period Format Qualifier Date Time Period
New Element New Element
BE
Name Change
Name Change
HI10-9
Page 57 of 93
New Element New Element
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1 HI11 HI11-1 HI11-2 HI11-3 HI11-4 HI11-5 HI11-6 HI11-7
HEALTH CARE CODE INFORMATION Code List Qualifier Code Value Code Date Time Period Format Qualifier Date Time Period Value Code Associated Amount Quantity Version Identifier
HI12 HI12-1 HI12-2 HI12-3 HI12-4 HI12-5 HI12-6 HI12-7
ID AN
1-3 1-30
S R R
ID AN
2-3 1-35
N/U N/U
HI11-3 HI11-4
R R AN
1-18 1-15 1-30
R N/U N/U
HI11-5 HI11-6 HI11-7 HI11-8
BE
HI11 HI11-1 HI11-2
HI01 HI01-1 HI01-2 HI01-3 HI01-4 HI01-5 HI01-6 HI01-7
CONDITION INFORMATION HEALTH CARE CODE INFORMATION Code List Qualifier Code Condition Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
ID AN
1-3 1-30
S R R
ID AN
2-3 1-35
N/U N/U
HI12-3 HI12-4
R R AN
1-18 1-15 1-30
R N/U N/U
HI12-5 HI12-6 HI12-7 HI12-8
BE
HI12 HI12-1 HI12-2
HI02 HI02-1 HI02-2 HI02-3
Loop
Loop Repeat
Values
HEALTH CARE CODE INFORMATION Qualifier Value Code Date Time Period Format Qualifier Date Time Period
ID AN
1-3 1-30
S R R
ID AN
2-3 1-35
N/U N/U
R R AN AN
1-18 1-15 1-30 1-30
R N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN
2-3 1-35
N/U N/U
Value Code Amount R Quantity R Version Identifier AN Industry code AN Yes/No Condition or response Code ID
1-18 1-15 1-30 1-30
R N/U N/U N/U
1-1
N/U
2
R
ID AN
1-3 1-30
R R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID
2-3
N/U
BE
Name Change
Value Code Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Value Code Date Time Period Format Qualifier Date Time Period
New Element New Element
BE
Name Change
Name Change
2
R
ID AN
1-3 1-30
R R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
2300
HI
BG
HI01 HI01-1 HI01-2 HI01-3 HI01-4 HI01-5 HI01-6 HI01-7 HI01-8 HI01-9
HEALTH CARE CODE INFORMATION Code List Qualifier Code Condition Code Date Time Period Format Qualifier
Usage Reg.
Name Change
HI12-9
HI
Min. Max.
837-I 5010
HI11-9 HEALTH CARE CODE INFORMATION Code List Qualifier Code Value Code Date Time Period Format Qualifier Date Time Period Value Code Associated Amount Quantity Version Identifier
ID
ID AN
1-3 1-30
S R R
ID
2-3
N/U
BG
HI02 HI02-1 HI02-2 HI02-3
CONDITION INFORMATION HEALTH CARE CODE INFORMATION Qualifier Condition Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Condition Code Date Time Period Format Qualifier
Page 58 of 93
New Element New Element
2300
BG
Name Change
New Element New Element
BG
Name Change
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
HI02-4 HI02-5 HI02-6 HI02-7
Date Time Period Monetary Amount Quantity Version Identifier
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
1-35 1-18 1-15 1-30
Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Condition Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Condition Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Condition Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Condition Code
AN R R AN AN
1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U
ID
1-1
N/U
HI03 HI03-1 HI03-2 HI03-3 HI03-4 HI03-5 HI03-6 HI03-7
ID AN
1-3 1-30
S R R
ID AN
1-3 1-30
S R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
HI02-4 HI02-5 HI02-6 HI02-7 HI02-8
BG
HI03 HI03-1 HI03-2 HI03-3 HI03-4 HI03-5 HI03-6 HI03-7 HI03-8 HI03-9
HI04 HI04-1 HI04-2 HI04-3 HI04-4 HI04-5 HI04-6 HI04-7
HEALTH CARE CODE INFORMATION Code List Qualifier Code Condition Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN
1-3 1-30
S R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
BG
HI04 HI04-1 HI04-2 HI04-3 HI04-4 HI04-5 HI04-6 HI04-7 HI04-8 HI04-9
HI05 HI05-1 HI05-2 HI05-3 HI05-4 HI05-5 HI05-6 HI05-7
HEALTH CARE CODE INFORMATION Code List Qualifier Code Condition Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN
1-3 1-30
S R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
BG
HI05 HI05-1 HI05-2 HI05-3 HI05-4 HI05-5 HI05-6 HI05-7 HI05-8 HI05-9
HI06 HI06-1 HI06-2
HEALTH CARE CODE INFORMATION Code List Qualifier Code Condition Code
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN
1-3 1-30
S R R
Loop
Loop Repeat
Values
837-I 5010
N/U N/U N/U N/U
HI02-9 HEALTH CARE CODE INFORMATION Code List Qualifier Code Condition Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
Usage Reg.
ID
837-I 4010A1 AN R R AN
Min. Max.
Description
BG
HI06 HI06-1 HI06-2
Page 59 of 93
New Element New Element
BG
Name Change
New Element New Element
BG
Name Change
New Element New Element
BG
Name Change
New Element New Element
BG
Name Change
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
HI06-3 HI06-4 HI06-5 HI06-6 HI06-7
Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1 ID AN R R AN
2-3 1-35 1-18 1-15 1-30
HI07 HI07-1 HI07-2
N/U N/U N/U N/U N/U
HI07-3 HI07-4 HI07-5 HI07-6 HI07-7
ID AN
1-3 1-30
S R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
HI06-3 HI06-4 HI06-5 HI06-6 HI06-7 HI06-8
BG
HI07 HI07-1 HI07-2 HI07-3 HI07-4 HI07-5 HI07-6 HI07-7 HI07-8 HI07-9
HI08 HI08-1 HI08-2 HI08-3 HI08-4 HI08-5 HI08-6 HI08-7
HEALTH CARE CODE INFORMATION Code List Qualifier Code Condition Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
ID AN
1-3 1-30
S R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
BG
HI08 HI08-1 HI08-2 HI08-3 HI08-4 HI08-5 HI08-6 HI08-7 HI08-8 HI08-9
HI09 HI09-1 HI09-2 HI09-3 HI09-4 HI09-5 HI09-6 HI09-7
HEALTH CARE CODE INFORMATION Code List Qualifier Code Condition Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
ID AN
1-3 1-30
S R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
BG
HI09 HI09-1 HI09-2 HI09-3 HI09-4 HI09-5 HI09-6 HI09-7 HI09-8 HI09-9
HI10
HEALTH CARE CODE INFORMATION
S
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010
HI06-9 HEALTH CARE CODE INFORMATION Code List Qualifier Code Condition Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
ID
HI10
Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Condition Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Condition Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Condition Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION
Page 60 of 93
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U S
New Element New Element
BG
Name Change
New Element New Element
BG
Name Change
New Element New Element
BG
Name Change
New Element New Element
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
HI10-3 HI10-4 HI10-5 HI10-6 HI10-7
Code List Qualifier Code Condition Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
ID AN
1-3 1-30
R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
Qualifier Condition Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Condition Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Condition Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code
ID AN
1-3 1-30
R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
HI11 HI11-1 HI11-2 HI11-3 HI11-4 HI11-5 HI11-6 HI11-7
ID AN
1-3 1-30
S R R
ID AN
1-3 1-30
S R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
HI10-1 HI10-2 HI10-3 HI10-4 HI10-5 HI10-6 HI10-7 HI10-8
BG
HI11 HI11-1 HI11-2 HI11-3 HI11-4 HI11-5 HI11-6 HI11-7 HI11-8 HI11-9
HI12 HI12-1 HI12-2 HI12-3 HI12-4 HI12-5 HI12-6 HI12-7
HEALTH CARE CODE INFORMATION Code List Qualifier Code Condition Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN
1-3 1-30
S R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
BG
HI12 HI12-1 HI12-2 HI12-3 HI12-4 HI12-5 HI12-6 HI12-7 HI12-8 HI12-9
HI HI01 HI01-1 HI01-2 HI01-3 HI01-4 HI01-5 HI01-6 HI01-7
TREATMENT CODE INFORMATION HEALTH CARE CODE INFORMATION Code List Qualifier Code Treatment Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
2
R
2
R
ID AN
1-3 1-30
R R R
ID AN
1-3 1-30
R R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
Loop
Loop Repeat
Values
837-I 5010 BG
HI10-9 HEALTH CARE CODE INFORMATION Code List Qualifier Code Condition Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
Usage Reg.
ID
837-I 4010A1 HI10-1 HI10-2
Min. Max.
Description
2300
HI
TC
HI01 HI01-1 HI01-2 HI01-3 HI01-4 HI01-5 HI01-6 HI01-7
TREATMENT CODE INFORMATION HEALTH CARE CODE INFORMATION Qualifier Treatment Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
Page 61 of 93
BG
Name Change
New Element New Element
BG
Name Change
New Element New Element
BG
Name Change
New Element New Element
2300
TC
Name Change
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Treatment Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Treatment Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Treatment Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Treatment Code Date Time Period Format Qualifier Date Time Period Monetary Amount
AN
1-30
N/U
ID
1-1
N/U
HI01-9
HI02-3 HI02-4 HI02-5 HI02-6 HI02-7
ID AN
1-3 1-30
S R R
ID AN
1-3 1-30
S R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
TC
HI02 HI02-1 HI02-2 HI02-3 HI02-4 HI02-5 HI02-6 HI02-7 HI02-8 HI02-9
HI03 HI03-1 HI03-2 HI03-3 HI03-4 HI03-5 HI03-6 HI03-7
HEALTH CARE CODE INFORMATION Code List Qualifier Code Treatment Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN
1-3 1-30
S R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
TC
HI03 HI03-1 HI03-2 HI03-3 HI03-4 HI03-5 HI03-6 HI03-7 HI03-8 HI03-9
HI04 HI04-1 HI04-2 HI04-3 HI04-4 HI04-5 HI04-6 HI04-7
HEALTH CARE CODE INFORMATION Code List Qualifier Code Treatment Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN
1-3 1-30
S R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
TC
HI04 HI04-1 HI04-2 HI04-3 HI04-4 HI04-5 HI04-6 HI04-7 HI04-8 HI04-9
HI05 HI05-1 HI05-2 HI05-3 HI05-4 HI05-5
HEALTH CARE CODE INFORMATION Code List Qualifier Code Treatment Code Date Time Period Format Qualifier Date Time Period Monetary Amount
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN
1-3 1-30
S R R
ID AN R
2-3 1-35 1-18
N/U N/U N/U
ID AN R
2-3 1-35 1-18
N/U N/U N/U
Loop
Loop Repeat
Values
837-I 5010 HI01-8
HI02 HI02-1 HI02-2
Usage Reg.
ID
837-I 4010A1
HEALTH CARE CODE INFORMATION Code List Qualifier Code Treatment Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
Min. Max.
Description
TC
HI05 HI05-1 HI05-2 HI05-3 HI05-4 HI05-5
Page 62 of 93
New Element New Element
TC
Name Change
New Element New Element
TC
Name Change
New Element New Element
TC
Name Change
New Element New Element
TC
Name Change
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
HI05-6 HI05-7
Quantity Version Identifier
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1 R AN
1-15 1-30
HI06 HI06-1 HI06-2 HI06-3 HI06-4 HI06-5 HI06-6 HI06-7
ID AN
1-3 1-30
S R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
HI05-6 HI05-7 HI05-8
TC
HI06 HI06-1 HI06-2 HI06-3 HI06-4 HI06-5 HI06-6 HI06-7 HI06-8 HI06-9
HI07 HI07-1 HI07-2 HI07-3 HI07-4 HI07-5 HI07-6 HI07-7
HEALTH CARE CODE INFORMATION Code List Qualifier Code Treatment Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
ID AN
1-3 1-30
S R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
TC
HI07 HI07-1 HI07-2 HI07-3 HI07-4 HI07-5 HI07-6 HI07-7 HI07-8 HI07-9
HI08 HI08-1 HI08-2 HI08-3 HI08-4 HI08-5 HI08-6 HI08-7
HEALTH CARE CODE INFORMATION Code List Qualifier Code Treatment Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
ID AN
1-3 1-30
S R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
TC
HI08 HI08-1 HI08-2 HI08-3 HI08-4 HI08-5 HI08-6 HI08-7 HI08-8 HI08-9
HI09 HI09-1 HI09-2 HI09-3
HEALTH CARE CODE INFORMATION Code List Qualifier Code Treatment Code Date Time Period Format Qualifier
ID AN
1-3 1-30
S R R
ID
2-3
N/U
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010
N/U N/U
HI05-9 HEALTH CARE CODE INFORMATION Code List Qualifier Code Treatment Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
ID
TC
HI09 HI09-1 HI09-2 HI09-3
Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Treatment Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Treatment Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Treatment Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Treatment Code Date Time Period Format Qualifier
Page 63 of 93
R AN AN
1-15 1-30 1-30
N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID
2-3
N/U
New Element New Element
TC
Name Change
New Element New Element
TC
Name Change
New Element New Element
TC
Name Change
New Element New Element
TC
Name Change
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
HI09-4 HI09-5 HI09-6 HI09-7
Date Time Period Monetary Amount Quantity Version Identifier
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
1-35 1-18 1-15 1-30
Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Treatment Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Treatment Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Treatment Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code
AN R R AN AN
1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U
ID
1-1
N/U
HI10 HI10-1 HI10-2 HI10-3 HI10-4 HI10-5 HI10-6 HI10-7
ID AN
1-3 1-30
S R R
ID AN
1-3 1-30
S R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
HI09-4 HI09-5 HI09-6 HI09-7 HI09-8
TC
HI10 HI10-1 HI10-2 HI10-3 HI10-4 HI10-5 HI10-6 HI10-7 HI10-8 HI10-9
HI11 HI11-1 HI11-2 HI11-3 HI11-4 HI11-5 HI11-6 HI11-7
HEALTH CARE CODE INFORMATION Code List Qualifier Code Treatment Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN
1-3 1-30
S R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
TC
HI11 HI11-1 HI11-2 HI11-3 HI11-4 HI11-5 HI11-6 HI11-7 HI11-8 HI11-9
HI12 HI12-1 HI12-2 HI12-3 HI12-4 HI12-5 HI12-6 HI12-7
HEALTH CARE CODE INFORMATION Code List Qualifier Code Treatment Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN
1-3 1-30
S R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
TC
HI12 HI12-1 HI12-2 HI12-3 HI12-4 HI12-5 HI12-6 HI12-7 HI12-8 HI12-9
QTY QTY01 QTY02
CLAIM QUANTITY Quantity Qualifier Claim Days Count
ID R
4 2-2 1-15
S R R
Loop
Loop Repeat
Values
837-I 5010
N/U N/U N/U N/U
HI09-9 HEALTH CARE CODE INFORMATION Code List Qualifier Code Treatment Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
Usage Reg.
ID
837-I 4010A1 AN R R AN
Min. Max.
Description
New Element New Element
TC
Name Change
New Element New Element
TC
Name Change
New Element New Element
TC
Name Change
New Element New Element
Segment Deleted
2300 CA, CD, LA, NA
Page 64 of 93
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1
QTY03-13 QTY03-14 QTY03-15 QTY04
COMPOSITE UNIT OF MEASURE Unit or Basis for Measurement Code Exponent Multiplier Unit or Basis for Measurement Code Exponent Multiplier Unit or Basis for Measurement Code Exponent Multiplier Unit or Basis for Measurement Code Exponent Multiplier Unit or Basis for Measurement Code Exponent Multiplier Free-Form Message
HCP
CLAIM PRICING/REPRICING INFORMATION
QTY03 QTY03-1 QTY03-2 QTY03-3 QTY03-4 QTY03-5 QTY03-6 QTY03-7 QTY03-8 QTY03-9 QTY03-10 QTY03-11 QTY03-12
HCP06
Pricing Methodology Repriced Allowed Amount Repriced Saving Amount Repricing Organization Identifier Repricing Per Diem or Flat Rate Amount Repriced Approved DRG Code
HCP07 HCP08
HCP01 HCP02 HCP03
Usage Reg.
Loop
Loop Repeat
Values
R ID R R
2-2 1-15 1-10
R N/U N/U
ID R R
2-2 1-15 1-10
N/U N/U N/U
ID R R
2-2 1-15 1-10
N/U N/U N/U
ID R R
2-2 1-15 1-10
N/U N/U N/U
ID R R AN
2-2 1-15 1-10 1-30
N/U N/U N/U N/U
1
S
DA
2300
HCP 00, 01, 02, 03, 04, 05, 06, 07, 08, 09, 10 ,11, 12, 13, 14
CLAIM PRICING/REPRICING INFORMATION
HCP07 HCP08
Pricing Methodology Repriced Allowed Amount Repriced Saving Amount Repricing Organization Identifier Repricing Per Diem or Flat Rate Amount Ambulatory Patient Group Code Ambulatory Patient Group Amount Product/Service ID
HCP09 HCP10
2-2 1-18 1-18
R R S
AN
1-30
S
HCP04
R
1-9
S
HCP05
AN
1-30
S
HCP06
Repriced Approved Amount Product/Service ID
R AN
1-18 1-48
S S
HCP09
Product/Service ID Qualifier
ID
2-2
S
HCP10
Product/Service ID Unit or Basis for Measurement Code Quantity
AN
1-48
S
ID R
2-2 1-15
S S
HCP05
Min. Max.
837-I 5010
ID R R
HCP04
ID
HCP01 HCP02 HCP03
1
S
ID R R
2-2 1-18 1-18
R R S
AN
1-50
S
R
1-9
S
AN
1-50
S
R AN
1-18 1-48
S S
Product/Service ID Qualifier
ID
2-2
N/U
Product/Service ID Unit or Basis for Measurement Code Quantity
AN
1-48
N/U
ID R
2-2 1-15
S S
2300 00, 01, 02, 03, 04, 05, 06, 07, 08, 09, 10 ,11, 12, 13, 14
Increase from 30 - 50
Increase from 30 - 50 Name Change Name Change
Usage change to Not Used HC
Usage change to Not Used
HCP11 HCP12
DA, UN
HCP11 HCP12
Page 65 of 93
DA, UN
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1 HCP13 HCP14 HCP15
Reject Reason Code Policy Compliance Code Exception Code
CR7
HOME HEALTH CARE PLAN INFORMATION
CR701 CR702 CR703
HSD HSD01 HSD02 HSD03 HSD04 HSD05 HSD06
Disipline Type Code Vsits Prior to Recertification Date Count Total Visits Projected This Certification Count HOME CARE SERVICES DELIVERY Visits Number of Visits Frequency Period Frequency Count Duration of Visits Units Duration of Visits, Number of Units
HSD07 HSD08
Ship, Delivery or Caledar Pattern Code Delivery Pattern Time Code
NM1 NM101 NM102
ID ID ID
2-2 1-2 1-2
S S S
1
S
ID
2-2
R
NO
1-9
R
NO
1-9
R
ID R ID R ID
12 2-2 1-15 2-2 1-6 1-2
S S S S S S
NO
1-3
S
ID
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010 T1, T2, T3, T4, T5, T6 1, 2, 3, 4, 5 1, 2, 3, 4, 5, 6
HCP13 HCP14 HCP15
Reject Reason Code Policy Compliance Code Exception Code
ID ID ID
2-2 1-2 1-2
T1, T2, T3, T4, T5, T6 1, 2, 3, 4, 5 1, 2, 3, 4, 5, 6
S S S
Segment Deleted 2305
6 AI, MS, OT, PT, SN, ST
Segment Deleted
ID ID
1-2 1-1
S S
ATTENDING PHYSICIAN NAME Entity Identifier Code Entity Type Qualifier
ID ID
1 2-3 1-1
S R R
NM103
Name Last
AN
1-35
NM104 NM105 NM106 NM107
NameFirst Name Middle Name Prefix Name Suffix
AN AN AN AN
1-25 1-25 1-10 1-10
2305
DA, MO, Q1, WK 7, 35
1, 2, 3, 4, 5, 6, 7, 8, 9, A, B, C, D, E, F, G, J, K, L, N, O, S, SA, SB, SC, SD, SG, SL, SP, SX, SY, SZ, W, D, E, F
NM1 NM101 NM102
ATTENDING PROVIDER NAME Entity Identifier Code Entity Type Qualifier
R
NM103
S S N/U S
NM104 NM105 NM106 NM107
NM108
Identification Code Qualifier
ID
1-2
R
NM109 NM110 NM111
Provider Identifier Entity Relationship Code Entity Identifier Code
AN ID ID
2-80 2-2 2-3
R N/U N/U
2310A
1 71 1, 2
24, 34, XX
Name Change ID ID
1 2-3 1-1
S R R
Last Name
AN
1-60
R
First Name Middle Name Name Prefix Name Suffix
AN AN AN AN
1-35 1-25 1-10 1-10
S S N/U S
NM108
Identification Code Qualifier
ID
1-2
S
NM109 NM110 NM111
Provider Identifier Entity Relationship Code Entity Identifier Code
AN ID ID
2-80 2-2 2-3
S N/U N/U
Page 66 of 93
2310A
1 71 1
XX
Code Deleted Name Change Increase from 35 - 60 Name Change Increase 25 - 35 Name Change
Code Deleted Usage change to Situational Usage change to Situational
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
NM112
Name Last or Organization Name
837-I 4010A1
ID
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010 New Element AN
1-60
N/U Name Change
PRV PRV01 PRV02 PRV03 PRV04 PRV05
ATTENDING PHYSICIAN SPECIALTY INFORMATION Provider Code ID Reference Identification Qualifier ID Provider Taxonomy Code AN State or Province Code ID PROVIDER SPECIALTY INFORMATION
PRV06
Provider Organization Code
REF
ATTENDING PHYSICIAN SECONDARY IDENTIFICATION
ID
1 1-3
S R
2-3 1-30 2-2
R R N/U
3-3
5
REF02 REF03 REF04
Reference Identification Qualifier Attending Physician Secondary Identifier Description REFERENCE IDENTIFIER
NM1 NM101 NM102 NM103
OPERATING PHYSICIAN NAME Entity Identifier Code Entity Type Qualifier Last or Organization Name
ID ID AN
1 2-3 1-1 1-35
NM104 NM105 NM106 NM107
Name First Middle Name Name Prefix Name Suffix
AN AN AN AN
1-25 1-25 1-10 1-10
REF01
2310A AT, SU ZZ
PRV PRV01 PRV02 PRV03 PRV04
ATTENDING PROVIDER SPECIALTY INFORMATION Provider Code ID Reference Identification Qualifier ID Provider Taxonomy Code AN State or Province Code ID PROVIDER SPECIALTY INFORMATION
N/U
PRV05
N/U
PRV06
Provider Organization Code
REF
ATTENDING PROVIDER SECONDARY IDENTIFICATION
S
ID
2-3
R
AN AN
1-30 1-80
R N/U N/U
S R R R
R S N/U S
NM108
Identification Code Qualifier
ID
1-2
R
NM109 NM110 NM111
Identifier Entity Relationship Code Entity Identifier Code
AN ID ID
2-80 2-2 2-3
R N/U N/U
2310A 0B, 1A, 1B, 1C, 1D, 1G, 1H, EI, G2, LU, N5, SY, X5
2310B
1 72 1
24, 34, XX
ID
1 1-3
S R
2-3 1-50 2-2
R R N/U
2310A AT
Code Deleted Code Change
PXC Increase from 30 - 50
N/U 3-3
N/U Name Change # Repeats change to 4
4
S
2310A Code Deleted
REF01
Reference Identification Qualifier
REF02 REF03 REF04
Secondary Identifier Description REFERENCE IDENTIFIER
NM1 NM101 NM102 NM103
NM104 NM105 NM106 NM107
ID
2-3
R
AN AN
1-50 1-80
R N/U N/U
OPERATING PHYSICIAN NAME Entity Identifier Code Entity Type Qualifier Last or Organization Name
ID ID AN
1 2-3 1-1 1-60
S R R R
First Name Middle Name Name Prefix Name Suffix
AN AN AN AN
1-35 1-25 1-10 1-10
S S N/U S
NM108
Identification Code Qualifier
ID
1-2
S
NM109 NM110 NM111
Identifier Entity Relationship Code Entity Identifier Code Name Last or Organization Name
AN ID ID
2-80 2-2 2-3
S N/U N/U
AN
1-60
N/U
NM112
Page 67 of 93
0B, 1G, G2, LU Increase from 30 - 50 Name Change
2310B
1 72 1 Increase from 35 - 60 Increase from 25 - 35 Usage change to Situational
XX
Code Deleted Usage change to Situational Usage change to Situational
New Element
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
REF
OPERATING PHYSICIAN SECONDARY IDENTIFICATION
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
REF
OPERATING PHYSICIAN SECONDARY IDENTIFICATION
837-I 4010A1
REF01 REF02 REF03 REF04
Reference Identification Qualifier Secondary Identifier Description REFERENCE IDENTIFIER
NM1 NM101 NM102 NM103
NM104 NM105 NM106 NM107
NM108 NM109 NM110 NM111
REF
REF01 REF02 REF03 REF04
5
S
ID AN AN
2-3 1-30 1-80
R R N/U N/U
OTHER PROVIDER NAME Entity Identifier Code Entity Type Qualifier Last or Organization Name
ID ID AN
1 2-3 1-1 1-35
S R R R
First Name Middle Name Name Prefix Name Suffix
AN AN AN AN
1-25 1-25 1-10 1-10
R S N/U S
Identification Code Qualifier Identifier Entity Relationship Code Entity Identifier Code
ID AN ID ID
OTHER PROVIDER SECONDARY IDENTIFICATION
Reference Identification Qualifier Rendering Provider Secondary Identifier Description REFERENCE IDENTIFIER
1-2 2-80 2-2 2-3
5
ID
2-3
R
AN AN
1-30 1-80
R N/U N/U
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010 2310B 0B, 1A, 1B, 1C, 1D, 1G, 1H, EI, G2, LU, N5, SY, X5
2310C
1 73 1, 2
24, 34, XX
R S N/U N/U
S
ID
2310C 0B, 1A, 1B, 1C, 1D, 1G, 1H, EI, G2, LU, N5, SY, X5
# Repeats change to 4 4
S
2310B Code Deleted
REF01 REF02 REF03 REF04
Qualifier Secondary Identifier Description REFERENCE IDENTIFIER
NM1 NM101 NM102 NM103
NM104 NM105 NM106 NM107
ID AN AN
2-3 1-50 1-80
R R N/U N/U
OTHER OPERATING PHYSICIAN NAME Entity Identifier Code Entity Type Qualifier Last or Organization Name
ID ID AN
1 2-3 1-1 1-60
S R R R
First Name Middle Name Name Prefix Name Suffix
AN AN AN AN
1-35 1-25 1-10 1-10
S S N/U S
NM112
Identification Code Qualifier Identifier Entity Relationship Code Entity Identifier Code Name Last or Organization Name
REF
OPERATING PHYSICIAN SECONDARY IDENTIFICATION
NM108 NM109 NM110 NM111
0B, 1G, G2, LU Increase from 30 - 50
Name Change
ID AN ID ID
1-2 2-80 2-2 2-3
S S N/U N/U
AN
1-60
N/U
2310C
1 ZZ 1
XX
Code Change Code Deleted Increase from 35 - 60 Increase from 25 - 35 Usage change to Situational
Code Deleted Usage change to Situational
New Element
Name Chnge # of Repeats change to 4 4
S
2310C Code Deleted
REF01 REF02 REF03 REF04
NM1 NM101 NM102 NM103
Reference Identification Qualifier Rendering Provider Secondary Identifier Description REFERENCE IDENTIFIER RENDERING PHYSICIAN NAME Entity Identifier Code Entity Type Qualifier Rendering Provider Last or Organization Name
Page 68 of 93
ID
2-3
R
AN AN
1-50 1-80
R N/U N/U
ID ID
1 2-3 1-1
S R R
AN
1-60
R
0B, 1G, G2, LU Increase from 30 - 50
New Segment 2310D
1 82 1
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1
NM107 NM108
Identification Code Qualifier
ID
1-2
S
NM109 NM110 NM111
Rendering Provider Identifier Entity Relationship Code Entity Identifier Code Name Last or Organization Name
AN ID ID
2-80 2-2 2-3
S N/U N/U
AN
1-60
N/U
NM112
NM103 NM104 NM105 NM106 NM107
Laboratory or Facility Name Name First Name Middle Name Prefix Name Suffix
ID ID AN AN AN AN AN
1-35 1-25 1-25 1-10 1-10
R N/U N/U N/U N/U
Identification Code Qualifier ID Laboratory or Facility Primary Identifier AN Entity Relationship Code ID Entity Identifier Code ID
1-2
S
2-80 2-2 2-3
S N/U N/U
2310E
1 FA 2
1-35
S
AN AN
1-25 1-10
S N/U
AN
1-10
S
Loop
Loop Repeat
Values
XX
New Segment
REF02 REF03 REF04
NM1 NM101 NM102
SERVICE FACILITY LOCATION Entity Identifier Code Entity Type Qualifier
ID ID
1 2-3 1-1
NM103 NM104 NM105 NM106 NM107
Laboratory or Facility Name Name First Name Middle Name Prefix Name Suffix
AN AN AN AN AN
1-60 1-35 1-25 1-10 1-10
R N/U N/U N/U N/U
Identification Code Qualifier ID Laboratory or Facility Primary Identifier AN Entity Relationship Code ID Entity Identifier Code ID Name Last or Organization Name AN
1-2
S
2-80 2-2 2-3
S N/U N/U
1-60
N/U
1
R
1-55
R
REF01
S R R
AN
RENDERING PHYSICIAN SECONDARY IDENTIFICATION Reference Identification Qualifier Rendering Provider Secondary Identifier Description REFERENCE IDENTIFIER
REF
1 2-3 1-1
Usage Reg.
837-I 5010
NM105 NM106
SERVICE FACILITY NAME Entity Identifier Code Entity Type Qualifier
Min. Max.
Rendering Provider First Name Rendering Provider Middle Name Name Prefix Rendering Provider Name Suffix
NM104
NM1 NM101 NM102
ID
4
S
ID
2-3
R
AN AN
1-50 1-80
R N/U N/U
S R R
2310D 0B, 1G, G2, LU
Name Change 2310E
1 77 2
Code Change Increase from 35 - 60 Increase from 25 - 35
Code Deleted NM108 NM109 NM110 NM111
24, 34, XX
NM108 NM109 NM110 NM111 NM112
N3 N301
SERVICE FACILITY ADDRESS Laboratory or Facility Address Line AN
1
R
1-55
R
2310E
N3 N301
SERVICE FACILITY LOCATION ADDRESS Laboratory or Facility Address Line AN
Page 69 of 93
XX
New Element
Name Change 2310E
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1 N302
N4 N401 N402 N403 N404 N405 N406
REF
REF01 REF02 REF03 REF04
Laboratory or Facility Address Line AN SERVICE FACILITY CITY/STATE/ZIP CODE Laboratory or Facility City Name AN Laboratory or Facility State or Province Code ID Laboratory or Facility Postal Zone or ZIP Code ID Laboratory/Facility Country Code ID Location Qualifier ID Location Identifier AN
SERVICE FACILITY SECONDARY IDENTIFICATION
Reference Identification Qualifier Laboratory or Facility Secondary Identifier Description REFERENCE IDENTIFIER
S
1
R
2-30
R
N401
2-2
R
N402
3-15
R
N403
2-3 1-2 1-30
S N/U N/U
N404 N405 N406 N407
S
ID
2-3
R
AN AN
1-30 1-80
R N/U N/U
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010
1-55
5
ID
N302
2310E
N4
2310E
REF 0B, 1A, 1B, 1C, 1D, 1G, 1H, EI, G2, LU, N5, SY, X5
Laboratory or Facility Address Line AN SERVICE FACILITY LOCATION CITY/STATE/ZIP Laboratory or Facility City Name AN Laboratory or Facility State or Province Code ID Laboratory or Facility Postal Zone ZIP Code ID Laboratory/Facility Country Code ID Location Qualifier ID Location Identifier AN Country Subdivision Code ID
1-55
S
1
R
2-30
R
2-2
S
3-15
S
2-3 1-2 1-30 1-3
S N/U N/U S
3
S
Name Change 2310E
Usage change to Situational Usage change to Situational
New Element Name Change # of Repeats change to 3
SERVICE FACILITY LOCATION SECONDARY IDENTIFICATION
2310E Code Deleted
REF02 REF03 REF04
Reference Identification Qualifier Laboratory or Facility Secondary Identifier Description REFERENCE IDENTIFIER
NM1 NM101 NM102
REFERRING PROVIDER NAME Entity Identifier Code Entity Type Qualifier
REF01
ID
2-3
R
AN AN
1-50 1-80
R N/U N/U
ID ID
1 2-3 1-1
S R R
NM103
Referring Provider Last Name AN
1-60
R
NM104
AN
1-35
S
AN AN
1-25 1-10
S N/U
NM107
Referring Provider First Name Referring Provider Middle Name Name Prefix Referring Provider Name Suffix
AN
1-10
S
NM108
Identification Code Qualifier
ID
1-2
S
NM109 NM110 NM111
Referring Provider Identifier Entity Relationship Code Entity Identifier Code Name Last or Organization Name
AN ID ID
2-80 2-2 2-3
S N/U N/U
AN
1-60
N/U
NM105 NM106
NM112
Page 70 of 93
0B, G2, LU Increase from 30 - 50
New Segment 2310F
1 DN 1
XX
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1
REF01 REF02 REF03 REF04
SBR01
SBR02 SBR03 SBR04 SBR05 SBR06 SBR07 SBR08
SBR09
CAS CAS01 CAS02 CAS03 CAS04 CAS05 CAS06 CAS07 CAS08 CAS09
OTHER SUBSCRIBER INFORMATION Payer Responsibility Sequence Number Code
Individual Relationship Code Insured Group or Policy Number Other Insured Group Name Insurance Type Code
ID
1
S
2320
10
SBR
1-1
R
P, S, T
SBR01
01, 04, 05, 07, 10, 15, 17, 18, 19, 20, 21, 22, 23, 24, 29, 32, 33, 36, 39, 40, 41, 43, 53, G8
SBR02
ID
2-2
R
AN AN ID
1-30 1-60 1-3
S S N/U
SBR03 SBR04 SBR05
Coordination of Benefits Code ID Yes/No Condition or Response Code ID Employment Status Code ID
1-1
N/U
SBR06
1-1 2-2
N/U N/U
SBR07 SBR08
Claim Filing Indicator Code CLAIM LEVEL ADJUSTMENTS Claim Adjustment Group Code Adjustment Reason Code Adjustment Amount Adjustment Quantity Adjustment Reason Code Adjustment Amount Adjustment Quantity Adjustment Reason Code Adjustment Amount
ID
ID ID R R ID R R ID R
1-2
S
5
S
1-2 1-5 1-18 1-15 1-5 1-18 1-15 1-5 1-18
R R R S S S S S S
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010
REF
SBR
ID
09, 10, 11, 12, 13, 14, 15, 16, AM, BL, CH, CI, DS, HM, LI, LM, MA, MB, MC, OF, TV, VA, WC, ZZ
2320
SBR09
CAS CO, CR, OA, PI, PR
CAS01 CAS02 CAS03 CAS04 CAS05 CAS06 CAS07 CAS08 CAS09
REFERRING PROVIDER SECONDARY IDENTIFICATION Reference Identification Qualifier ID Referring Provider Secondary Identifier AN Description AN REFERENCE IDENTIFIER
New Segment 3
S
2-3
R
1-50 1-80
R N/U N/U
1
S
ID
1-1
R
ID
2-2
R
AN AN ID
1-50 1-60 1-3
S S N/U
Coordination of Benefits Code ID Yes/No Condition or Response Code ID Employment Status Code ID
1-1
N/U
1-1 2-2
N/U N/U
OTHER SUBSCRIBER INFORMATION Payer Responsibility Sequence Number Code
Individual Relationship Code Insured Group or Policy Number Other Insured Group Name Insurance Type Code
Claim Filing Indicator Code CLAIM LEVEL ADJUSTMENTS Claim Adjustment Group Code Adjustment Reason Code Adjustment Amount Adjustment Quantity Adjustment Reason Code Adjustment Amount Adjustment Quantity Adjustment Reason Code Adjustment Amount
Page 71 of 93
2310F 0B, 1G, G2
2320
10 A, B, C, D, E, F, Code Added G, H, P, S, T, U Code Deleted
01, 18, 19, 20, 21, 39, 40, 53, G8 Increase from 30 - 50
ID
ID ID R R ID R R ID R
1-2
S
5
S
1-2 1-5 1-18 1-15 1-5 1-18 1-15 1-5 1-18
R R R S S S S S S
11, 12, 13, 14, 15, 16, 17, AM, BL, CH, CI, DS, FI, HM, LM, MA, MB, MC, OF, TV, VA, WC, ZZ
2320 CO, CR, OA, PI, PR
Code Change
INSTITUTIONAL CLAIM
4010A1 Description
CAS10 CAS11 CAS12 CAS13 CAS14 CAS15 CAS16 CAS17 CAS18 CAS19
Adjustment Quantity Adjustment Reason Code Adjustment Amount Adjustment Quantity Adjustment Reason Code Adjustment Amount Adjustment Quantity Adjustment Reason Code Adjustment Amount Adjustment Quantity
AMT AMT01 AMT02 AMT03
PAYER PRIOR PAYMENT Amount Qualifier Code Other Payer Patient Paid Amount Credit/Debit Flag Code
AMT AMT01 AMT02 AMT03
COORDINATION OF BENEFITS (COB) TOTAL ALLOWED AMOUNT Amount Qualifier Code Allowed Amount Credit/Debit Flag Code
AMT AMT01
COORDINATION OF BENEFITS (COB) TOTAL SUBMITED CHARGES Amount Qualifier Code
ID
1 1-3
S R
AMT02 AMT03
Coordination of Benefits Total Submitted Charge Amount Credit/Debit Flag Code
R ID
1-18 1-1
R N/U
AMT AMT01 AMT02 AMT03
DIAGNOSTIC RELATED GROUP (DRG) OUTLIER AMOUNT Amount Qualifier Code Claim DRG Outlier Amount Credit/Debit Flag Code
AMT AMT01 AMT02 AMT03
COORDINATION OF BENEFITS (COB) TOTAL MEDICARE PAID AMOUNT Amount Qualifier Code Total Medicare Paid Amout Credit/Debit Flag Code
AMT
MEDICARE PAID AMOUNT 100%
ID
Min. Max.
Usage Reg.
Element Identifier
5010 Loop
Loop Repeat
Values
Element Identifier
Description
CAS10 CAS11 CAS12 CAS13 CAS14 CAS15 CAS16 CAS17 CAS18 CAS19
Adjustment Quantity Adjustment Reason Code Adjustment Amount Adjustment Quantity Adjustment Reason Code Adjustment Amount Adjustment Quantity Adjustment Reason Code Adjustment Amount Adjustment Quantity
AMT AMT01 AMT02 AMT03
837-I 4010A1 R ID R R ID R R ID R R
1-15 1-5 1-18 1-15 1-5 1-18 1-15 1-5 1-18 1-15
S S S S S S S S S S
ID
1 1-3
S R
R ID
1-18 1-1
R N/U
ID
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010 R ID R R ID R R ID R R
1-15 1-5 1-18 1-15 1-5 1-18 1-15 1-5 1-18 1-15
S S S S S S S S S S
COB PAYER PAID AMOUNT Amount Qualifier Code
ID
1 1-3
S R
Payer Paid Amount Credit/Debit Flag Code
R ID
1-18 1-1
R N/U
Name Change 2320 C4
2320 D
Code Change Name Change
Segment Deleted
ID R ID
1 1-3 1-18 1-1
S R R N/U
2320 B6
Segment Deleted 2320 T3
Segment Deleted
ID R ID
1 1-3 1-18 1-1
S R R N/U
2320 ZZ
Segment Deleted
ID R ID
1 1-3 1-18 1-1
S R R N/U
2320
1
S
2320
N1
Segment Deleted
Page 72 of 93
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1 AMT01 AMT02 AMT03
AMT AMT01 AMT02 AMT03
AMT AMT01 AMT02 AMT03
Amount Qualifier Code Medicare Paid at 100% Amount Credit/Debit Flag Code MEDICARE PAID AMOUNT 80% Amount Qualifier Code Medicare Paid at 80% Amount Credit/Debit Flag Code COORDINATION OF BENEFITS (COB) MEDICARE A TRUST FUND PAID AMOUNT Amount Qualifier Code Paid From Part A Medicare Trust Fund Amount Credit/Debit Flag Code
ID
1-3
R
R ID
1-18 1-1
R N/U
ID
1 1-3
S R
R ID
1-18 1-1
R N/U
ID
1 1-3
S R
R ID
1-18 1-1
R N/U
AMT AMT01
ID
1 1-3
S R
AMT02 AMT03
Non-Covered Charge Amount Credit/Debit Flag Code
R ID
1-18 1-1
R N/U
AMT02 AMT03
Loop
Loop Repeat
Values
837-I 5010 KF
2320 PG
2320 AA
Segment Deleted
COORDINATION OF BENEFITS (COB) TOTAL NON-COVERED AMOUNT Amount Qualifier Code
AMT AMT01
Usage Reg.
Segment Deleted
AMT02 AMT03
COORDINATION OF BENEFITS (COB) TOTAL DENIED AMOUNT Amount Qualifier Code Claim Total Denied Charge Amount Credit/Debit Flag Code
Min. Max.
Segment Deleted
COORDINATION OF BENEFITS (COB) MEDICARE B TRUST FUND PAID AMOUNT Amount Qualifier Code Paid From Part B Medicare Trust Fund Amount Credit/Debit Flag Code
AMT AMT01
ID
ID
1 1-3
S R
R ID
1-18 1-1
R N/U
2320 B1
Segment Deleted 2320 A8
Segment Deleted
ID
1 1-3
S R
R ID
1-18 1-1
R N/U
2320 YT
AMT AMT01
REMAINING PATIENT LIABILITY Amount Qualifier Code
Page 73 of 93
New Segment ID
1 1-3
S R
2320 EAF
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
AMT02 AMT03
Remaining Patient Liability Amount Credit/Debit Flag Code
AMT AMT01 AMT02 AMT03
COB TOTAL NONCOVERED AMOUNT Amount Qualifier Code Non-Covered Amount Credit/Debit Flag Code
837-I 4010A1
DMG DMG01 DMG02 DMG03 DMG04 DMG05 DMG06 DMG07 DMG08 DMG09
OTHER SUBSCRIBER DEMOGRAPHIC INFORMATION Date Time Period Format Qualifier Other Insured Birth Date Gender Code Marital Status Code Race or Ethnicity Code Citizenship Status Code Country Code Basis of Veification Code Quantity
1
S
ID AN ID ID ID ID ID ID R
2-3 1-35 1-1 1-1 1-1 1-2 2-3 1-2 1-15
R R R N/U N/U N/U N/U N/U N/U
ID
1 1-2
R N/U
ID
2-2
N/U
ID
1-1
R
OI04 OI05
ID ID
1-1 1-1
N/U N/U
OI06
Release of Information Code
ID
1-1
R
MIA
MEDICARE INPATIENT ADJUDICATION INFORMATION
1
S
MIA01
Covered Days or Visits Count
R
1-15
MIA02 MIA03
Lifetime Reserve Days Count Lifetime Psychiatric Days
R R
MIA04
Claim DRG Amount
R
OI02 OI03
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010 R ID
1-18 1-1
R N/U
ID R ID
1 1-3 1-18 1-1
S R R N/U
New Segment 2320 A8
Segment Deleted
OTHER INSURANCE COVERAGE INFORMATION Claim Filing Indicator Code Claim Submission Reason Code Benefits Assignment Certification Indicator Patient Signature Source Code Provider Agreement Code
OI OI01
ID
2320 D8 F, M, U
OI04 OI05
OTHER INSURANCE COVERAGE INFORMATION Claim Filing Indicator Code Claim Submission Reason Code Benefits Assignment Certification Indicator Patient Signature Source Code Provider Agreement Code
OI06
Release of Information Code
MIA
INPATIENT ADJUDICATION INFORMATION
R
MIA01
Covered Days or Visits Count
1-15 1-15
S S
MIA02 MIA03
1-18
S
MIA04
Amount Lifetime Psychiatric Days Remaining Patient Liability Amount
2320
OI OI01 OI02 N, Y
OI03
ID
1 1-2
R N/U
ID
2-2
N/U
ID
1-1
R
ID ID
1-1 1-1
N/U N/U
ID
1-1
R
1
S
R
1-15
S
R R
1-18 1-15
N/U S
R
1-18
S
2320
Code Added N, W, Y
Code Deleted A, I, M, N, O, Y
2320
Page 74 of 93
I, Y
2320 Usage change to Situational Usage change to Not Used Increase from 15 - 18 Name Change
Name Change
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1 MIA05 MIA06 MIA07 MIA08 MIA09 MIA10 MIA11 MIA12 MIA13 MIA14 MIA15 MIA16 MIA17 MIA18 MIA19
Remark Code AN Claim Disproportionate Share Amount R Claim MSP Pass-through Amount R Claim PPS Capital Amount R PPS-Capital FSP DRG Amount R PPS-Capital HSP DRG Amount R PPS-Capital DSH DRG Amount R Old Capital Amount R PPS-Capital IME Amount R PPS-Operating Hospital Specific DRG Amount R Cost Report Day Count R PPS-Operating Federal Specific DRG Amount R Claim PPS Capital Outlier Amount R Claim Indirect Teaching Amount R Non-Payable Professional Component Amount R
ID
Min. Max.
Usage Reg.
MIA19
Claim Payment Remark Code AN Claim Disproportionate Share Amount R Claim MSP Pass-through Amount R Claim PPS Capital Amount R PPS-Capital FSP DRG Amount R PPS-Capital HSP DRG Amount R PPS-Capital DSH DRG Amount R Old Capital Amount R PPS-Capital IME Amount R PPS-Operating Hospital Specific DRG Amount R Cost Report Day Count R PPS-Operating Federal Specific DRG Amount R Claim PPS Capital Outlier Amount R Claim Indirect Teaching Amount R Non-Payable Professional Component Billed Amount R
1-30
S
MIA05
1-18
S
MIA06
1-18 1-18
S S
MIA07 MIA08
1-18
S
MIA09
1-18
S
MIA10
1-18 1-18 1-18
S S S
MIA11 MIA12 MIA13
1-18 1-15
S S
MIA14 MIA15
1-18
S
MIA16
1-18
S
MIA17
1-18
S
MIA18
1-18
S
1-50
S
1-18
S
1-18 1-18
S S
1-18
S
1-18
S
1-18 1-18 1-18
S S S
1-18 1-15
S S
1-18
S
1-18
S
1-18
S
1-18
S
AN
1-30
S
MIA20
Claim Payment Remark Code AN
1-50
S
MIA21
Remark Code
AN
1-30
S
MIA21
Claim Payment Remark Code AN
1-50
S
MIA22
Remark Code
AN
1-30
S
MIA22
Claim Payment Remark Code AN
1-50
S
MIA23
Remark Code PPS-Capital Exception Amount
AN
1-30
S
MIA23
1-50
S
R
1-18
S
MIA24
Claim Payment Remark Code AN PPS-Capital Exception Amount R
1-18
S
MOA MOA01 MOA02 MOA03 MOA04 MOA05 MOA06 MOA07
R
1 1-10
S S
R AN AN AN AN AN
1-18 1-30 1-30 1-30 1-30 1-30
S S S S S S
Values
2320
Increase from 30 - 50 Name Change
Name Change
Remark Code
MEDICARE OUTPATIENT ADJUDICATION INFORMATION Reimbursement Rate Claim HCPCS Payable Amount Remark Code Remark Code Remark Code Remark Code Remark Code
Loop Repeat
837-I 5010
MIA20
MIA24
Loop
MOA MOA01
MEDICARE OUTPATIENT ADJUDICATION INFORMATION Reimbursement Rate
R
1 1-10
S S
MOA02 MOA03 MOA04 MOA05 MOA06 MOA07
HCPCS Payable Amount Remark Code Remark Code Remark Code Remark Code Remark Code
R AN AN AN AN AN
1-18 1-50 1-50 1-50 1-50 1-50
S S S S S S
Increase from 30 - 50 Name Change Increase from 30 - 50 Name Change Increase from 30 - 50 Name Change Increase from 30 - 50 Name Change
2320 Name Change
Page 75 of 93
Increase from 30 - 50 Increase from 30 - 50 Increase from 30 - 50 Increase from 30 - 50 Increase from 30 - 50
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1
MOA09
Claim ESRD Payment Amount Non-Payable Professional Component Amount
NM1 NM101 NM102 NM103 NM104 NM105 NM106 NM107 NM108 NM109 NM110 NM111
OTHER SUBSCRIBER NAME Entity Identifier Code Entity Type Qualifier Other Insured Last Name Other Insured First Name Other Insured Middle Name Name Prefix Other Insured Name Suffix Identification Code Qualifier Other Insured Identifier Entity Relationship Code Entity Identifier Code
MOA08
N3
OTHER SUBSCRIBER ADDRESS
N301
Other Insured Address Line
N302
Other Insured Address Line
N4 N401
OTHER SUBSCRIBER CITY/STATE/ZIP CODE Other Insured City Name
N402 N403 N404 N405 N406
REF REF01 REF02 REF03 REF04
Min. Max.
Usage Reg.
1-18
S
MOA08
R
1-18
S
MOA09
ID ID AN AN AN AN AN ID AN ID ID
1 2-3 1-1 1-35 1-25 1-25 1-10 1-10 1-2 2-80 2-2 2-3
R R R R S S N/U S R R N/U N/U
2330A
1 IL 1, 2
MI, ZZ
NM112
OTHER SUBSCRIBER NAME Entity Identifier Code Entity Type Qualifier Other Insured Last Name Other Insured First Name Other Insured Middle Name Name Prefix Other Insured Name Suffix Identification Code Qualifier Other Insured Identifier Entity Relationship Code Entity Identifier Code Name Last or Organization Name
N3
OTHER SUBSCRIBER ADDRESS
NM1 NM101 NM102 NM103 NM104 NM105 NM106 NM107 NM108 NM109 NM110 NM111
1-18
S
R
1-18
S
ID ID AN AN AN AN AN ID AN ID ID
1 2-3 1-1 1-60 1-35 1-25 1-10 1-10 1-2 2-80 2-2 2-3
R R R R S S N/U S R R N/U N/U
AN
1-60
N/U
1
S
R
N301
Other Insured Address Line
AN
1-55
R
AN
1-55
S
N302
Other Insured Address Line
AN
1-55
S
AN
1 2-30
S R
N4 N401
OTHER SUBSCRIBER CITY/STATE/ZIP CODE Other Insured City Name
AN
1 2-30
R R
2-2
R
N402
2-2
S
3-15 2-3 1-2 1-30
R S N/U N/U
N403 N404 N405 N406 N407
3-15 2-3 1-2 1-30 1-3
S S N/U N/U S
R
AN AN
1-30 1-80
R N/U N/U
2330A
2330A
REF 1W, 23, !G, SY
REF01 REF02 REF03 REF04
Other Insured State Code ID Other Insured Postal Zone or ZIP Code ID Subscriber Country Code ID Location Qualifier ID Location Identifier AN Country Subdivision Code ID OTHER SUBSCRIBER SECONDARY IDENTIFICATION Reference Identification Qualifier Other Insured Additional Identifier Description REFERENCE IDENTIFIER
Page 76 of 93
2330A
1 IL 1, 2 Increase from 35 - 60 Increase from 25 - 35
II, MI
Code Change
New Element
1-55
2-3
Values
Name Change
AN
ID
Loop Repeat
Name Change R
S
S
2330A
End Stage Renal Disease Payment Amount Non-Payable Professional Component Billed Amount
1
3
Loop
837-I 5010
R
Other Insured State Code ID Other Insured Postal Zone or ZIP Code ID Subscriber Country Code ID Location Qualifier ID Location Identifier AN
OTHER SUBSCRIBER SECONDARY IDENTIFICATION Reference Identification Qualifier Other Insured Additional Identifier Description REFERENCE IDENTIFIER
ID
2330A
2330A Usage change to Situational Usage change to Situational
New Element # of Repeat change to 2
2
S
ID
2-3
R
AN AN
1-50 1-80
R N/U N/U
2330A Code Deleted SY Increase from 30 - 50
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
2330B
1
Values
Element Identifier
PR 2
NM1 NM101 NM102
PI, XV
NM103 NM104 NM105 NM106 NM107 NM108
Description
837-I 4010A1 NM1 NM101 NM102 NM103 NM104 NM105 NM106 NM107 NM108 NM109 NM110 NM111
OTHER PAYER NAME Entity Identifier Code Entity Type Qualifier Other Payer Last or Organization Name Name First Name Middle Name Prefix Name Suffix Identification Code Qualifier
ID ID
1 2-3 1-1
R R R
AN AN AN AN AN ID
1-35 1-25 1-25 1-10 1-10 1-2
R N/U N/U N/U N/U R
Other Payer Primary Identifier AN Entity Relationship Code ID Entity Identifier Code ID
2-80 2-2 2-3
R N/U N/U
OTHER PAYER ADDRESS Other Payer Address Line Other Payer Address Line
N4 N401
OTHER PAYER CITY/STATE/ZIP CODE Other Payer City Name
N402 N403 N404 N405 N406
DTP DTP01 DTP02 DTP03
REF REF01 REF02 REF03
Other Payer State Code Other Payer Postal Zone or ZIP Code Payer Country Code Location Qualifier Location Identifier
CLAIM ADJUDICATION DATE Date Time Qualifier Date Time Period Format Qualifier
NM109 NM110 NM111
2330B
AN ID
2-2
R
N402
ID ID ID AN
3-15 2-3 1-2 1-30
R S N/U N/U
N403 N404 N405 N406 N407
2-3
Adjudication or Payment Date AN
1-35
OTHER PAYER SECONDARY IDENTIFICATION AND REFERENCE NUMBER Reference Identification Qualifier Other Payer Secondary Identifier Description
Loop Repeat
2330B
1
Values
2330B
R R R
AN AN AN AN AN ID
1-60 1-35 1-25 1-10 1-10 1-2
R N/U N/U N/U N/U R
Other Payer Primary Identifier AN Entity Relationship Code ID Entity Identifier Code ID Name Last or Organization Name AN
2-80 2-2 2-3
R N/U N/U
1-60
N/U
1 1-55 1-55
S R S
2330B
AN AN
R R
2330B
AN
1 2-30
ID
2-2
S
ID ID ID AN ID
3-15 2-3 1-2 1-30 1-3
S S N/U N/U S
ID
1 3-3
S R
ID
2-3
R
D8
Adjudication or Payment Date AN
1-35
R
CCYYMMDD
OTHER PAYER CITY/STATE/ZIP CODE Other Payer City Name
S R
ID
Loop
1 2-3 1-1
N4 N401
1 2-30
ID
Usage Reg.
ID ID
OTHER PAYER ADDRESS Other Payer Address Line Other Payer Address Line
S R S
S R
OTHER PAYER NAME Entity Identifier Code Entity Type Qualifier Other Payer Last or Organization Name Name First Name Middle Name Prefix Name Suffix Identification Code Qualifier
N3 N301 N302
1 1-55 1-55
2330B
AN AN
1 3-3
Min. Max.
837-I 5010
NM112 N3 N301 N302
ID
573
DTP DTP01
R
D8
DTP02
R
CCYYMMDD
DTP03
Other Payer State Code Other Payer Postal Zone or ZIP Code Other Payer Country Code Location Qualifier Location Identifier Country Subdivision Code DATE - CLAIM CHECK OR REMITTANCE DATE Date Time Qualifier Date Time Period Format Qualifier
PR 2 Increase from 35 - 60 Increase from 25 - 35
PI, XV
New Element
Usage change to Required
Usage change to Situational Usage change to Situational Name Change
New Element Name Change 2330B 573
Name Change
2
S
ID
2-3
R
AN AN
1-30 1-80
R N/U
2330B
REF 2U, F8, FY, NF, TJ
REF01 REF02 REF03
OTHER PAYER SECONDARY IDENTIFICATION Reference Identification Qualifier Other Payer Secondary Identifier Description
Page 77 of 93
2
S
ID
2-3
R
AN AN
1-50 1-80
R N/U
2330B Code Change 2U, EI, FY, NF Increase from 30 - 50
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
REF04
REFERENCE IDENTIFIER
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
REF04
REFERENCE IDENTIFIER
837-I 4010A1
REF REF01 REF02 REF03 REF04
OTHER PAYER PRIOR AUTHORIZATION OR REFERRAL NUMBER Reference Identification Qualifier Authorization or Referral Number Description REFERENCE IDENTIFIER
S
ID
2-3
R
AN AN
1-30 1-80
R N/U N/U
2330B
REF 9F, G1
REF01 REF02 REF03 REF04
OTHER PAYER PRIOR AUTHORIZATION NUMBER Reference Identification Qualifier Other Payer Prior Authorization Number Description REFERENCE IDENTIFIER
1
S
ID
2-3
R
Loop Repeat
Values
AN AN
1-50 1-80
R N/U N/U
1
S
New Segment
R
REF02 REF03 REF04
Other Payer Referral Number AN Description AN REFERENCE IDENTIFIER
1-50 1-80
R N/U N/U
1
S
ID
2-3
R
AN AN
1-50 1-80
R N/U N/U
1
S
ID
2-3
R
AN AN
1-50 1-80
R N/U N/U
REF02 REF03 REF04
REF REF01 REF02 REF03 REF04
OTHER PAYER CLAIM CONTROL NUMBER Reference Identification Qualifier Other Payer Claim Control Number Description REFERENCE IDENTIFIER
G1 Increase from 30 - 50
2-3
OTHER PAYER CLAIM ADJUSTMENT INDICATOR Reference Identification Qualifier Other Payer Claim Adjustment Indicator Description REFERENCE IDENTIFIER
2330B Code Change
ID
REF01
NM103 NM104 NM105 NM106 NM107
Loop
N/U
REF01
REF
OTHER PAYER PATIENT INFORMATION Entity Identifier Code Entity Type Qualifier Name Last or Organization Name Name First Name Middle Name Prefix Name Suffix
Usage Reg.
OTHER PAYER REFERRAL NUMBER Reference Identification Qualifier
REF
NM1 NM101 NM102
Min. Max.
837-I 5010
N/U
1
ID
2330B 9F
New Segment 2330B T4
New Segment 2330B F8
Segment Deleted ID ID
1 2-3 1-1
S R R
AN AN AN AN AN
1-35 1-25 1-25 1-10 1-10
N/U N/U N/U N/U N/U
2330C
1 QC 1
Page 78 of 93
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1 NM108 NM109 NM110 NM111
REF REF01 REF02 REF03 REF04
Identification Code Qualifier Other Payer Patient Primary Identifier Entity Relationship Code Entity Identifier Code OTHER PAYER PATIENT IDENTIFICATION NUMBER Reference Identification Qualifier Other Payer Patient Secondary Identifier Description REFERENCE IDENTIFIER
ID
1-2
R
AN ID ID
2-80 2-2 2-3
R N/U N/U
3
S
ID
2-3
R
AN AN
1-30 1-80
R N/U N/U
S R R
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010 EI, MI
Segment Deleted 2330C 1W, IG, SY
ID ID
1 2-3 1-1
NM103 NM104 NM105 NM106 NM107 NM108
OTHER PAYER ATTENDING PROVIDER Entity Identifier Code Entity Type Qualifier Name Last or Organization Name Name First Name Middle Name Prefix Name Suffix Identification Code Qualifier
AN AN AN AN AN ID
1-35 1-25 1-25 1-10 1-10 1-2
N/U N/U N/U N/U N/U N/U
NM103 NM104 NM105 NM106 NM107 NM108
NM109 NM110 NM111
Identification Code Entity Relationship Code Entity Identifier Code
AN ID ID
2-80 2-2 2-3
N/U N/U N/U
NM109 NM110 NM111
NM1 NM101 NM102
ID
2330D
1 71 1, 2
NM1 NM101 NM102
OTHER PAYER ATTENDING PROVIDER Entity Identifier Code Entity Type Qualifier Name Last or Organization Name Name First Name Middle Name Prefix Name Suffix Identification Code Qualifier
Loop Change ID ID
1 2-3 1-1
S R R
AN AN AN AN AN ID
1-60 1-35 1-25 1-10 1-10 1-2
N/U N/U N/U N/U N/U N/U
Other Payer Primary Identifier AN Entity Relationship Code ID Entity Identifier Code ID Name Last or Organization Name AN
2-80 2-2 2-3
N/U N/U N/U
1-60
N/U
2330C
1 71 1
Code Deleted Increase from 35 - 60 Increase from 25 - 35
Name Change
NM112
REF
REF01 REF02 REF03 REF04
NM1 NM101 NM102 NM103
OTHER PAYER ATTENDING PROVIDER SECONDARY IDENTIFICATION Reference Identification Qualifier Secondary Identifier Description REFERENCE IDENTIFIER OTHER PAYER OPERATING PROVIDER Entity Identifier Code Entity Type Qualifier Name Last or Organization Name
3
R
ID AN AN
2-3 1-30 1-80
R R N/U N/U
ID ID
1 2-3 1-1
S R R
AN
1-35
N/U
2330D 1A, 1B, 1C, 1D, 1G, 1H, EI, G2, LU, N5
2330E
1 72 1
REF
OTHER PAYER ATTENDING PROVIDER SECONDARY IDENTIFICATION
REF01 REF02 REF03 REF04
Reference Identification Qualifier Secondary Identifier Description REFERENCE IDENTIFIER
New Element
Loop Change # Repeats change to 4 4
R
2330C Code Change
NM1 NM101 NM102 NM103
OTHER PAYER OPERATING PROVIDER Entity Identifier Code Entity Type Qualifier Name Last or Organization Name
Page 79 of 93
ID AN AN
2-3 1-50 1-80
R R N/U N/U
ID ID
1 2-3 1-1
S R R
AN
1-60
N/U
0B, 1G, G2, LU Increase from 30 - 50
Loop Change 2330D
1 72 1 Increase from 35 - 60
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
NM104 NM105 NM106 NM107 NM108
Name First Name Middle Name Prefix Name Suffix Identification Code Qualifier
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Description
ID
Name First Name Middle Name Prefix Name Suffix Identification Code Qualifier
AN AN AN AN ID
1-35 1-25 1-10 1-10 1-2
N/U N/U N/U N/U N/U
Other Payer Primary Identifier AN Entity Relationship Code ID Entity Identifier Code ID Name Last or Organization Name AN
2-80 2-2 2-3
N/U N/U N/U
1-60
N/U
837-I 4010A1
NM109 NM110 NM111
1-25 1-25 1-10 1-10 1-2
N/U N/U N/U N/U N/U
NM104 NM105 NM106 NM107 NM108
Other Payer Primary Identifier AN Entity Relationship Code ID Entity Identifier Code ID
2-80 2-2 2-3
N/U N/U N/U
NM109 NM110 NM111 NM112
REF
REF01 REF02 REF03 REF04
NM1 NM101 NM102 NM103 NM104 NM105 NM106 NM107 NM108 NM109 NM110 NM111
Reference Identification Qualifier Secondary Identifier Description REFERENCE IDENTIFIER
3
R
2330E 1A, 1B, 1C, 1D, 1G, 1H, EI, G2, LU, N5
REF
OTHER PAYER OPERATING PROVIDER SECONDARY IDENTIFICATION
REF01 REF02 REF03 REF04
Reference Identification Qualifier Secondary Identifier Description REFERENCE IDENTIFIER
2-3 1-30 1-80
R R N/U N/U
ID ID
1 2-3 1-1
S R R
AN AN AN AN AN ID
1-35 1-25 1-25 1-10 1-10 1-2
N/U N/U N/U N/U N/U N/U
NM103 NM104 NM105 NM106 NM107 NM108
Other Payer Primary Identifier AN Entity Relationship Code ID Entity Identifier Code ID
2-80 2-2 2-3
N/U N/U N/U
NM109 NM110 NM111
2330F
1 73 1, 2
NM1 NM101 NM102
NM112
REF
REF01 REF02
OTHER PAYER OTHER PROVIDER IDENTIFICATION Reference Identification Qualifier Secondary Identifier
3
ID AN
2-3 1-30
R
R R
Loop Repeat
Values
2330F 1A, 1B, 1C, 1D, 1G, 1H, EI, G2, LU, N5, SY
Increase from 25 - 35
Loop Change Name Change # Repeats change to 4 4
R
2330D Code Change
ID AN AN
OTHER PAYER OTHER PROVIDER Entity Identifier Code Entity Type Qualifier Name Last or Organization Name Name First Name Middle Name Prefix Name Suffix Identification Code Qualifier
Loop
837-I 5010
AN AN AN AN ID
OTHER PAYER OPERATING PROVIDER IDENTIFICATION
Min. Max.
Usage Reg.
Element Identifier
ID AN AN
2-3 1-50 1-80
R R N/U N/U
ID ID
1 2-3 1-1
S R R
AN AN AN AN AN ID
1-60 1-35 1-25 1-10 1-10 1-2
N/U N/U N/U N/U N/U N/U
Other Payer Primary Identifier AN Entity Relationship Code ID Entity Identifier Code ID Name Last or Organization Name AN
2-80 2-2 2-3
N/U N/U N/U
1-60
N/U
OTHER PAYER OTHER OPERATING PROVIDER Entity Identifier Code Entity Type Qualifier Name Last or Organization Name Name First Name Middle Name Prefix Name Suffix Identification Code Qualifier
REF
OTHER PAYER OTHER OPERATING PROVIDER SECONDARY IDENTIFICATION
REF01 REF02
Reference Identification Qualifier Secondary Identifier
0B, 1G, G2, LU Increase from 30 - 50
2330E
1 ZZ 1
Loop Change Name Change Code Change Code Deleted Increase from 35 - 60 Increase from 25 - 35
New Element
Loop Change Name Change # Repeats change to 4 4
R
2330E Code Change
Page 80 of 93
ID AN
2-3 1-50
R R
0B, 1G, G2, LU Increase from 30 - 50
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
REF03 REF04
Description REFERENCE IDENTIFIER
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Description
ID
REF03 REF04
Description REFERENCE IDENTIFIER
AN
1-80
N/U N/U
ID ID
1 2-3 1-1
S R R
AN AN AN AN AN ID
1-60 1-35 1-25 1-10 1-10 1-2
N/U N/U N/U N/U N/U N/U
Other Payer Primary Identifier AN Entity Relationship Code ID Entity Identifier Code ID Name Last or Organization Name AN
2-80 2-2 2-3
N/U N/U N/U
1-60
N/U
837-I 4010A1
NM1 NM101 NM102 NM103 NM104 NM105 NM106 NM107 NM108 NM109 NM110 NM111 NM112
REF REF01 REF02 REF03 REF04
1-80
N/U N/U
ID ID
1 2-3 1-1
S R R
AN AN AN AN AN ID
1-35 1-25 1-25 1-10 1-10 1-2
N/U N/U N/U N/U N/U N/U
NM103 NM104 NM105 NM106 NM107 NM108
Other Payer Primary Identifier AN Entity Relationship Code ID Entity Identifier Code ID Name Last or Organization Name AN
2-80 2-2 2-3
N/U N/U N/U
NM109 NM110 NM111
1-60
N/U
NM112
OTHER PAYER SERVICE FACILITY PROVIDER IDENTIFICATION Reference Identification Qualifier Other Payer Service Facility Location Secondary Identifier Description REFERENCE IDENTIFIER
3
R
ID
2-3
R
AN AN
1-30 1-80
R N/U N/U
Loop
Loop Repeat
2330F
1
Values
837-I 5010
AN
OTHER PAYER SERVICE FACILITY PROVIDER Entity Identifier Code Entity Type Qualifier Name Last or Organization Name Name First Name Middle Name Prefix Name Suffix Identification Code Qualifier
Min. Max.
Usage Reg.
Element Identifier
2330H
1 FA 2
2330H
NM1 NM101 NM102
REF 1B, 1C, 1D, EI, G2, LU, N5
REF01 REF02 REF03 REF04
NM1 NM101 NM102 NM103 NM104 NM105 NM106 NM107 NM108 NM109 NM110 NM111 NM112
OTHER PAYER SERVICE FACILITY LOCATION Entity Identifier Code Entity Type Qualifier Name Last or Organization Name Name First Name Middle Name Prefix Name Suffix Identification Code Qualifier
OTHER PAYER SERVICE FACILITY LOCATION SECONDARY IDENTIFIER Reference Identification Qualifier Other Payer Service Facility Location Secondary Identifier Description REFERENCE IDENTIFIER
Increase from 35 - 60
R
ID
2-3
R
AN AN
1-50 1-80
R N/U N/U
ID ID
1 2-3 1-1
S R R
AN AN AN AN AN ID
1-60 1-35 1-25 1-10 1-10 1-2
N/U N/U N/U N/U N/U N/U
Other Payer Primary Identifier AN Entity Relationship Code ID Entity Identifier Code ID Name Last or Organization Name AN
2-80 2-2 2-3
N/U N/U N/U
1-60
N/U
Page 81 of 93
Increase from 25 - 35
Loop Change Name Change 3
OTHER PAYER RENDERING PROVIDER Entity Identifier Code Entity Type Qualifier Name Last or Organization Name Name First Name Middle Name Prefix Name Suffix Identification Code Qualifier
77 2
Loop Change Name Change Code Change
2330F Code Change 0B, G2, LU Increase from 30 - 50
New Segment 2330G
1 82 1
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1
ID
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010 REF REF01 REF02 REF03 REF04
NM1 NM101 NM102 NM103 NM104 NM105 NM106 NM107 NM108 NM109 NM110 NM111 NM112
OTHER PAYER RENDERING PROVIDER SECONDARY IDENTIFIER Reference Identification Qualifier Other Payer Rendering Provider Secondary Identifier Description REFERENCE IDENTIFIER
New Segment 4
R
ID
2-3
R
AN AN
1-50 1-80
R N/U N/U
ID ID
1 2-3 1-1
S R R
AN AN AN AN AN ID
1-60 1-35 1-25 1-10 1-10 1-2
N/U N/U N/U N/U N/U N/U
Other Payer Primary Identifier AN Entity Relationship Code ID Entity Identifier Code ID Name Last or Organization Name AN
2-80 2-2 2-3
N/U N/U N/U
1-60
N/U
OTHER PAYER REFERRING PROVIDER Entity Identifier Code Entity Type Qualifier Name Last or Organization Name Name First Name Middle Name Prefix Name Suffix Identification Code Qualifier
REF01
REF02 REF03 REF04
Other Payer Referring Provider Secondary Identifier Description REFERENCE IDENTIFIER
NM1 NM101 NM102 NM103 NM104 NM105 NM106 NM107
OTHER PAYER BILLING PROVIDER Entity Identifier Code Entity Type Qualifier Name Last or Organization Name Name First Name Middle Name Prefix Name Suffix
Page 82 of 93
0B, 1G, G2, LU
New Segment
OTHER PAYER REFERRING PROVIDER SECONDARY IDENTIFIER Reference Identification Qualifier ID
REF
2330G
2330H
1 DN 1
New Segment 3
R
2-3
R
AN AN
1-50 1-80
R N/U N/U
ID ID
1 2-3 1-1
S R R
AN AN AN AN AN
1-60 1-35 1-25 1-10 1-10
N/U N/U N/U N/U N/U
2330H 0B, 1G, G2
New Segment 2330I
1 85 2
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Description
ID
NM108
Identification Code Qualifier
ID
1-2
N/U
Other Payer Primary Identifier AN Entity Relationship Code ID Entity Identifier Code ID Name Last or Organization Name AN
2-80 2-2 2-3
N/U N/U N/U
1-60
N/U
837-I 4010A1
NM112
REF02 REF03 REF04 LX LX01
SERVICE LINE Assigned Number
1 1-6
R R
2400
N0
SV2 SV201
INSTITUTIONAL SERVICE LINE Revenue Code
1 1-48
R R
2400
AN
REF01
SV2 SV201
INSTITUTIONAL SERVICE LINE Revenue Code
Loop Repeat
Values
1 1-6
R R
2400
N0
R R
2400
AN
1 1-48
999
New Segment
OTHER PAYER BILLING PROVIDER SECONDARY IDENTIFICATION Reference Identification Qualifier Other Payer Billing Provider Secondary Identification Description REFERENCE IDENTIFIER
REF
SERVICE LINE NUMBER Assigned Number
Loop
837-I 5010 NM109 NM110 NM111
LX LX01
Min. Max.
Usage Reg.
Element Identifier
2
R
ID
2-3
R
AN AN
1-50 1-80
R N/U N/U
2330I G2, LU
Name Change
999
Usage change to Required
SV202-1 SV202-2 SV202-3 SV202-4 SV202-5 SV202-6
COMPOSITE Product or Service ID Qualifier Procedure Code Procedure Modifier Procedure Modifier Procedure Modifier Procedure Modifier
ID AN AN AN AN AN
2-2 1-48 2-2 2-2 2-2 2-2
R R S S S S
SV202-7
Description
AN
1-80
N/U
SV203
R
1-18
R
SV204 SV205
Line Item Charge Amount Unit or Basis for Measurement Code Service Unit Count
ID R
2-2 1-15
R R
SV206 SV207 SV208 SV209 SV210
Unit Rate Monetary Amount Y/N NHRSC Level of Care Code
ID R ID ID ID
1-10 1-18 1-1 1-1 1-1
S S N/U N/U N/U
PWK
LINE SUPPLEMENTAL INFORMATION
5
S
SV202
S
SV202 HC, IV, ZZ
SV202-1 SV202-2 SV202-3 SV202-4 SV202-5 SV202-6
2400
R ID AN AN AN AN AN
2-2 1-48 2-2 2-2 2-2 2-2
R R S S S S
AN AN R
1-80 1-48 1-18
S N/U R
SV204 SV205
Description Product/Service ID Line Item Charge Amount Unit or Basis for Measurement Code Service Units/Days
ID R
2-2 1-15
R R
SV206 SV207 SV208 SV209 SV210
Unit Rate Monetary Amount Y/N NHRSC Level of Care Code
ID R ID ID ID
1-10 1-18 1-1 1-1 1-1
N/U S N/U N/U N/U
PWK
LINE SUPPLEMENTAL INFORMATION
10
S
SV202-7 SV202-8 SV203 DA, F2, UN
COMPOSITE Product or Service ID Qualifier Procedure Code Procedure Modifier Procedure Modifier Procedure Modifier Procedure Modifier
Page 83 of 93
ER, HC, HP, IV, Code Change WK
Usage change to Situational New Element Code Deleted DA, UN Name Change Usage change to Not Used
# Repeats change to 10 2400
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1
ID
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010 Code Added
PWK01
Attachment Report Type Code
PWK02 PWK03 PWK04
Attachment Transmission Code Report Copies Needed Entity Identifier Code
PWK05 PWK06 PWK07 PWK08 PWK09
Identification Code Qualifier Identification Code Description ACTIONS INDICATED Request Category Code
ID
2-2
AS, B2, B3, B4, CT, D2, DA, DG, DS, EB, MT, NN, OB, OZ, PN, PO, PZ, RB, RR, RT
R
ID N0 ID
1-2 1-2 2-3
R N/U N/U
ID AN AN
1-2 2-80 1-80
ID
1-2
S S N/U N/U N/U
AA, AB, AD, AF, AG, BM, EL, EM, FX
AC
PWK01
Attachment Report Type Code
PWK02 PWK03 PWK04
Attachment Transmission Code Report Copies Needed Entity Identifier Code
PWK05 PWK06 PWK07 PWK08 PWK09
Identification Code Qualifier Identification Code Description ACTIONS INDICATED Request Category Code
ID
2-2
03, 04, 05, 06, 07, 08, 09, 10, 11, 13, 15, 21, A3, A4, AM, AS, B2, B3, B4, BR, BS, BT, CB, CK, CT, D2, DA, DB, DG, DJ, DS, EB, HC, HR, I5, IR, LA, M1, MT, NN, OB, OC, OD, OE, OX, OZ, P4, P5, PE, PN, PO, PQ, PY, PZ, RB, RR, RT, RX, SG, V5, XP
R
Code Change ID N0 ID
1-2 1-2 2-3
R N/U N/U
ID AN AN
1-2 2-80 1-80
ID
1-2
S S N/U N/U N/U
AA, BM, EL, EM, FT, FX
AC
Name Change Usage change to Required DTP DTP01 DTP02
SERVICE LINE DATE Date Time Qualifier Date Time Period Format Qualifier
DTP03
Service Date
DTP
ASSESSMENT DATE
DTP01
ID
1 3-3
R R
ID
2-3
2400 472
DTP DTP01
R
D8, RD8
DTP02
R
CYYMMDD, CCYYMMDDCCYYMMDD
AN
1-35 1
S
ID
3-3
R
DTP02
Date Time Qualifier Date Time Period Format Qualifier
ID
2-3
R
D8
DTP03
Assessment Date
AN
1-35
R
CCYYMMDD
DATE - SERVICE DATE Date Time Qualifier Date Time Period Format Qualifier
Service Date
DTP03
ID
1 3-3
R R
ID
2-3
R
D8, RD8
R
CYYMMDD, CCYYMMDDCCYYMMDD
AN
1-35
2400 472
Segment Deleted
2400 866
REF REF01 REF02
LINE ITEM CONTROL NUMBER Reference Identification Qualifier Line Item Control Number
Page 84 of 93
New Segment
ID AN
1
S
2-3 1-50
R R
2400 6R
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
ID
REF03 REF04
Description REFERENCE IDENTIFIER
AN
837-I 4010A1
REF01 REF02 REF03 REF04
AMT AMT01 AMT02 AMT03
SERVICE TAX AMOUNT Amount Qualifier Code Service Tax Amount Credit/Debit Flag Code
1 1-3 1-18 1-1
S R R N/U
2400
ID R ID
AMT AMT01 AMT02 AMT03
FACILITY TAX AMOUNT Amount Qualifier Code Facility Tax Amount Credit/Debit Flag Code
1 1-3 1-18 1-1
S R R N/U
2400
ID R ID
HCP01 HCP02 HCP03 HCP04 HCP05
Pricing Methodology Repriced Allowed Amount Repriced Saving Amount Repricing Organization Identifier Repricing Per Diem or Flat Rate Amount
S
GT
N8
2400 00, 01, 02, 03, 04, 05, 06, 07, 08, 09, 10, 11, 12, 13, 14
1-80
N/U N/U
1
S
2-3
R
1-50 1-80
R N/U N/U
1
S
ID
2-3
R
AN AN
1-50 1-80
R N/U N/U
REPRICED LINE ITEM REFERENCE NUMBER Reference Identification Qualifier ID Repriced Line Item Reference Number AN Description AN REFERENCE IDENTIFIER
Loop Repeat
Values
New Segment 2400 9B
New Segment
REF02 REF03 REF04 AMT AMT01 AMT02 AMT03
SERVICE TAX AMOUNT Amount Qualifier Code Tax Amount Credit/Debit Flag Code
1 1-3 1-18 1-1
S R R N/U
2400
ID R ID
AMT AMT01 AMT02 AMT03
FACILITY TAX AMOUNT Amount Qualifier Code Facility Tax Amount Credit/Debit Flag Code
1 1-3 1-18 1-1
S R R N/U
2400
ID R ID
NTE NTE01 NTE02
THIRD PARTY ORGANIZATION NOTES Note Reference Code Claim Note Text
S R R
2400
ID AN
1 3-3 1-80
HCP
LINE PRICING/REPRICING INFORMATION
1
S
2400
REF01
1
Loop
ITEM REFERENCE NUMBER Reference Identification Qualifier Adjusted Repriced Line Item Reference Number Description REFERENCE IDENTIFIER
REF
LINE PRICING/REPRICING INFORMATION
Usage Reg.
837-I 5010
REF
HCP
Min. Max.
ID R R
2-2 1-18 1-18
R R S
HCP01 HCP02 HCP03
AN
1-30
S
HCP04
R
1-9
S
HCP05
Pricing Methodology Repriced Allowed Amount Repriced Saving Amount Repricing Organization Identifier Repricing Per Diem or Flat Rate Amount
Page 85 of 93
2400 9D
GT Name Change
N8
Segment Added
ID R R
2-2 1-18 1-18
R R S
AN
1-50
S
R
1-9
S
TPO
00, 01, 02, 03, 04, 05, 06, 07, 08, 09, 10, 11, 12, 13, 14
Increase from 30 - 50
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1 HCP06 HCP07
Ambulatory Patient Group Code Ambulatory Patient Group Amount
ID
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010
AN
1-30
S
HCP06
R
1-18
S
HCP07
AN
1-48
S
HCP08
ID AN ID
2-2 1-48 2-2
S S S
R
1-15
S
Ambulatory Patient Group Code Ambulatory Patient Group Amount
Increase from 30 - 50 AN
1-50
S
R
1-18
S Usage change to Not Used
HCP08 HCP09 HCP10 HCP11 HCP12
Product/Service ID Product or Service ID Qualifier Procedure Code Measurement Code Repriced Approved Service Unit Count "DA" "UN"
HCP13 HCP14 HCP15
Reject Reason Code Policy Compliance Code Exception Code
LIN LIN01
DRUG IDENTIFICATION Assigned Identification Product or Service ID Qualifier National Drug Code Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier
LIN02 LIN03 LIN04 LIN05 LIN06 LIN07 LIN08 LIN09 LIN10 LIN11 LIN12 LIN13 LIN14 LIN15 LIN16 LIN17 LIN18 LIN19 LIN20 LIN21 LIN22 LIN23 LIN24 LIN25 LIN26 LIN27 LIN28 LIN29 LIN30
ID ID ID
2-2 1-2 1-2
S S S
AN
1 1-20
S N/U
ID AN ID AN ID AN ID AN ID AN ID AN ID AN ID AN ID AN ID AN ID AN ID AN ID AN ID AN ID
2-2 1-48 2-2 1-48 2-2 1-48 2-2 1-48 2-2 1-48 2-2 1-48 2-2 1-48 2-2 1-48 2-2 1-48 2-2 1-48 2-2 1-48 2-2 1-48 2-2 1-48 2-2 1-48 2-2
R R N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U
HC DA, UN
T1, T2, T3, T4, T5, T6 1, 2, 3, 4, 5 1, 2, 3, 4, 5, 6
2410
25
N4
AN
1-48
N/U
ID AN ID
2-2 1-48 2-2
S S S
HCP12
Product/Service ID Product or Service ID Qualifier Procedure Code Measurement Code Repriced Approved Service Unit Count "DA" "UN"
R
1-15
S
HCP13 HCP14 HCP15
Reject Reason Code Policy Compliance Code Exception Code
ID ID ID
2-2 1-2 1-2
S S S
LIN LIN01
DRUG IDENTIFICATION Assigned Identification Product or Service ID Qualifier National Drug Code Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier
AN
1 1-20
S N/U
ID AN ID AN ID AN ID AN ID AN ID AN ID AN ID AN ID AN ID AN ID AN ID AN ID AN ID AN ID
2-2 1-48 2-2 1-48 2-2 1-48 2-2 1-48 2-2 1-48 2-2 1-48 2-2 1-48 2-2 1-48 2-2 1-48 2-2 1-48 2-2 1-48 2-2 1-48 2-2 1-48 2-2 1-48 2-2
R R N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U
HCP09 HCP10 HCP11
LIN02 LIN03 LIN04 LIN05 LIN06 LIN07 LIN08 LIN09 LIN10 LIN11 LIN12 LIN13 LIN14 LIN15 LIN16 LIN17 LIN18 LIN19 LIN20 LIN21 LIN22 LIN23 LIN24 LIN25 LIN26 LIN27 LIN28 LIN29 LIN30
Page 86 of 93
ER, HC, HP, IV, Code Added WK DA, UN
T1, T2, T3, T4, T5, T6 1, 2, 3, 4, 5 1, 2, 3, 4, 5, 6
2410
# Loop Repeats change to 1
1
N4
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
LIN31
Product/Service ID
CTP CTP01 CTP02
DRUG QUANTITY Class of Trade Code Price Identifier Code
CTP03 CTP04
Unit Price National Drug Unit Count COMPOSITE UNIT OF MEASURE Unit or Basis For Measurement Code Exponent Multiplier Unit or Basis For Measurement Code Exponent Multiplier Unit or Basis For Measurement Code Exponent Multiplier Unit or Basis For Measurement Code Exponent Multiplier Unit or Basis For Measurement Code Exponent Multiplier Price Multiplier Qualifier Multiplier Monetary Amount Basis of Unit Price Code Condition Value Multiple Price Quantity
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Description
ID
LIN31
Product/Service ID
AN
1-48
N/U
CTP CTP01 CTP02
DRUG QUANTITY Class of Trade Code Price Identifier Code
ID ID
1 2-2 3-3
R N/U N/U
Unit Price National Drug Unit Count COMPOSITE UNIT OF MEASURE Unit or Basis For Measurement Code Exponent Multiplier Unit or Basis For Measurement Code Exponent Multiplier Unit or Basis For Measurement Code Exponent Multiplier Unit or Basis For Measurement Code Exponent Multiplier Unit or Basis For Measurement Code Exponent Multiplier Price Multiplier Qualifier Multiplier Monetary Amount Basis of Unit Price Code Condition Value Multiple Price Quantity
R R
1-17 1-15
N/U R
837-I 4010A1
Min. Max.
Usage Reg.
Element Identifier
Loop
Loop Repeat
Values
837-I 5010
AN
1-48
N/U
ID ID
1 2-2 3-3
S N/U N/U
R R
1-17 1-15
R R
CTP03 CTP04
R
CTP05
Usage Change to Required 2410
2410
Usage change to Not Used
CTP05 CTP05-1 CTP05-2 CTP05-3 CTP05-4 CTP05-5 CTP05-6 CTP05-7 CTP05-8 CTP05-9 CTP05-10 CTP05-11 CTP05-12 CTP05-13 CTP05-14 CTP05-15 CTP06 CTP07 CTP08 CTP09 CTP10 CTP11
REF01 REF02 REF03 REF04
PRESCRIPTION NUMBER Reference Identification Qualifier Prescription Number Desciption REFERENCE IDENTIFIER
NM1
ATTENDING PHYSICIAN NAME
REF
F2, GR, ML, UN
ID R R
2-2 1-15 1-10
R N/U N/U
ID R R
2-2 1-15 1-10
N/U N/U N/U
CTP05-4 CTP05-5 CTP05-6
ID R R
2-2 1-15 1-10
N/U N/U N/U
CTP05-7 CTP05-8 CTP05-9
ID R R
2-2 1-15 1-10
N/U N/U N/U
CTP05-10 CTP05-11 CTP05-12
ID R R ID R R ID AN N0
2-2 1-15 1-10 3-3 1-10 1-18 2-2 1-10 1-2
N/U N/U N/U N/U N/U N/U N/U N/U N/U
CTP05-13 CTP05-14 CTP05-15 CTP06 CTP07 CTP08 CTP09 CTP10 CTP11
ID AN AN
1
S
2-3 1-30 1-80
R R N/U N/U
1
S
2410
CTP05-1 CTP05-2 CTP05-3
REF XZ
REF01 REF02 REF03 REF04
PRESCRIPTION OR COMPOUND DRUG ASSOCIATION NUMBER Reference Identification Qualifier Prescription Number Desciption REFERENCE IDENTIFIER
R ID R R
2-2 1-15 1-10
R N/U N/U
ID R R
2-2 1-15 1-10
N/U N/U N/U
ID R R
2-2 1-15 1-10
N/U N/U N/U
ID R R
2-2 1-15 1-10
N/U N/U N/U
ID R R ID R R ID AN N0
2-2 1-15 1-10 3-3 1-10 1-18 2-2 1-10 1-2
N/U N/U N/U N/U N/U N/U N/U N/U N/U
F2, GR, ME, ML, Code Added UN
Name Change 1
S
2-3 1-50 1-80
R R N/U N/U
2410 Code Added
ID AN AN
VY, XZ Increase from 30 - 50
Segment Deleted 2420A
1
Page 87 of 93
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
NM101 NM102 NM103 NM104 NM105 NM106 NM107 NM108 NM109 NM110 NM111
Entity Identifier Code Entity Type Qualifier Last Name First Name Middle Name Name Prefix Name Suffix Identification Code Qualifier Identifier Entity Relationship Code Entity Identifier Code
REF
ATTENDING PHYSICIAN SECONDARY IDENTIFICATION
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1
REF01 REF02 REF03 REF04
Reference Identification Qualifier Secondary Identifier Description REFERENCE IDENTIFIER
NM1 NM101 NM102 NM103 NM104 NM105 NM106 NM107 NM108 NM109 NM110 NM111
OPERATING PHYSICIAN NAME Entity Identifier Code Entity Type Qualifier Last Name First Name Middle Name Name Prefix Name Suffix Identification Code Qualifier Identifier Entity Relationship Code Entity Identifier Code
REF
ID ID AN AN AN AN AN ID AN ID ID
Reference Identification Qualifier Secondary Identifier Description
REF04
REFERENCE IDENTIFIER
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010 71 1, 2
R R R S S N/U S S S N/U N/U
24, 34, XX
Segment Deleted 1
S
ID AN AN
2-3 1-30 1-80
R R N/U S
ID ID AN AN AN AN AN ID AN ID ID
1 2-3 1-1 1-35 1-25 1-25 1-10 1-10 1-2 2-80 2-2 2-3
S R R R S S N/U S S S N/U N/U
OPERATING PHYSICIAN SECONDARY IDENTIFICATION
REF01 REF02 REF03
2-3 1-1 1-35 1-25 1-25 1-10 1-10 1-2 2-80 2-2 2-3
ID
1
ID AN AN
2-3 1-30 1-80
S
R R N/U
2420A OB, 1A, 1B, 1C, 1D, 1G, 1H, EI, G2, LU, N5, SY, X5
2420B
1 72 1
24, 34, XX
2420B OB, 1A, 1B, 1C, 1D, 1G, 1H, EI, G2, LU, N5, SY, X5
NM112
OPERATING PHYSICIAN NAME Entity Identifier Code Entity Type Qualifier Last Name First Name Middle Name Name Prefix Name Suffix Identification Code Qualifier Identifier Entity Relationship Code Entity Identifier Code Name Last or Organization Name
REF
OPERATING PHYSICIAN SECONDARY IDENTIFICATION
NM1 NM101 NM102 NM103 NM104 NM105 NM106 NM107 NM108 NM109 NM110 NM111
ID ID AN AN AN AN AN ID AN ID ID
1 2-3 1-1 1-60 1-35 1-25 1-10 1-10 1-2 2-80 2-2 2-3
S R R R S S N/U S S S N/U N/U
AN
1-60
N/U
2420A
1 72 1 Increase from 35 - 60 Increase from 25 - 35
XX
Code Deleted
New Element
# Reeats change to 20 20
S
2420A Code Change
REF01 REF02 REF03
Reference Identification Qualifier Secondary Identifier Description
REF04
REFERENCE IDENTIFIER
ID AN AN
2-3 1-50 1-80
R R N/U
OB, 1G, G2, LU Increase from 30 - 50 Usage change to Siuational
N/U
Page 88 of 93
S
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1
ID
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010 New Element REF04-1 REF04-2 REF04-3 REF04-4 REF04-5 REF04-6
NM1 NM101 NM102 NM103 NM104 NM105 NM106 NM107 NM108 NM109 NM110 NM111 NM112
REF REF01 REF02 REF03 REF04 REF04-1 REF04-2 REF04-3 REF04-4 REF04-5 REF04-6 NM1 NM101 NM102
OTHER PROVIDER NAME Entity Identifier Code Entity Type Qualifier
ID ID
1 2-3 1-1
S R R
NM103
Other Physician Last Name
AN
1-35
R
NM104
Other Physician First Name
AN
1-25
S
2420C
Reference Identifier Qualifier Idenitifer Reference Identification Qualifier Reference Identification Reference Identification Qualifier Reference Identification OTHER OPERATING PHYSICIAN NAME Entity Identifier Code Entity Type Qualifier Last Name First Name Middle Name Name Prefix Name Suffix Identification Code Qualifier Identifier Entity Relationship Code Entity Identifier Code Name Last or Organization Name OTHER OPERATING PHYSICIAN SECONDARY IDENTIFICATION Reference Identification Qualifier Secondary Identifier Description REFERENCE IDENTIFIER Reference Identifier Qualifier Idenitifer Reference Identification Qualifier Reference Identification Reference Identification Qualifier Reference Identification
ID AN
2-3 1-50
R R
ID AN
2-3 1-50
N/U N/U
ID AN
2-3 1-50
N/U N/U
ID ID AN AN AN AN AN ID AN ID ID
1 2-3 1-1 1-60 1-35 1-25 1-10 1-10 1-2 2-80 2-2 2-3
S R R R S S N/U S S S N/U N/U
AN
1-60
N/U
2U New Element New Element New Element New Element New Element New Segment 2420B
1 ZZ 1
XX
New Segment 20
S
2420B
ID AN AN
2-3 1-50 1-80
R R N/U S
OB, 1G, G2, LU
ID AN
2-3 1-50
R R
2U
ID AN
2-3 1-50
N/U N/U
ID AN
2-3 1-50
N/U N/U Segment Deleted
1 73 1, 2
Page 89 of 93
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
NM105 NM106 NM107 NM108 NM109 NM110 NM111
Middle Name Name Prefix Name Suffix Identification Code Qualifier Identifier Entity Relationship Code Entity Identifier Code
REF
OTHER PROVIDER SECONDARY IDENTIFICATION
REF01 REF02 REF03 REF04
Reference Identification Qualifier Secondary Identifier Description REFERENCE IDENTIFIER
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1 AN AN AN ID AN ID ID
1-25 1-10 1-10 1-2 2-80 2-2 2-3
ID
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010
S N/U S R R N/U N/U
24, 34, XX
Segment Deleted 1
ID AN AN
2-3 1-30 1-80
S
R R N/U S
2420B OB, 1A, 1B, 1C, 1D, 1G, 1H, EI, G2, LU, N5, SY, X5
NM1 NM101 NM102 NM103 NM104 NM105 NM106 NM107 NM108 NM109 NM110 NM111 NM112
REF REF01 REF02 REF03 REF04
RENDERING PROVIDER NAME Entity Identifier Code Entity Type Qualifier Rendering Provider Last or Organization Name Rendering Provider First Name Rendering Provider Middle Name Name Prefix Rendering Provider Name Suffix Identification Code Qualifier Rendering Provider Identifier Entity Relationship Code Entity Identifier Code Name Last or Organization Name RENDERING PROVIDER SECONDARY IDENTIFICATION Reference Identification Qualifier Rendering Provider Secondary Identifier Description REFERENCE IDENTIFIER
Page 90 of 93
New Segment ID ID
1 2-3 1-1
S R R
AN
1-60
R
AN
1-35
S
AN AN
1-25 1-10
S N/U
AN ID
1-10 1-2
S S
AN ID ID
2-80 2-2 2-3
S N/U N/U
AN
1-60
N/U
2420C
1 82 1
XX
New Segment 20
S
ID
2-3
R
AN AN
1-50 1-80
R N/U S
2420C OB, 1G, G2, LU
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1
ID
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010 REF04-1
Reference Identifier Qualifier
ID
2-3
R
REF04-2
Other Payer Primary Idenitifer AN Reference Identification Qualifier ID Reference Identification AN Reference Identification Qualifier ID Reference Identification AN
1-50
R
2-3 1-50
N/U N/U
2-3 1-50
N/U N/U
ID ID
1 2-3 1-1
S R R
NM103
Referring Provider Last Name AN
1-60
R
NM104
Referring Provider First Name Referring Provider Middle Name or Initial Name Prefix Referring Provider Name Suffix Identification Code Qualifier
AN
1-35
S
AN AN
1-25 1-10
S N/U
AN ID
1-10 1-2
S S
Other Payer Primary Identifier AN Entity Relationship Code ID Entity Identifier Code ID Name Last or Organization Name AN
2-80 2-2 2-3
S N/U N/U
1-60
N/U
REF04-3 REF04-4 REF04-5 REF04-6
NM1 NM101 NM102
NM105 NM106 NM107 NM108 NM109 NM110 NM111 NM112
REF REF01 REF02 REF03 REF04
REFERRING PROVIDER NAME Entity Identifier Code Entity Type Qualifier
New Segment
REFERRING PROVIDER SECONDARY IDENTIFICATION Reference Identification Qualifier ID Referring Provider Secondary Identifier AN Description AN REFERENCE IDENTIFIER
20
S
2-3
R
1-50 1-80
R N/U S
Reference Identifier Qualifier
ID
2-3
R
REF04-2
Other Payer Primary Idenitifer AN Reference Identification Qualifier ID Reference Identification AN Reference Identification Qualifier ID
1-50
R
2-3 1-50
N/U N/U
2-3
N/U
REF04-5
Page 91 of 93
2420D
1 DN 1
XX
New Segment
REF04-1
REF04-3 REF04-4
2U
2420D OB, 1G, G2
2U
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
ID
REF04-6
Reference Identification
AN
SVD
LINE ADJUDICATION INFORMATION
837-I 4010A1
SVD
LINE ADJUDICATION INFORMATION
Min. Max.
Usage Reg.
Loop
Loop Repeat
2430
15
Values
837-I 5010
1
S
2430
25
2-80 1-18
R R
SVD01 SVD02
R
SVD03
1-50
N/U
1
S
2-80 1-18
R R
Name Change
SVD03-1 SVD03-2 SVD03-3 SVD03-4 SVD03-5 SVD03-6
Payer Identifier Service Line Paid Amount COMPOSITE MEDICAL PROCEDURE IDENTIFIER Product or Service ID Qualifier Procedure Code Procedure Modifier Procedure Modifier Procedure Modifier Procedure Modifier
ID AN AN AN AN AN
2-2 1-48 2-2 2-2 2-2 2-2
R R S S S S
SVD03-7
Procedure Code Description
AN
1-80
S
SVD01 SVD02 SVD03
SVD04 SVD05 SVD06
Product or Service ID Paid Service Unit Count Bundled or Unbundled Line Number
CAS01 CAS02 CAS03 CAS04 CAS05 CAS06 CAS07 CAS08 CAS09 CAS10 CAS11 CAS12 CAS13 CAS14 CAS15 CAS16 CAS17 CAS18 CAS19
LINE ADJUSTMENT Claim Adjustment Group Code Adjustment Reason Code Adjustment Amount Adjustment Quantity Adjustment Reason Code Adjustment Amount Adjustment Quantity Adjustment Reason Code Adjustment Amount Adjustment Quantity Adjustment Reason Code Adjustment Amount Adjustment Quantity Adjustment Reason Code Adjustment Amount Adjustment Quantity Adjustment Reason Code Adjustment Amount Adjustment Quantity
DTP
SERVICE ADJUDICATION DATE
CAS
AN R
HC, IV, ZZ
SVD03-1 SVD03-2 SVD03-3 SVD03-4 SVD03-5 SVD03-6
Other Payer Primary Identifier Service Line Paid Amount COMPOSITE MEDICAL PROCEDURE IDENTIFIER Product or Service ID Qualifier Procedure Code Procedure Modifier Procedure Modifier Procedure Modifier Procedure Modifier
ID AN AN AN AN AN
2-2 1-48 2-2 2-2 2-2 2-2
R R S S S S
SVD03-7 SVD03-8
Procedure Code Description Product/Service ID
AN AN
1-80 1-48
S N/U
Product or Service ID Paid Service Unit Count Bundled or Unbundled Line Number
AN R
1-48 1-15
N/U R
N0
1-6
S
5
S
1-2 1-5 1-18 1-15 1-5 1-18 1-15 1-5 1-18 1-15 1-5 1-18 1-15 1-5 1-18 1-15 1-5 1-18 1-15
R R R S S S S S S S S S S S S S S S S
AN R
1-48 1-15
R R
SVD04 SVD05
N0
1-6
S
SVD06
99
S
ID ID R R ID R R ID R R ID R R ID R R ID R R
1-2 1-5 1-18 1-15 1-5 1-18 1-15 1-5 1-18 1-15 1-5 1-18 1-15 1-5 1-18 1-15 1-5 1-18 1-15
1
2430
R R R S S S S S S S S S S S S S S S S
S
2430
CAS01 CAS02 CAS03 CAS04 CAS05 CAS06 CAS07 CAS08 CAS09 CAS10 CAS11 CAS12 CAS13 CAS14 CAS15 CAS16 CAS17 CAS18 CAS19
LINE ADJUSTMENT Claim Adjustment Group Code Adjustment Reason Code Adjustment Amount Adjustment Quantity Adjustment Reason Code Adjustment Amount Adjustment Quantity Adjustment Reason Code Adjustment Amount Adjustment Quantity Adjustment Reason Code Adjustment Amount Adjustment Quantity Adjustment Reason Code Adjustment Amount Adjustment Quantity Adjustment Reason Code Adjustment Amount Adjustment Quantity
DTP
LINE CHECK OR REMITTANCE DATE
CAS CO, CR, OA, PI, PR
Page 92 of 93
AN R
R
ID ID R R ID R R ID R R ID R R ID R R ID R R
ER, HC, HP, IV, Code Change WK
New Element Usage change to Not Used
2430 CO, CR, OA, PI, PR
Name Change Usage change to Required 1
R
2430
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
DTP02 DTP03
Date Time Qualifier Date Time Period Format Qualifier
3-3
R
573
DTP01
ID
2-3
R
D8
DTP02
Adjudication or Payment Date AN
1-35
R
CCYYMMDD
DTP03
AMT02 AMT03
SE02
GE GE01 GE02
TRANSACTION SET TRAILER Transaction Segment Count Transaction Set Control Number FUNCTION GROUP TRAILER Number of Transaction Sets Included Group Control Number
N0
1 1-10
R R
AN
4-9
R
1
R
1-6 1-9
R R
1
R
N0 N0
IEA01
INTERCHANGE CONTROL TRAILER Number of Included Functional Groups
N0
1-5
R
IEA02
Interchange Control Number
N0
9-9
R
IEA
Loop Repeat
Date Time Qualifier Date Time Period Format Qualifier
ID
3-3
R
573
ID
2-3
R
D8
Adjudication or Payment Date AN
1-35
R
CCYYMMDD
ID
1 1-3
S R
R ID
1-18 1-1
R N/U
N0
1 1-10
R R
AN
4-9
R
1
R
1-6 1-9
R R
1
R
Loop
Values
837-I 5010
ID
AMT AMT01
SE SE01
Usage Reg.
ID
837-I 4010A1 DTP01
Min. Max.
Description
___
>1
SE SE01 SE02
___
1
GE GE01 GE02
___
1
REMAINING PATIENT LIABILITY Amount Qualifier Code Remaining Patient Liability Amount Credit/Debit Flag Code TRANSACTION SET TRAILER Transaction Segment Count Transaction Set Control Number FUNCTION GROUP TRAILER Number of Transaction Sets Included Group Control Number
New Segment
N0 N0
IEA01
INTERCHANGE CONTROL TRAILER Number of Included Functional Groups
N0
1-5
R
IEA02
Interchange Control Number
N0
9-9
R
IEA
Page 93 of 93
2430 EAF
___
>1
___
1
___
1
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1
ISA01 ISA02
ID 2-2 AN 10-10
R R
00, 03
ISA03 ISA04
Security Information Qualifier Security Information
ID 2-2 AN 10-10
R R
00, 01
ISA05 ISA06
Interchange ID Qualifier Interchange Sender ID
ID 2-2 AN 15-15
R R
ISA07 ISA08 ISA09 ISA10
ID 2-2 AN 15-15 DT 6-6 TM 4-4
R R R R
ISA12
Interchange ID Qualifier Interchange Receiver ID Interchange Date Interchange Time Interchange Control Standards ID Interchange Control Version Number
ISA13
Interchange Control Number
ISA11
ISA14 ISA15 ISA16
GS GS01 GS02 GS03 GS04
GS05 GS06 GS07 GS08
1
R
___
1
ISA03 ISA04
Security Information Qualifier Security Information
ID 2-2 AN 10-10
R R
00, 01
01, 14, 20, 27, 28, 29, 30, 33, ZZ
ISA05 ISA06
Interchange ID Qualifier Interchange Sender ID
ID 2-2 AN 15-15
R R
01, 14, 20, 27, 28, 29, 30, 33, ZZ
ISA07 ISA08 ISA09 ISA10
ID 2-2 AN 15-15 DT 6-6 TM 4-4
R R R R
5-5
R
ISA12
N0
9-9
R
ISA13
Interchange Control Number
Acknowledgement Requested ID Usage Indicator ID Component Element Separator AN
1-1 1-1
R R
1-1
R
1 2-2 2-15 2-15 8-8
R R R R R
R R R R
1 00, 03
ID
4-8 1-9 1-2 1-12
___
Values
R R
ISA11
TM N0 ID AN
Loop Repeat
ID 2-2 AN 10-10
R
Time Group Control Number Responsible Agency Code Version Identifier Code
Loop
ISA01 ISA02
ISA
1-1
ID AN AN DT
Usage Reg.
INTERCHANGE CONTROL HEADER Authorization Information Qualifier Authorization Information
Interchange ID Qualifier Interchange Receiver ID Interchange Date Interchange Time Interchange Control Standards ID Interchange Control Version Number
FUNCTIONAL GROUP HEADER Functional Identifier Code Application Sender Code Application Receiver Code Date
Min. Max.
837-I 5010
INTERCHANGE CONTROL HEADER Authorization Information Qualifier Authorization Information
ISA
ID
YYMMDD HHMM
0, 1 P, T
ISA14 ISA15 ISA16
___
1
CCYYMMDD HHMM, HHMMSS, HHMMSSD, HHMMSSDD X 004010X096A1
GS GS01 GS02 GS03 GS04
GS05 GS06 GS07 GS08
1
R
1-1
R
ID
5-5
R
N0
9-9
R
Acknowledgement Requested ID Usage Indicator ID Component Element Separator AN
1-1 1-1
R R
1-1
R
1 2-2 2-15 2-15 8-8
R R R R R
FUNCTIONAL GROUP HEADER Functional Identifier Code Application Sender Code Application Receiver Code Date
Time Group Control Number Responsible Agency Code Version Identifier Code
Page 1 of 93
ID AN AN DT
TM N0 ID AN
4-8 1-9 1-2 1-12
R R R R
01, 14, 20, 27, 28, 29, 30, 33, ZZ
01, 14, 20, 27, 28, 29, 30, 33, ZZ YYMMDD HHMM
00501
0, 1 P, T
___
1
CCYYMMDD HHMM, HHMMSS, HHMMSSD, HHMMSSDD X 005010X223
Code Change
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1 ST ST01 ST02
TRANSACTION SET HEADER Transaction Set Identifier Code Transaction Set Control Number
1
R
ID
3-3
R
AN
4-9
R
BHT BHT01 BHT02 BHT03 BHT04
BHT05 BHT06
REF REF01 REF02 REF03 REF04 NM1 NM101 NM102 NM103 NM104 NM105 NM106 NM107 NM108 NM109 NM110 NM111
Transaction Set Creation Time Claim or Encounter ID
___
>1
ST 837
ST01 ST02
TRANSMISSION TYPE IDENTIFICATION Reference Identification Qualifier Reference Identification Description Reference Identifier SUBMITTER NAME Entity Identifier Code Entity Type Qualifier Submitter Last or Organization Name Submitter First Name Submitter Middle Name Name Prefix Name Suffix Identification Code Qualifier Submitter Identifier Entity Relationship Code Entity Identifier Code
ID
1 4-4
R R
ID
2-2
R
AN
1-30
R
DT
8-8
R
CCYYMMDD
4-8 2-2
R R
HHMM, HHMMSS, HHMMSSD, HHMMSSDD CH, RP
1
S
ID AN AN
2-3 1-30 1-80
R R N/U N/U
ID ID
1 2-3 1-1
R R R
AN AN AN AN AN ID AN ID ID
1-35 1-25 1-25 1-10 1-10 1-2 2-80 2-2 2-3
R S S N/U N/U R R N/U N/U
TM ID
Min. Max.
Usage Reg.
Loop
Loop Repeat
___
>1
Values
837-I 5010
ST03 BEGINNING OF HIERARCHICAL TRANSACTION Hierarchical Structure Code Transaction Set Purpose Code Originator Application Transaction ID Transaction Set Creation Date
ID
___
1 0019
BHT BHT01
00, 18
BHT02 BHT03 BHT04
BHT05 BHT06
TRANSACTION SET HEADER Transaction Set Identifier Code Transaction Set Control Number Implementation Convention Reference BEGINNING OF HIERARCHICAL TRANSACTION Hierarchical Structure Code Transaction Set Purpose Code Originator Application Transaction ID Transaction Set Creation Date Transaction Set Creation Time Claim or Encounter ID
1
R
ID
3-3
R
AN
4-9
R
AN
1-35
R
ID
1 4-4
R R
ID
2-2
R
AN
1-50
R
DT
8-8
R
837
New Element
___
1 0019 00, 18 Increase from 30 - 50
TM ID
4-8 2-2
CCYYMMDD HHMM, HHMMSS, HHMMSSD, HHMMSSDD 31, CH, RP Code Added
R R
Segment Deleted
87
1000A
1 41 1, 2
46
NM1 NM101 NM102 NM103 NM104 NM105 NM106 NM107 NM108 NM109 NM110 NM111 NM112
SUBMITTER NAME Entity Identifier Code Entity Type Qualifier Submitter Last or Organization Name Submitter First Name Submitter Middle Name Name Prefix Name Suffix Identification Code Qualifier Submitter Identifier Entity Relationship Code Entity Identifier Code Name Last or Organization Name
Page 2 of 93
ID ID
1 2-3 1-1
R R R
AN AN AN AN AN ID AN ID ID
1-60 1-35 1-25 1-10 1-10 1-2 2-80 2-2 2-3
R S S N/U N/U R R N/U N/U
AN
1-60
N/U
1000A
1 41 1, 2 Increase from 35 - 60 Increase from 25 - 35
46
New Element
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
PER PER01
SUBMITTER EDI CONTACT INFORMATION Contact Function Code
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
PER PER01
SUBMITTER EDI CONTACT INFORMATION Contact Function Code
837-I 4010A1 ID
2 2-2
R R
AN
1-60
R
ID AN
2-2 1-80
R R
PER07 PER08 PER09
Submitter Contact Name Communication Number Qualifier Communication Number Communication Number Qualifier Communication Number Communication Number Qualifier Communication Number Contact Inquiry Reference
ID AN AN
2-2 1-80 1-20
S S N/U
NM1 NM101 NM102 NM103 NM104 NM105 NM106 NM107 NM108 NM109 NM110 NM111
RECEIVER NAME Entity Identifier Code Entity Type Qualifier Receiver Name Name First Name Middle Name Prefix Name Suffix Identification Code Qualifier Receiver Primary Identifier Entity Relationship Code Entity Identifier Code
ID ID AN AN AN AN AN ID AN ID ID
1 2-3 1-1 1-35 1-25 1-25 1-10 1-10 1-2 2-80 2-2 2-3
R R R R N/U N/U N/U N/U R R N/U N/U
PER02 PER03 PER04 PER05 PER06
ID AN
2-2 1-80
HL HL01 HL02 HL03 HL04
PRV PRV01 PRV02 PRV03 PRV04
BILLING/PAY-TO PROVIDER SPECIALTY INFORMATION Provider Code Reference Identification Qualifier Provider Taxonomy Code State or Province Code
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010 1000A IC
PER02 ED, EM, FX. TE ED, EM, EX, FX, TE
S S
ED, EM, EX, FX, TE
1000B
1 40 2
46
PER03 PER04 PER05 PER06 PER07 PER08 PER09 NM1 NM101 NM102 NM103 NM104 NM105 NM106 NM107 NM108 NM109 NM110 NM111 NM112
BILLING/PAY-TO PROVIDER HIERARCHICAL LEVEL Hierarchical ID Number AN Hierarchical Parent ID Number AN Hierarchical Level Code ID Hierarchical Child Code ID
ID
Submitter Contact Name Communication Number Qualifier Communication Number Communication Number Qualifier Communication Number Communication Number Qualifier Communication Number Contact Inquiry Reference RECEIVER NAME Entity Identifier Code Entity Type Qualifier Receiver Name Name First Name Middle Name Prefix Name Suffix Identification Code Qualifier Receiver Primary Identifier Entity Relationship Code Entity Identifier Code Name Last or Organization Name
ID
2 2-2
R R
1000A
AN
1-60
S
ID 2-2 AN 1-256
R R
EM, FX. TE
ID 2-2 AN 1-256
S S
EM, EX, FX, TE
ID 2-2 AN 1-256 AN 1-20
S S N/U
EM, EX, FX, TE
ID ID AN AN AN AN AN ID AN ID ID
1 2-3 1-1 1-60 1-35 1-25 1-10 1-10 1-2 2-80 2-2 2-3
R R R R N/U N/U N/U N/U R R N/U N/U
AN
1-60
N/U
IC Usage change to Situational Code deleted Increase from 80 - 256 Code deleted Increase from 80 - 256 Code deleted Increase from 80 - 256
1000B
1 40 2 Increase from 35 - 60 Increase from 25 - 35
46
New Element
Name Change 1 1-12
R R
1-12 1-2 1-1
N/U R R
2000A
>1
HL HL01
20 1
HL02 HL03 HL04
BILLING PROVIDER HIERARCHICAL LEVEL Hierarchical ID Number Hierarchical Parent ID Number Hierarchical Level Code Hierarchical Child Code
AN
1 1-12
R R
AN ID ID
1-12 1-2 1-1
N/U R R
2000A
>1
20 1 Name Change
ID
1 1-3
S R
ID AN ID
2-3 1-30 2-2
R R N/U
2000A BI, PT ZZ
PRV PRV01 PRV02 PRV03 PRV04
BILLING PROVIDER SPECIALTY INFORMATION Provider Code ID Reference Identification Qualifier ID Provider Taxonomy Code AN State or Province Code ID
Page 3 of 93
1 1-3
S R
2-3 1-50 2-2
R R N/U
2000A BI
Code Deleted Code Change
PXC Increase from 30 - 50
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
PRV05
PROVIDER SPECIALTY INFORMATION
PRV06
Provider Organization Code
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1
CUR CUR01 CUR02 CUR03 CUR04 CUR05 CUR06 CUR07 CUR08 CUR09 CUR10 CUR11 CUR12 CUR13 CUR14 CUR15 CUR16 CUR17 CUR18 CUR19 CUR20 CUR21
FOREIGN CURRENCY INFORMATION Entity Identifier Code Currency Code Exchange Rate Entity Identifier Code Currency Code Currency Market/Exchange Code Date/Time Qualifier Date Time Date/Time Qualifier Date Time Date/Time Qualifier Date Time Date/Time Qualifier Date Time Date/Time Qualifier Date Time
N/U
PRV05
ID
3-3
N/U
PRV06
Provider Organization Code
ID ID R ID ID
1 2-3 3-3 4-10 2-3 3-3
S R R N/U N/U N/U
ID ID DT TM ID DT TM ID DT TM ID DT TM ID DT TM
3-3 3-3 8-8 4-8 3-3 8-8 4-8 3-3 8-8 4-8 3-3 8-8 4-8 3-3 8-8 4-8
N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U
ID ID
1 2-3 1-1
R R R
NM103 NM104
AN AN
1-35 1-25
R N/U
NM105 NM106
Name Middle Name Prefix
AN AN
1-25 1-10
NM107
Name Suffix
AN
1-10
NM108 NM109 NM110 NM111
Identification Code Qualifier Billing Provider Identifier Entity Relationship Code Entity Identifier Code
ID AN ID ID
1-2 2-80 2-2 2-3
Min. Max.
Usage Reg.
Loop Repeat
Values
2000A 85
CUR CUR01 CUR02 CUR03 CUR04 CUR05 CUR06 CUR07 CUR08 CUR09 CUR10 CUR11 CUR12 CUR13 CUR14 CUR15 CUR16 CUR17 CUR18 CUR19 CUR20 CUR21
FOREIGN CURRENCY INFORMATION Entity Identifier Code Currency Code Exchange Rate Entity Identifier Code Currency Code Currency Market/Exchange Code Date/Time Qualifier Date Time Date/Time Qualifier Date Time Date/Time Qualifier Date Time Date/Time Qualifier Date Time Date/Time Qualifier Date Time
N/U ID
3-3
N/U
ID ID R ID ID
1 2-3 3-3 4-10 2-3 3-3
S R R N/U N/U N/U
ID ID DT TM ID DT TM ID DT TM ID DT TM ID DT TM
3-3 3-3 8-8 4-8 3-3 8-8 4-8 3-3 8-8 4-8 3-3 8-8 4-8 3-3 8-8 4-8
N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U
ID ID
1 2-3 1-1
R R R
NM103 NM104
Billing Provider Name Entity Identifier Code Entity Type Qualifier Billing Provider Last or Organizational Name Billing Provider First Name
AN AN
1-60 1-35
R N/U
N/U N/U
NM105 NM106
Billing Provider Middle Name Name Prefix
AN AN
1-25 1-10
N/U N/U
N/U
NM107
Billing Provider Name Suffix
AN
1-10
N/U
R S N/U N/U
Loop
837-I 5010 PROVIDER SPECIALTY INFORMATION
Billing Provider Name Entity Identifier Code Entity Type Qualifier Billing Provider Last or Organizational Name Name First
NM1 NM101 NM102
ID
2010AA
1 85 2
24, 34, XX
NM1 NM101 NM102
NM108 NM109 NM110 NM111 NM112
Identification Code Qualifier Billing Provider Identifier Entity Relationship Code Entity Identifier Code Name Last or Organization Name
Page 4 of 93
2000A 85
2010AA
1 85 2 Increase from 35 - 60
ID AN ID ID
1-2 2-80 2-2 2-3
S S N/U N/U
AN
1-60
N/U
Increase from 25 - 35
XX
Code Deleted Usage change to Situational
New Element
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
N3
BILLING PROVIDER ADDRESS
N301
Billing Provider Address Line
N302
Billing Provider Address Line
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
N3
BILLING PROVIDER ADDRESS
837-I 4010A1
N4 N401 N402 N403 N404 N405 N406
REF
REF01 REF02 REF03 REF04
BILLING PROVIDER CITY/STATE/ZIP CODE Billing Provider City Name Billing Provider State or Province Code Billing Provider Postal Zone or ZIP Code Country Code Location Qualifier Location Identifier
Reference Identification Qualifier Billing Provider Additional Identifier Description REFERENCE IDENTIFIER
REF02 REF03 REF04
CREDIT/DEBIT CARD BILLING INFORMATION Reference Identification Qualifier Billing Provider Additional Identifier Description REFERENCE IDENTIFIER
PER PER01
BILLING PROVIDER CONTACT INFORMATION Contact Function Code
REF REF01
PER02 PER03 PER04 PER05
R
AN
1-55
R
N301
Billing Provider Address Line
AN
1-55
S
N302
Billing Provider Address Line
AN
1 2-30
R R
ID
2-2
R
N402
ID ID ID AN
3-15 2-3 1-2 1-30
R S N/U N/U
N403 N404 N405 N406 N407
BILLING PROVIDER CITY/STATE/ZIP CODE Billing Provider City Name Billing Provider State or Province Code Billing Provider Postal Zone or ZIP Code Country Code Location Qualifier Location Identifier Country Subdivision Code
REF
BILLING PROVIDER TAX IDENTIFICATION
8
R
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010
1
BILLING PROVIDER TAX IDENTIFICATION
ID
2010AA
2010AA
N4 N401
2010AA 0B, 1A, 1B, 1C, 1D, 1G, 1H, 1J, B3, BQ, EI, FH, G2, G5, LU, SY, X5
ID
2-3
R
AN AN
1-30 1-80
R N/U N/U
8
S
ID
2-3
R
AN AN
1-30 1-80
R N/U N/U
ID
2 2-2
S R
1-60
R
2-2 1-80
R R
EM, FX, TE
2-2
S
EM, EX, FX, TE
1
R
AN
1-55
R
AN
1-55
S
AN
1 2-30
R R
ID
2-2
S
ID ID ID AN ID
3-15 2-3 1-2 1-30 1-3
S S N/U N/U S
1
R
2010AA
2010AA Usage change to Situational Usage change to Situational
New Element # Repeats change to 1 2010AA Code Deleted
REF01 REF02 REF03 REF04
Reference Identification Qualifier Billing Provider Additional Identifier Description REFERENCE IDENTIFIER
ID
2-3
R
AN AN
1-50 1-80
R N/U N/U
EI Increase from 30 - 50
Segment Deleted
Billing Provider Contact Name AN Communication Number Qualifier ID Communication Number AN Communication Number Qualifier ID
2010AA 06, 8U, EM, IJ, LU, RB, ST, TT
2010AA IC
PER PER01 PER02 PER03 PER04 PER05
BILLING PROVIDER CONTACT INFORMATION Contact Function Code
ID
2 2-2
Billing Provider Contact Name AN 1-60 Communication Number Qualifier ID 2-2 Communication Number AN 1-256 Communication Number Qualifier ID 2-2
Page 5 of 93
S R
2010AA IC Usage change to Situational
S R R
EM, FX, TE
S
EM, EX, FX, TE
Increase from 80 - 256
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1 PER06 PER07 PER08 PER09
Communication Number Communication Number Qualifier Communication Number Contact Inquiry Reference
AN
1-80
S
ID AN AN
2-2 1-80 1-20
S S N/U
ID ID
1 2-3 1-1
S R R
NM103
PAY-TO PROVIDER NAME Entity Identifier Code Entity Type Qualifier Pay-to Provider Last or Organization Name
AN
1-35
N/U
NM104
Name First
AN
1-25
NM105 NM106
Name Middle Name Prefix
AN AN
NM107
Name Suffix
NM108 NM109 NM110 NM111
Identification Code Qualifier Pay-to Provider Identifier Entity Relationship Code Entity Identifier Code
NM1 NM101 NM102
ID
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010 PER06 EM, EX, FX, TE
PER07 PER08 PER09
Communication Number Communication Number Qualifier Communication Number Contact Inquiry Reference
AN 1-256
S
ID 2-2 AN 1-256 AN 1-20
S S N/U
ID ID
1 2-3 1-1
S R R
NM103
PAY-TO ADDRESS NAME Entity Identifier Code Entity Type Qualifier Pay-to Provider Last or Organization Name
AN
1-60
N/U
N/U
NM104
Pay-to Provider First Name
AN
1-35
N/U
1-25 1-10
N/U N/U
NM105 NM106
Pay-to Provider Middle Name AN Name Prefix AN
1-25 1-10
N/U N/U
AN
1-10
N/U
NM107
Pay-to Provider Name Suffix
AN
1-10
N/U
ID AN ID ID
1-2 2-80 2-2 2-3
N/U N/U N/U N/U
NM108 NM109 NM110 NM111
ID AN ID ID
1-2 2-80 2-2 2-3
N/U N/U N/U N/U
NM112
Identification Code Qualifier Pay-to Provider Identifier Entity Relationship Code Entity Identifier Code Name Last or Organization Name
AN
1-60
N/U
N3
PAY-TO PROVIDER ADDRESS
1
R
2010AB
1 87 2
NM1 NM101 NM102
Increase from 80 - 256 EM, EX, FX, TE Increase from 80 - 256
2010AB
Name Change
1 87 2
Increase from 35 - 60 Increase from 25 - 35 Name Change Name Change
Name Change
N3
PAY-TO PROVIDER ADDRESS
1
R
24, 34, XX
2010AB
Code Deleted
New Element
2010AB
N301
Pay-to Provider Address Line AN
1-55
R
N301
Pay-to Provider Address Line AN
1-55
R
N302
Pay-to Provider Address Line AN
1-55
S
N302
Pay-to Provider Address Line AN
1-55
S
AN
1 2-30
R R
AN
1 2-30
R R
ID
2-2
R
N402
ID
2-2
S
Usage change to Situational Usage change to
ID
3-15
R
N403
ID
3-15
S
Situational
Pay-to Provider Country Code ID Location Qualifier ID Location Identifier AN
2-3 1-2 1-30
S N/U N/U
N404 N405 N406 N407
Pay-to Provider Country Code ID Location Qualifier ID Location Identifier AN Country Subdivision Code ID
2-3 1-2 1-30 1-3
S N/U N/U S
N4 N401 N402 N403 N404 N405 N406
REF
PAY-TO PROVIDER CITY/STATE/ZIP CODE Pay-to Provider City Name Pay-to Provider State Code Pay-to Provider Postal Zone or ZIP Code
PAY-TO PROVIDER SECONDARY IDENTIFICATION
5
S
2010AB
2010AB
N4 N401
PAY-TO PROVIDER CITY/STATE/ZIP CODE Pay-to Provider City Name Pay-to Provider State Code Pay-to Provider Postal Zone or ZIP Code
2010AB
New Element Segment Deleted
0B, 1A, 1B, 1C, 1D, 1G, 1H, 1J, B3, BQ, EI, FH, G2, G5, LU, SY, X5
Page 6 of 93
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1 REF01 REF02 REF03 REF04
Reference Identification Qualifier Billing Provider Additional Identifier Description REFERENCE IDENTIFIER
ID
2-3
R
AN AN
1-30 1-80
R N/U N/U
ID
Min. Max.
Usage Reg.
Loop
Loop Repeat
2010AC
1
Values
837-I 5010
NM1 NM101 NM102 NM103 NM104 NM105 NM106 NM107
PAY TO PLAN NAME Entity Identifier Code Entity Type Qualifier Pay to Plan Organizational Name Name First Name Middle Name Prefix Name Suffix
NM112
Identification Code Qualifier Identification Code Entity Relationship Code Entity Identifier Code Name Last or Organization Name
N3 N301 N302
PAY-TO PLAN ADDRESS Pay-to Plan Address Line Pay-to Plan Address Line
NM108 NM109 NM110 NM111
N4 N401 N402 N403 N404 N405 N406 N407
PAY-TO PLAN CITY/STATE/ZIP CODE Pay-to Plan City Name Pay-to Plan State Code Pay-to Plan Postal Zone or ZIP Code Pay-to Plan Country Code Location Qualifier Location Identifier Country Subdivision Code
REF01 REF02 REF03 REF04
SECONDARY IDENTIFICATION Reference Identification Qualifier Reference Identification Description REFERENCE IDENTIFIER
REF
PAY-TO PLAN TAX IDENTIFICATION
REF
Page 7 of 93
ID ID
1 2-3 1-1
S R R
AN AN AN AN AN
1-60 1-35 1-25 1-10 1-10
R N/U N/U N/U N/U
ID AN ID ID
1-2 2-80 2-2 2-3
R R N/U N/U
AN
1-60
N/U
1 1-55 1-55
R R S
2010AC
AN AN
R R S
2010AC
AN ID
1 2-30 2-2
ID ID ID AN ID
3-15 2-3 1-2 1-30 1-3
S S N/U N/U S
1
S
2-3 1-50 1-80
R R N/U N/U
1
R
New Segment PE 2
PI, XV
New Segment
New Segment
New Segment
ID AN AN
2010AC 2U, FY, NF
New Segment 2010AC
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
REF01 REF02 REF03 REF04
Reference Identification Qualifier Reference Identification Description REFERENCE IDENTIFIER
837-I 4010A1
HL HL01 HL02 HL03 HL04
SBR SBR01 SBR02 SBR03 SBR04 SBR05 SBR06 SBR07 SBR08
SUBSCRIBER HIERARCHICAL LEVEL Hierarchical ID Number Hierarchical Parent ID Number Hierarchical Level Code Hierarchical Child Code
AN
R R
AN ID ID
1-12 1-2 1-1
R R R
1
R
ID
1-1
R
P, S, T
SBR01
ID
2-2
S
18
SBR02
AN AN ID
1-30 1-60 1-3
S S N/U
SBR03 SBR04 SBR05
Coordination of Benefits Code ID Yes/No Condition or Response Code ID Employment Status Code ID
1-1
N/U
SBR06
1-1 2-2
N/U N/U
SBR07 SBR08
Individual Relationship Code Insured Group or Policy Number Insured Group Name Insurance Type Code
SBR09
Claim Filing Indicator Code
ID
1-2
S
NM1 NM101 NM102 NM103 NM104 NM105 NM106 NM107
SUBSCRIBER NAME Entity Identifier Code Entity Type Qualifier Subscriber Last Name Subscriber First Name Subscriber Middle Name Name Prefix Subscriber Name Suffix
ID ID AN AN AN AN AN
1 2-3 1-1 1-35 1-25 1-25 1-10 1-10
R R R R S S N/U S
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010
1 1-12
SUBSCRIBER INFORMATION Payer Responsibility Sequence Number Code
ID
2000B
>1
HL HL01
22 0, 1
2000B
SBR
09, 10, 11, 12, 13, 14, 15, 16, AM, BL, CH, CI, DS, HM, LI, LM, MA, MB, MC, OF, TV, VA, WC, ZZ 2010BA
HL02 HL03 HL04
1 IL 1, 2
ID AN AN
2-3 1-50 1-80
R R N/U N/U
AN
1 1-12
R R
AN ID ID
1-12 1-2 1-1
R R R
1
R
ID
1-1
R
ID
2-2
S
AN AN ID
1-50 1-60 1-3
S S N/U
Coordination of Benefits Code ID Yes/No Condition or Response Code ID Employment Status Code ID
1-1
N/U
1-1 2-2
N/U N/U
SUBSCRIBER HIERARCHICAL LEVEL Hierarchical ID Number Hierarchical Parent ID Number Hierarchical Level Code Hierarchical Child Code SUBSCRIBER INFORMATION Payer Responsibility Sequence Number Code Individual Relationship Code Insured Group or Policy Number Insured Group Name Insurance Type Code
EI
2000B
>1
22 0, 1
2000B A, B, C, D, E, F, Code Added G, H, P, S, T, U 18 Increase from 30 - 50
SBR09
Claim Filing Indicator Code
ID
1-2
S
NM1 NM101 NM102 NM103 NM104 NM105 NM106 NM107
SUBSCRIBER NAME Entity Identifier Code Entity Type Qualifier Subscriber Last Name Subscriber First Name Subscriber Middle Name Name Prefix Subscriber Name Suffix
ID ID AN AN AN AN AN
1 2-3 1-1 1-60 1-35 1-25 1-10 1-10
R R R R S S N/U S
11, 12, 13, 14, 15, Code Change 16, 17, AM, BL, CH, CI, DS, FI, HM, LM, MA, MB, MC, OF, TV, VA, WC, ZZ 2010BA
1 IL 1, 2 Increase from 35 - 60 Increase from 25 - 35
Code Change Usage change to Required NM108
Identification Code Qualifier
ID
1-2
S
NM109 NM110
Subscriber Primary Identifier Entity Relationship Code
AN ID
2-80 2-2
S N/U
MI, ZZ
NM108
Identification Code Qualifier
ID
1-2
R
NM109 NM110
Subscriber Primary Identifier Entity Relationship Code
AN ID
2-80 2-2
R N/U
II, MI Usage change to Required
Page 8 of 93
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
NM111
Entity Identifier Code
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
N3 N301 N302
SUBSCRIBER ADDRESS Subscriber Address Line Subscriber Address Line
N4 N401
SUBSCRIBER CITY/STATE/ZIP CODE Subscriber City Name
N402 N403 N404 N405 N406
Subscriber State Code Subscriber Postal Zone or ZIP Code Subscriber Country Code Location Qualifier Location Identifier
DMG01 DMG02 DMG03 DMG04 DMG05 DMG06
SUBSCRIBER DEMOGRAPHIC INFORMATION Date Time Period Format Qualifier Subscriber Birth Date Subscriber Gender Code Marital Status Code Race or Ethnicity Code Citizenship Status Code
DMG07 DMG08 DMG09
Country Code Basis of Verification Code Quantity
DMG
REF REF01 REF02 REF03 REF04
REF
ID
2-3
N/U
NM112
Entity Identifier Code Name Last or Organization Name
AN
1-60
N/U
N3 N301 N302
SUBSCRIBER ADDRESS Subscriber Address Line Subscriber Address Line
1 1-55 1-55
S R S
2010BA
AN AN
N4 N401
SUBSCRIBER CITY/STATE/ZIP CODE Subscriber City Name
1 2-30
S R
2010BA
AN ID
2-2
S
ID ID ID AN ID
3-15 2-3 1-2 1-30 1-3
S S N/U N/U S
1
S
REF01
NM111
1 1-55 1-55
S R S
2010BA
S R
2010BA
AN
1 2-30
ID
2-2
R
N402
ID ID ID AN
3-15 2-3 1-2 1-30
R S N/U N/U
N403 N404 N405 N406 N407
1
S
ID AN ID ID ID ID
2-3 1-35 1-1 1-1 1-1 1-2
R R R N/U N/U N/U
ID ID R
2-3 1-2 1-15
N/U N/U N/U
ID
4
S
2-3
R
1-30 1-80
R N/U N/U
1
S
2-3
R
Loop
Loop Repeat
Values
837-I 5010
N/U
AN AN
SUBSCRIBER SECONDARY IDENTIFICATION Reference Identification Qualifier ID Subscriber Supplemental Identifier AN Description AN REFERENCE IDENTIFIER CASUALTY CLAIM NUMBER Reference Identification Qualifier
2-3
Usage Reg.
ID
837-I 4010A1 ID
Min. Max.
Description
2010BA
DMG01 DMG02 DMG03 DMG04 DMG05 DMG06
SUBSCRIBER DEMOGRAPHIC INFORMATION Date Time Period Format Qualifier Subscriber Birth Date Subscriber Gender Code Marital Status Code Race or Ethnicity Code Citizenship Status Code
ID AN ID ID ID ID
2-3 1-35 1-1 1-1 1-1 1-2
R R R N/U N/U N/U
DMG07 DMG08 DMG09 DMG10 DMG11
Country Code Basis of Verification Code Quantity Code List Qualifier Code Industry Code
ID ID R ID AN
2-3 1-2 1-15 1-3 1-30
N/U N/U N/U N/U N/U
1
S
2-3
R
1-50 1-80
R N/U N/U
1
S
2-3
R
DMG D8 CCYYMMDD F, M, U
2010BA
REF 1W, 23, IG, SY
REF01 REF02 REF03 REF04
2010BA
REF Y4
Subscriber State Code Subscriber Postal Zone or ZIP Code Subscriber Country Code Location Qualifier Location Identifier Country Subdivision Code
New Element
REF01
SUBSCRIBER SECONDARY IDENTIFICATION Reference Identification Qualifier ID Subscriber Supplemental Identifier AN Description AN REFERENCE IDENTIFIER CASUALTY CLAIM NUMBER Reference Identification Qualifier
Page 9 of 93
ID
Usage change to Situational Usage change to Situational
New Element
2010BA D8 CCYYMMDD F, M, U
New Element New Element
2010BA Code Deleted SY Increase rom 30 - 50
2010BA Y4
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
REF02 REF03 REF04
Property Casualty Claim Number Description REFERENCE IDENTIFIER
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
REF02 REF03 REF04
Property Casualty Claim Number Description REFERENCE IDENTIFIER
837-I 4010A1
NM107
CREDIT/DEBIT CARD ACCOUNT HOLDER NAME Entity Identifier Code Entity Type Qualifier Credit or Debt Card Holder Last or Organization Name Credit or Debt Card Holder First Name Credit or Debt Card Holder Middle Name Name Prefix Credit or Debt Card Holder Name Suffix
NM108 NM109 NM110 NM111
Identification Code Qualifier Payer Identifier Entity Relationship Code Entity Identifier Code
NM1 NM101 NM102 NM103 NM104 NM105 NM106
AN AN
1-30 1-80
R N/U N/U
ID ID
1 2-3 1-1
S R R
AN
1-35
R
AN
1-25
S
AN AN
1-25 1-10
S N/U
AN
1-10
S
ID AN ID ID
1-2 2-80 2-2 2-3
R R N/U N/U
2
S
ID
2-3
R
AN AN
1-30 1-80
R N/U N/U
NM1 NM101 NM102 NM103 NM104 NM105 NM106 NM107
PAYER NAME Entity Identifier Code Entity Type Qualifier Payer Name Name First Name Middle Name Prefix Name Suffix
ID ID AN AN AN AN AN
1 2-3 1-1 1-35 1-25 1-25 1-10 1-10
R R R R N/U N/U N/U N/U
NM108 NM109 NM110 NM111
Identification Code Qualifier Payer Identifier Entity Relationship Code Entity Identifier Code
ID AN ID ID
1-2 2-80 2-2 2-3
R R N/U N/U
N3
PAYER ADDRESS
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010 Increase rom 30 - 50 AN AN
1-50 1-80
R N/U N/U
2010BB
1 AO 1, 2
MI
Segment Deleted
REF02 REF03 REF04
REF01
Min. Max.
Segment Deleted
CREDIT/DEBT CARD INFORMATION Reference Identification Qualifier Credit or Debt Card Authorization Number Description REFERENCE IDENTIFIER
REF
ID
1
S
2010BB AB, BB
2010BC
1 PR 2
PI, XV
2010BC
NM1 NM101 NM102 NM103 NM104 NM105 NM106 NM107
PAYER NAME Entity Identifier Code Entity Type Qualifier Payer Name Name First Name Middle Name Prefix Name Suffix
NM108 NM109 NM110 NM111 NM112
Identification Code Qualifier Payer Identifier Entity Relationship Code Entity Identifier Code Name Last or Organization Name
N3
PAYER ADDRESS
Page 10 of 93
ID ID AN AN AN AN AN
1 2-3 1-1 1-60 1-35 1-25 1-10 1-10
R R R R N/U N/U N/U N/U
ID AN ID ID
1-2 2-80 2-2 2-3
R R N/U N/U
AN
1-60
N/U
1
S
2010BB
Loop Change
1 PR 2
Increase from 35 - 60 Increase from 25 - 35
PI, XV
New Element
2010BB
Loop Change
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
N301 N302
Payer Address Line Payer Address Line
N4 N401
PAYER CITY/STATE/ZIP CODE Payer City Name
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Description
ID
N301 N302
Payer Address Line Payer Address Line
AN AN
1-55 1-55
R S
N4 N401
PAYER CITY/STATE/ZIP CODE Payer City Name
AN
1 2-30
R R
ID
2-2
S
ID ID ID AN ID
3-15 2-3 1-2 1-30 1-3
S S N/U N/U S
3
S
2-3 1-50 1-80
R R N/U N/U
837-I 4010A1
N402 N403 N404 N405 N406
REF REF01 REF02 REF03 REF04
Payer State Code Payer Postal Zone or ZIP Code Payer Country Code Location Qualifier Location Identifier
PAYER SECONDARY IDENTIFICATION Reference Identification Qualifier Payer Additional Identifier Description REFERENCE IDENTIFIER
1-55 1-55
R S
AN
1 2-30
R R
ID
2-2
R
N402
ID ID ID AN
3-15 2-3 1-2 1-30
R S N/U N/U
N403 N404 N405 N406 N407
ID AN AN
S
2-3 1-30 1-80
R R N/U N/U
2010BC
2010BC
REF 2U, FY, NF, TJ
REF01 REF02 REF03 REF04
REF REF01 REF02 REF03 REF04
NM1 NM101 NM102 NM103 NM104 NM105 NM106 NM107
RESPONSIBLE PARTY NAME Entity Identifier Code Entity Type Qualifier Payer Name Name First Name Middle Name Prefix Name Suffix
NM108 NM109 NM110 NM111
Identification Code Qualifier Identification Code Entity Relationship Code Entity Identifier Code
N3
RESPONSIBLE PARTY ADDRESS
Loop
Loop Repeat
Values
837-I 5010
AN AN
3
Min. Max.
Usage Reg.
Element Identifier
Payer State Code Payer Postal Zone or ZIP Code Payer Country Code Location Qualifier Location Identifier Country Subdivision Code PAYER SECONDARY IDENTIFICATION Reference Identification Qualifier Payer Additional Identifier Description REFERENCE IDENTIFIER BILLING PROVIDER SECONDARY IDENTIFICATION Reference Identification Qualifier Payer Additional Identifier Description REFERENCE IDENTIFIER
Loop Change 2010BB Usage change to Situational Usage change to Situational
New Element Loop Change 2010BB Code Change
ID AN AN
2U, EI, FY, NF Increase from 30 - 50
Segment Added
ID AN AN
1
S
2-3 1-50 1-80
R R N/U N/U
2010BB G2, LU
Segment Deleted ID ID AN AN AN AN AN
1 2-3 1-1 1-35 1-25 1-25 1-10 1-10
S R R R S S N/U S
ID AN ID ID
1-2 2-80 2-2 2-3
N/U N/U N/U N/U
1
S
2010BD
1 QD
Segment Deleted 2010BC
Page 11 of 93
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1
N302
Responsible Party Address Line Responsible Party Address Line
N4
RESPONSIBLE PARTY CITY/STATE/ZIP CODE
N301
AN
1-55
R
AN
1-55
S
1
R
Responsible Party City Name AN
2-30
R
N402
Responsible Party State Code ID
2-2
R
ID
3-15
R
ID ID AN
2-3 1-2 1-30
S N/U N/U
AN
1 1-12
S R
AN ID ID
1-12 1-2 1-1
R R R
1
R
N404 N405 N406
Responsible Party ZIP Code Responsible Party Country Code Location Qualifier Location Identifier
HL02 HL03 HL04
PATIENT HIERARCHICAL LEVEL Hierarchical ID Number Hierarchical Parent ID Number Hierarchical Level Code Hierarchical Child Code
PAT
PATIENT INFORMATION
HL HL01
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010
Segment Deleted
N401
N403
ID
2010BC
2000C
>1
HL02 HL03 HL04
PATIENT HIERARCHICAL LEVEL Hierarchical ID Number Hierarchical Parent ID Number Hierarchical Level Code Hierarchical Child Code
PAT
PATIENT INFORMATION
HL HL01
23 0 2000C
AN
1 1-12
S R
AN ID ID
1-12 1-2 1-1
R R R
1
R
2000C
>1
23 0 2000C Code Deleted
ID ID ID ID
2-2 1-1 2-2 1-1
R N/U N/U N/U
PAT05 PAT06
Individual Relationship Code Patient Location Code Employment Status Code Student Status Code Date Time Period Format Qualifier Patient Unit orDeath Basis Date for
ID AN
2-3 1-35
N/U N/U
PAT07 PAT08 PAT09
Measurement Code Patient Weight Pregnancy Indicator
ID R ID
2-2 1-10 1-1
N/U N/U N/U
NM1 NM101 NM102 NM103
PATIENT NAME Entity Identifier Code Entity Type Qualifier Patient Last Name
ID ID AN
1 2-3 1-1 1-35
R R R R
PAT01 PAT02 PAT03 PAT04
01, 04, 05, 07, 10, 15, 17, 19, 20, 21, 22, 23, 24, 29, 32, 33, 36, 39, 40, 41, 43, 53, G8
2010CA
1 QC 1
ID ID ID ID
2-2 1-1 2-2 1-1
R N/U N/U N/U
PAT05 PAT06
Individual Relationship Code Patient Location Code Employment Status Code Student Status Code Date Time Period Format Qualifier Patient Unit orDeath Basis Date for
ID AN
2-3 1-35
N/U N/U
PAT07 PAT08 PAT09
Measurement Code Patient Weight Pregnancy Indicator
ID R ID
2-2 1-10 1-1
N/U N/U N/U
NM1 NM101 NM102 NM103
PATIENT NAME Entity Identifier Code Entity Type Qualifier Patient Last Name
ID ID AN
1 2-3 1-1 1-60
R R R R
PAT01 PAT02 PAT03 PAT04
Page 12 of 93
01, 19, 20, 21, 39, 40, 53, G8
2010CA
1 QC 1 Increase from 35 - 60
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1 NM104 NM105 NM106 NM107
Patient First Name Patient Middle Name Name Prefix Patient Name Suffix
AN AN AN AN
1-25 1-25 1-10 1-10
ID
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010
R S N/U S
NM104 NM105 NM106 NM107
Patient First Name Patient Middle Name Name Prefix Patient Name Suffix
AN AN AN AN
1-35 1-25 1-10 1-10
Increase from 25 - 35 Usage change to Situational
S S N/U S
Code Deleted Usage change to Not Used NM108
Identification Code Qualifier
ID
1-2
S
NM109 NM110 NM111
Patient Primary Identifier Entity Relationship Code Entity Identifier Code
AN ID ID
2-80 2-2 2-3
S N/U N/U
MI, ZZ
NM108
Identification Code Qualifier
ID
1-2
N/U
NM109 NM110 NM111
AN ID ID
2-80 2-2 2-3
N/U N/U N/U
NM112
Patient Primary Identifier Entity Relationship Code Entity Identifier Code Name Last or Organization Name
AN
1-60
N/U
N3 N301 N302
PATIENT ADDRESS Patient Address Line Patient Address Line
1 1-55 1-55
R R S
2010CA
AN AN
N4 N401
PATIENT CITY/STATE/ZIP CODE Patient City Name
1 2-30
R R
2010CA
AN ID
2-2
S
ID ID ID AN ID
3-15 2-3 1-2 1-30 1-3
S S N/U N/U S
1
R
2-3 1-35 1-1 1-1 1-1 1-2 2-3 1-2 1-15 1-3 1-30
R R R N/U N/U N/U N/U N/U N/U N/U N/U
Usage change to Not Used
N3 N301 N302
PATIENT ADDRESS Patient Address Line Patient Address Line
N4 N401
PATIENT CITY/STATE/ZIP CODE Patient City Name
N402 N403 N404 N405 N406
DMG DMG01 DMG02 DMG03 DMG04 DMG05 DMG06 DMG07 DMG08 DMG09
Patient State Code Patient Postal Zone or ZIP Code Patient Country Code Location Qualifier Location Identifier
PATIENT DEMOGRAPHIC INFORMATION Date Time Period Format Qualifier Patient Birth Date Patient Gender Code Marital Status Code Race or Ethnicity Code Citizenship Status Code Country Code Basis of Verification Code Quantity
1 1-55 1-55
R R S
2010CA
AN AN
R R
2010CA
AN
1 2-30
ID
2-2
R
N402
ID ID ID AN
3-15 2-3 1-2 1-30
R S N/U N/U
N403 N404 N405 N406 N407
ID AN ID ID ID ID ID ID R
1
R
2-3 1-35 1-1 1-1 1-1 1-2 2-3 1-2 1-15
R R R N/U N/U N/U N/U N/U N/U
2010CA
DMG D8 CCYYMMDD F, M, U
DMG01 DMG02 DMG03 DMG04 DMG05 DMG06 DMG07 DMG08 DMG09 DMG10 DMG11
Patient State Code Patient Postal Zone or ZIP Code Patient Country Code Location Qualifier Location Identifier Country Subdivision Code PATIENT DEMOGRAPHIC INFORMATION Date Time Period Format Qualifier Patient Birth Date Patient Gender Code Marital Status Code Race or Ethnicity Code Citizenship Status Code Country Code Basis of Verification Code Quantity Code List Qualifier Code Industry Code
New Element
ID AN ID ID ID ID ID ID R ID AN
Usage change to Situational Usage change to Situational
New Element
2010CA D8 CCYYMMDD F, M, U
New Element New Element Segment Deleted
REF
PATIENT SECONDARY IDENTIFICATION NUMBER
5
S
2010CA
Page 13 of 93
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
REF01
Reference Identification Qualifier
REF02 REF03 REF04
Patient Secondary Identifier Description REFERENCE IDENTIFIER
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1
REF
PROPERTY AND CASUALTY CLAIM NUMBER Reference Identification Qualifier Property Casualty Claim Number Description REFERENCE IDENTIFIER
ID
2-3
R
AN AN
1-30 1-80
R N/U N/U
ID
2-3
R
AN AN
1-30 1-80
R N/U N/U
AN R ID
1 1-38 1-18 1-2
R R R N/U
ID
1-2
N/U R
CLM05
Facility Type Code Facility Code Qualifier Claim Frequency Code Provider or Supplier Signature Indicator
AN ID ID
1-2 1-2 1-1
R R R
A
CLM05-1 CLM05-2 CLM05-3
ID
1-1
N/U
N, Y
CLM06
ID
1-1
R
A, C
CLM07
CLM08
Medicare Assignment Code Benefits Assignment Certification Indicator
ID
1-1
R
N
CLM09
Release of Information Code
ID
1-1
R
A, I, M, N, O, Y
CLM CLM01 CLM02 CLM03 CLM04 CLM05 CLM05-1 CLM05-2 CLM05-3 CLM06
CLAIM INFORMATION Patient Account Number Total Claim Charge Amount Claim Filing Indicator Code Non-Institutional Claim Type Code HEALTH CARE SERVICE LOCATION INFORMATION
Usage Reg.
Loop
Loop Repeat
Values
1W, 23, IG, SY
S
REF02 REF03 REF04
Min. Max.
837-I 5010
1
REF01
ID
2010CA
REF Y4
1
S
ID
2-3
R
AN AN
1-50 1-80
R N/U N/U
AN R ID
1 1-38 1-18 1-2
R R R N/U
ID
1-2
N/U
Facility Type Code Facility Code Qualifier Claim Frequency Code Provider or Supplier Signature Indicator
AN ID ID
1-2 1-2 1-1
R R R
A
ID
1-1
N/U
N, Y
ID
1-1
R
A, B, C
CLM08
Medicare Assignment Code Benefits Assignment Certification Indicator
ID
1-1
R
N, W, Y
CLM09
Release of Information Code
ID
1-1
R
I, Y
REF01 REF02 REF03 REF04
2300
100
PROPERTY AND CASUALTY CLAIM NUMBER Reference Identification Qualifier Property Casualty Claim Number Description REFERENCE IDENTIFIER
CLM CLM01 CLM02 CLM03 CLM04
CLAIM INFORMATION Patient Account Number Total Claim Charge Amount Claim Filing Indicator Code Non-Institutional Claim Type Code HEALTH CARE SERVICE LOCATION INFORMATION
2010CA Y4 Increase from 30 - 50
2300
100
R
Code Added CLM07
Code Added Code Deleted
CLM10 CLM11
CLM12 CLM13 CLM14 CLM15
Patient Signature Source Code RELATED CAUSES INFORMATION
Special Program Indicator Yes/No Condition or Response Code Level of Service Code Yes/No Condition or Response Code
ID
1-1
N/U
CLM10
N/U
CLM11
ID
2-3
N/U
CLM12
ID ID
1-1 1-3
N/U N/U
CLM13 CLM14
ID
1-1
N/U
CLM15
Patient Signature Source Code RELATED CAUSES INFORMATION
Special Program Indicator Yes/No Condition or Response Code Level of Service Code Yes/No Condition or Response Code
Page 14 of 93
ID
1-1
S
P
Usage change to Situational Code Added
02, 03, 05, 09
Usage change to Situational Code Added
N/U
ID
2-3
S
ID ID
1-1 1-3
N/U N/U
ID
1-1
N/U
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
CLM18 CLM19
Participation Agreement Claim Status Code Yes/No Condition or Response Code Claim Submission Reason Code
CLM20
Delay Reason Code
DTP DTP01
DATE - DISCHARGE HOUR Date Time Qualifier Date Time Period Format Qualifier Discharge Hour
ID ID
1-1 1-2
N/U N/U
ID
1-1
R
ID
2-2
N/U
ID
1-2
S
ID
1 3-3
S R
ID AN
2-3 1-35
R R
ID
1 3-3
R R
DTP02
DATE - STATEMENT DATES Date Time Qualifier Date Time Period Format Qualifier
ID
2-3
R
DTP03
Statement From or To Date
AN
1-35
R
ID
1 3-3
S R
ID
2-3
DTP02 DTP03
DTP DTP01
DTP DTP01 DTP02
DTP03
DATE - ADMISSION DATE/HOUR Date Time Qualifier Date Time Period Format Qualifier
Admission Date and Hour
AN
1-35
ID ID
1-1 1-2
N/U N/U
ID
1-1
N/U
ID
2-2
N/U
ID
1-2
S
ID
1 3-3
S R
ID AN
2-3 1-35
R R
ID
1 3-3
S R
ID
2-3
R
Statement From and To Date AN
1-35
R
ID
1 3-3
S R
ID
2-3
R
INSTITUTIONAL CLAIM CODE Admission Type Code Admission Source Code
CLM19 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11
CLM20
Delay Reason Code
96
DTP DTP01
TM HHMM
DTP02 DTP03
DATE - DISCHARGE HOUR Date Time Qualifier Date Time Period Format Qualifier Discharge Time
434
DTP DTP01
N, Y
2300
2300
CLM18
D8, RD8 CCYYMMDDCCY YMMDD
DTP03
435
DTP DTP01
R
DT
DTP02
R
CCYYMMDDHHM M
CL103 CL104
Patient Status Code Nursing Home Code
PWK
CLAIM SUPPLEMENTAL INFORMATION
ID ID
1 1-1 1-1
S S S
ID ID
1-2 1-1
S NU
10
S
Loop
Loop Repeat
Values
837-I 5010 Participation Agreement Claim Status Code Yes/No Condition or Response Code Claim Submission Reason Code
CLM16 CLM17
2300
DTP02
DTP03
2300
DATE - STATEMENT DATES Date Time Qualifier Date Time Period Format Qualifier
DATE - ADMISSION DATE/HOUR Date Time Qualifier Date Time Period Format Qualifier
Admission Date and Hour
Usage change to Not Used
1, 2, 3, 4, 5, 6, 7, Code Added 8, 9, 10, 11, 15
2300 96 TM HHMM
Name Change Usage change to Situational
2300 434
Code Deleted RD8 CCYYMMDDCCY Name Change YMMDD
2300 435 Code Added
AN
1-35
R
S R
D8, DT CCYYMMDD, Code Added CCYYMMDDHHM M New Segment
ID
1 3-3
DTP02 DTP03
DATE - REPRICER RECEIVED DATE Date Time Qualifier Date Time Period Format Qualifier Order Date
ID AN
2-3 1-35
R R
CL1 CL101 CL102
INSTITUTIONAL CLAIM CODE Admission Type Code Admission Source Code
ID ID
1 1-1 1-1
S S S
CL103 CL104
Patient Status Code Nursing Home Code
ID ID
1-2 1-1
R NU
PWK
CLAIM SUPPLEMENTAL INFORMATION
10
S
DTP DTP01
CL1 CL101 CL102
Usage Reg.
ID
837-I 4010A1 CLM16 CLM17
Min. Max.
Description
2300 050 D8 CCYYMMDD
2300
Usage change to Required
2300
Page 15 of 93
2300
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1
ID
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010 Code Added
ID
2-2
R
PWK02 PWK03 PWK04
Attachment Report Type Code Attachment Transmission Code Report Copies Needed Entity Identifier Code
ID N0 ID
1-2 1-2 2-3
R N/U N/U
PWK05
Identification Code Qualifier
ID
1-2
S
PWK06
Attachment Control Number
AN
2-80
PWK07 PWK08 PWK09
Description ACTIONS INDICATED Request Category Code
AN
1-80
ID
CN1
CONTRACT INFORMATION
PWK01
AS, B2, B3, B4, CT, DA, DG, DS, EB, MT, NN, OB, OZ, PN, PO, PZ, RB, RR, RT AA, BM, EL, EM, FX
ID
2-2
R
PWK02 PWK03 PWK04
Attachment Report Type Code Attachment Transmission Code Report Copies Needed Entity Identifier Code
ID N0 ID
1-2 1-2 2-3
R N/U N/U
PWK05
Identification Code Qualifier
ID
1-2
S
S
PWK06
Attachment Control Number
AN
2-80
S
PWK07 PWK08 PWK09
Description ACTIONS INDICATED Request Category Code
AN
1-80
1-2
S N/U N/U
ID
1-2
N/U N/U N/U
1
S
CN1
CONTRACT INFORMATION
1
S
CN101 CN102 CN103 CN104 CN105 CN106
Contract Type Code Contract Amount Contract Percentage Contract Code Terms Discount Percent Contract Version Identifier
2-2 1-18 1-6 1-50 1-6 1-30
R S S S S S
AC
PWK01
03, 04, 05, 06, 07, 08, 09, 10, 11, 13, 15, 21, A3, A4, AM, AS, B2, B3, B4, BR, BS, BT, CB, CK, CT, D2, DA, DB, DG, DJ, DS, EB, HC, HR, I5, IR, LA, M1, MT, NN, OB, OC, OD, OE, OX, OZ, P4, P5, PE, PN, PO, PQ, PY, PZ, RB, RR, RT, RX, SG, V5, XP AA, BM, EL, EM, Code Added FT, FX
AC
Usage change to Not Used
CN101 CN102 CN103 CN104 CN105 CN106
Contract Type Code Contract Amount Contract Percentage Contract Code Terms Discount Percent Contract Version Identifier
AMT AMT01
ID R R AN R AN
2-2 1-18 1-6 1-30 1-6 1-30
R S S S S S
PAYER ESTIMATED AMOUNT DUE Amount Qualifier Code
ID
1 1-3
S R
AMT02 AMT03
Patient Responsibility Amount Credit/Debit Flag Code
R ID
1-18 1-1
R N/U
AMT AMT01
PATIENT ESTIMATED AMOUNT DUE Amount Qualifier Code
ID
1 1-3
S R
2300 01, 02, 03, 04, 05, 06, 09
ID R R AN R AN
2300 01, 02, 03, 04, 05, 06, 09
Increase from 30 - 50
Segment Deleted 2300 C5
2300 F3
AMT AMT01
PATIENT ESTIMATED AMOUNT DUE Amount Qualifier Code
Page 16 of 93
ID
1 1-3
S R
2300 F3
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1 Patient Responsibility Amount Credit/Debit Flag Code
R ID
1-18 1-1
R N/U
AMT AMT01 AMT02 AMT03
PATIENT PAID AMOUNT Amount Qualifier Code Patient Paid Amount Credit/Debit Flag Code
1 1-3 1-18 1-1
S R R N/U
2300
ID R ID
1 1-3
S R
2300
1-18 1-1
R N/U
1
S
2-3
R
4N
REF01
1-30 1-80
R N/U N/U
1, 2, 3, 4, 5, 6, 7
REF02 REF03 REF04
AMT02 AMT03
REF REF01 REF02 REF03 REF04
CREDIT/DEBIT CARD MAXIMUM AMOUNT Amount Qualifier Code ID Credit or Debit Card Maximum Amount R Credit/Debit Flag Code ID
SERVICE AUTHORIZATION EXCEPTION CODE Reference Identification Qualifier ID Service Authorization Exception Code AN Description AN REFERENCE IDENTIFIER
AMT02 AMT03
REF02 REF03 REF04
Prior Authorization Number Description REFERENCE IDENTIFIER
REF REF01 REF02 REF03
ORIGINAL REFERENCE NUMBER (ICN/DCN) Reference Identification Qualifier Claim Original Reference Number Description
Loop Repeat
Values
Patient Responsibility Amount Credit/Debit Flag Code
R ID
1-18 1-1
R N/U
Segment Deleted MA
2300
REF
REF02 REF03 REF04
REF01
Loop
Segment Deleted
REF01
PRIOR AUTHORIZATION Reference Identification Qualifier
Usage Reg.
F5
REF
REF
Min. Max.
837-I 5010
AMT02 AMT03
AMT AMT01
ID
2
S
ID
2-3
R
AN AN
1-30 1-80
R N/U N/U
1
S
ID
2-3
R
AN AN
1-30 1-80
R N/U
2300
REF 9F, G1
REF01 REF02 REF03 REF04
2300
REF F8
REF01 REF02 REF03
SERVICE AUTHORIZATION EXCEPTION CODE Reference Identification Qualifier ID Service Authorization Exception Code AN Description AN REFERENCE IDENTIFIER REFERRAL NUMBER Reference Identification Qualifier Prior Authorization or Referral Number Description REFERENCE IDENTIFIER
1
S
2-3
R
4N
1-50 1-80
R N/U N/U
1, 2, 3, 4, 5, 6, 7
1
S
ID
2-3
R
AN AN
1-50 1-80
R N/U N/U
1
S
2-3
R
1-50 1-80
R N/U N/U
1
S
ID
2-3
R
AN AN
1-50 1-80
R N/U
PRIOR AUTHORIZATION Reference Identification Qualifier ID Prior Authorization or Referral Number AN Description AN REFERENCE IDENTIFIER PAYER CLAIM CONTROL NUMBER Reference Identification Qualifier Claim Original Reference Number Description
Page 17 of 93
2300
Increase from 30 - 50
New Segment
2300 9F
# Repeats change to 1 Code Deleted
2300 G1
Increase from 30 - 50 Name Change
Name Change 2300 F8 Increase from 30 - 50
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
REF04
REFERENCE IDENTIFIER
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
REF04
REFERENCE IDENTIFIER
837-I 4010A1
REF REF01 REF02 REF03 REF04
REF REF01 REF02 REF03 REF04
REF REF01 REF02 REF03 REF04
REF REF01 REF02 REF03 REF04
REF REF01 REF02 REF03 REF04
ADJUSTED REPRICED CLAIM NUMBER Reference Identification Qualifier Adjusted Repriced Claim Reference Number Description REFERENCE IDENTIFIER
1
S
2-3
R
1-30 1-80
R N/U N/U
1
S
ID
2-3
R
AN AN
1-30 1-80
R N/U N/U
1
S
2-3
R
1-30 1-80
R N/U N/U
INVESTIGATIONAL DEVICE EXEMPTION NUMBER Reference Identification Qualifier ID Investigational Device Exemption Number AN Description AN REFERENCE IDENTIFIER CLAIM IDENTIFIER FOR TRANSMISSION INTERMEDIARIES Reference Identification Qualifier Value Added Network Trace Number Description REFERENCE IDENTIFIER DOCUMENT IDENTIFICATION CODE Reference Identification Qualifier Document ControlIdentifier Description REFERENCE IDENTIFIER
1
S
ID
2-3
R
AN AN
1-30 1-80
R N/U N/U
2
S
2-3 1-30 1-80
R R N/U N/U
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010
N/U
REPRICED CLAIM NUMBER Reference Identification Qualifier ID Repriced Claim Reference Number AN Description AN REFERENCE IDENTIFIER
ID
2300
REF 9A
REF01 REF02 REF03 REF04
2300
REF 9C
REF01 REF02 REF03 REF04
2300
REF LX
REF01 REF02 REF03 REF04
2300
REF D9
REF01 REF02 REF03 REF04
N/U
REPRICED CLAIM NUMBER Reference Identification Qualifier ID Repriced Claim Reference Number AN Description AN REFERENCE IDENTIFIER
1
S
2-3
R
1-50 1-80
R N/U N/U
1
S
ID
2-3
R
AN AN
1-50 1-80
R N/U N/U
5
S
2-3
R
1-50 1-80
R N/U N/U
1
S
ID
2-3
R
Clearinghouse Trace Number AN Description AN REFERENCE IDENTIFIER
1-50 1-80
R N/U N/U
ADJUSTED REPRICED CLAIM NUMBER Reference Identification Qualifier Adjusted Repriced Claim Reference Number Description REFERENCE IDENTIFIER
9A Increase from 30 - 50
2300 9C Increase from 30 - 50
INVESTIGATIONAL DEVICE EXEMPTION NUMBER Reference Identification Qualifier ID Investigational Device Exemption Number AN Description AN REFERENCE IDENTIFIER CLAIM IDENTIFIER FOR TRANSMISSION INTERMEDIARIES Reference Identification Qualifier
2300
2300 LX Increase from 30 - 50
2300 D9 Increase from 30 - 50 Name Change
Segment Deleted
ID AN AN
2300 DD
REF
AUTO ACCIDENT STATE
Page 18 of 93
1
S
2300
New Segment
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1
REF02 REF03 REF04
REF01 REF02 REF03 REF04
REF REF01 REF02 REF03 REF04
REF REF01 REF02 REF03 REF04
MEDICAL RECORD NUMBER Reference Identification Qualifier Medical Record Number Description REFERENCE IDENTIFIER DEMONSTRATION PROJECT IDENTIFIER Reference Identification Qualifier Demonstration Project Identifier Description REFERENCE IDENTIFIER PEER REVIEW ORGANIZARION (PRO) APPROVAL NUMBER Reference Identification Qualifier PRO Number Description REFERENCE IDENTIFIER
K303
FILE INFORMATION Fixed Format Information Record Format Code COMPOSITE UNIT OF MEASURE
NTE
CLAIM NOTE
K3 K301 K302
1
S
2-3 1-30 1-80
R R N/U N/U
1
S
ID
2-3
R
AN AN
1-30 1-80
R N/U N/U
ID AN AN
1
S
ID AN AN
2-3 1-30 1-80
R R N/U N/U
AN ID
10 1-80 1-2
S R N/U
2300
REF EA
2300
S
NTE01 NTE02
Note Reference Code Claim Note Text
ID AN
3-3 1-80
R R
NTE NTE01
BILLING NOTE Note Reference Code
ID
1 3-3
S R
REF01 REF02 REF03 REF04
REF P4
REF01 REF02 REF03 REF04
2300
REF G4
2300
REF01 REF02 REF03 REF04
2300 ALG, DCP, DGN, DME, MED, NTR, ODT, RHB, RLH, RNH, SET, SFM, SPT, UPI
2300 ADD
Reference Identification Qualifier Auto Accident State or Province Description REFERENCE IDENTIFIER MEDICAL RECORD NUMBER Reference Identification Qualifier Medical Record Number Description REFERENCE IDENTIFIER DEMONSTRATION PROJECT IDENTIFIER Reference Identification Qualifier Demonstration Project Identifier Description REFERENCE IDENTIFIER PEER REVIEW ORGANIZARION (PRO) APPROVAL NUMBER Reference Identification Qualifier PRO Number Description REFERENCE IDENTIFIER
K303
FILE INFORMATION Fixed Format Information Record Format Code COMPOSITE UNIT OF MEASURE
NTE
CLAIM NOTE
K3 K301 K302
N/U 10
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010 REF01
REF
ID
ID
2-3
R
AN AN
1-50 1-80
R N/U N/U
1
S
2-3 1-50 1-80
R R N/U N/U
1
S
ID
2-3
R
AN AN
1-50 1-80
R N/U N/U
1
S
ID AN AN
2-3 1-50 1-80
R R N/U N/U
AN ID
10 1-80 1-2
S R N/U
ID AN AN
2300 EA Increase from 30 - 50
2300 P4 Increase from 30 - 50
2300 G4 Increase from 30 - 50
2300
N/U 10
S
NTE01 NTE02
Note Reference Code Claim Note Text
ID AN
3-3 1-80
R R
NTE NTE01
BILLING NOTE Note Reference Code
ID
1 3-3
S R
Page 19 of 93
LU
2300 ALG, DCP, DGN, DME, MED, NTR, ODT, RHB, RLH, RNH, SET, SFM, SPT, UPI
2300 ADD
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
NTE02
Billing Note Text
CR6
HOME HEALTH CARE INFORMATION
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
ID
NTE02
Billing Note Text
AN
837-I 4010A1
CR601 CR602 CR603 CR604 CR605 CR606
Prognosis Indicator Service From Date Date Time Period Format Qualifier Home Health Certification Period Diagnosis Date Skilled Nursing Facility Indicator
CR615 CR616
Medicare Coverage Indicator Certification Type Indicator Surgery Date Product or Service ID Qualifier Surgical Procedure Code Physician Order Date Last Visit Date Physician Contact Date Date Time Period Format Qualifier Last Admission Period
CR617 CR618 CR619 CR620 CR621
Patient Discharge Facility Type Code Diagnosis Date Diagnosis Date Diagnosis Date Diagnosis Date
CR607 CR608 CR609 CR610 CR611 CR612 CR613 CR614
AN
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010
1-80
R
1
S
ID DT
1-1 8-8
R R
1, 2, 3, 4, 5, 6, 7, 8 CCYYMMDD
ID
2-3
S
RD8
AN DT
1-35 8-8
S R
CCYYMMDD
ID
1-1
R
N, U, Y
ID ID DT
1-1 1-1 8-8
R R
N, Y I, R, S CCYYMMDD
ID AN DT DT DT
2-2 1-15 8-8 8-8 8-8
S S S S S
HC, ID
ID AN
2-3 1-35
S S
1-80
R Segment Deleted
ID DT DT DT DT
1-1 8-8 8-8 8-8 8-8
2300
CCYYMMDD CCYYMMDD CCYYMMDD RD8 A, B, C, D, E, F, G, H, L, M, O, R, S, T CCYYMMDD CCYYMMDD CCYYMMDD CCYYMMDD
R S S S S
Segment Deleted CRC CRC01 CRC02
HOME HEALTH FUNCTIONAL LIMITATIONS Code Category Certification Condition Indicator
ID
3 2-2
S R
ID
1-1
R
N, Y AA, AL, BL, CO, DY, EL, HL, LB, OL, PA, SL
CRC03
Functional Limitations Code
ID
2-2
R
CRC04
Functional Limitations Code
ID
2-2
S
CRC05
Functional Limitations Code
ID
2-2
S
CRC06
Functional Limitations Code
ID
2-2
S
CRC07
Functional Limitations Code
ID
2-2
S
2300 75
Page 20 of 93
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1
ID
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010 Segment Deleted
CRC CRC01
HOME HEALTH FUNCTIONAL LIMITATIONS Code Category
ID
3 2-2
S R
CRC02
Functional Limitations Code
ID
1-1
R
N, Y BR, CA, CB, CR, EP, IH, NR, PW, TR, UT, WA, WR
CRC03
Activities Permitted Code
ID
2-2
R
CRC04
Activities Permitted Code
ID
2-2
S
CRC05
Activities Permitted Code
ID
2-2
S
CRC06
Activities Permitted Code
ID
2-2
S
CRC07
Activities Permitted Code
ID
2-2
S
2
S
2300 76
Segment Deleted
CRC01
HOME HEALTH MENTAL STATUS Certification Condition Indicator
ID
2-2
R
77
CRC02
Functional Limitations Code
ID
1-1
R
CRC03 CRC04 CRC05 CRC06 CRC07
Mental Status Code Mental Status Code Mental Status Code Mental Status Code Mental Status Code
ID ID ID ID ID
2-2 2-2 2-2 2-2 2-2
R S S S S
N, Y AG, CM, DI, DP, FO, LE, MC, OT
CRC
2300
CRC CRC01 CRC02 CRC03 CRC04 CRC05 CRC06 CRC07
EPSDT REFERRAL Code Category Certification Condition Indicator Condition Code Condition Code Condition Code Condition Indicator Condition Indicator
ID
1 2-2
S R
ID ID ID ID ID ID
1-1 2-3 2-3 2-3 2-3 2-3
R R S S N/U N/U
1
R
ID AN
1-3 1-30
R R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
New Segment
2300 ZZ N, Y AV, NU, S2, ST AV, NU, S2, ST AV, NU, S2, ST
Usage change to Required HI HI01 HI01-1 HI01-2 HI01-3 HI01-4 HI01-5 HI01-6 HI01-7
PRINCIPAL DIAGNOSIS HEALTH CARE CODE INFORMATION Code List Qualifier Code Industry Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
1
S
ID AN
1-3 1-30
R R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
2300
HI
BK
HI01 HI01-1 HI01-2 HI01-3 HI01-4 HI01-5 HI01-6 HI01-7
PRINCIPAL DIAGNOSIS HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
Page 21 of 93
2300
ABK, BK
Name Change Name Change
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION
AN
1-30
N/U
ID
1-1
S
Loop
Loop Repeat
Values
837-I 5010 HI01-8 HI01-9
HI02
Usage Reg.
ID
837-I 4010A1
HEALTH CARE CODE INFORMATION
Min. Max.
Description
S
HI02
New Element New Element N, U, W, Y Usage change to Not Used
N/U Usage change to Not Used Name Change
HI02-1
Code List Qualifier Code
ID
1-3
R
BJ, ZZ
HI02-1
Diagnosis Type Code
ID
1-3
N/U Usage change to Not Used Name Change
HI02-2 HI02-3 HI02-4 HI02-5 HI02-6 HI02-7
Industry Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
AN
1-30
R
HI02-2
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
HI02-3 HI02-4 HI02-5 HI02-6 HI02-7 HI02-8 HI02-9
HI03
HEALTH CARE CODE INFORMATION
S
HI03
Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION
AN
1-30
N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
New Element New Element Usage change to Not Used
N/U Usage change to Not Used Name Change
HI03-1
Code List Qualifier Code
ID
1-3
R
BN
HI03-1
Diagnosis Type Code
ID
1-3
N/U Usage change to Not Used Name Change
HI03-2 HI03-3 HI03-4 HI03-5 HI03-6 HI03-7
Industry Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
AN
1-30
R
HI03-2
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
HI03-3 HI03-4 HI03-5 HI03-6 HI03-7 HI03-8 HI03-9
HI04
HEALTH CARE CODE INFORMATION
N/U
HI04 HI04-1 HI04-2 HI04-3 HI04-4 HI04-5 HI04-6 HI04-7 HI04-8 HI04-9
Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator
Page 22 of 93
AN
1-30
N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
New Element New Element
New Element New Element New Element New Element New Element New Element New Element New Element New Element
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
HI05
HEALTH CARE CODE INFORMATION
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1 N/U
HI05 HI05-1 HI05-2
HI05-9 HI06
N/U
HI06 HI06-1 HI06-2 HI06-3 HI06-4 HI06-5 HI06-6 HI06-7 HI06-8 HI06-9
HI07
HEALTH CARE CODE INFORMATION
N/U
HI07 HI07-1 HI07-2 HI07-3 HI07-4 HI07-5 HI07-6 HI07-7 HI07-8 HI07-9
HI08
HEALTH CARE CODE INFORMATION
N/U
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010
HI05-3 HI05-4 HI05-5 HI05-6 HI05-7 HI05-8
HEALTH CARE CODE INFORMATION
ID
HI08 HI08-1 HI08-2 HI08-3 HI08-4 HI08-5 HI08-6 HI08-7
HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
Page 23 of 93
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R
2-3 1-35 1-18 1-15
N/U N/U N/U N/U
AN AN
1-30 1-30
N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
New Element New Element New Element New Element New Element New Element New Element New Element New Element
New Element New Element New Element New Element New Element New Element New Element New Element New Element
New Element New Element New Element New Element New Element New Element New Element New Element New Element
New Element New Element New Element New Element New Element New Element New Element
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount
AN
1-30
N/U
ID
1-1
N/U
HI08-9 N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
HI09 HI09-1 HI09-2 HI09-3 HI09-4 HI09-5 HI09-6 HI09-7 HI09-8 HI09-9
HI10
HEALTH CARE CODE INFORMATION
ID
1-1
N/U
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
HI10 HI10-1 HI10-2 HI10-3 HI10-4 HI10-5 HI10-6 HI10-7 HI10-8 HI10-9
HI11
HEALTH CARE CODE INFORMATION
ID
1-1
N/U
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
HI11 HI11-1 HI11-2 HI11-3 HI11-4 HI11-5 HI11-6 HI11-7 HI11-8 HI11-9
HI12
HEALTH CARE CODE INFORMATION
ID
1-1
N/U
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R
2-3 1-35 1-18
N/U N/U N/U
Loop
Loop Repeat
Values
837-I 5010 HI08-8
HI09
Usage Reg.
ID
837-I 4010A1
HEALTH CARE CODE INFORMATION
Min. Max.
Description
HI12 HI12-1 HI12-2 HI12-3 HI12-4 HI12-5
Page 24 of 93
New Element New Element
New Element New Element New Element New Element New Element New Element New Element New Element New Element
New Element New Element New Element New Element New Element New Element New Element New Element New Element
New Element New Element New Element New Element New Element New Element New Element New Element New Element
New Element New Element New Element New Element New Element
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1
ID
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010 HI12-6 HI12-7 HI12-8 HI12-9 HI HI01 HI01-1 HI01-2 HI01-3 HI01-4 HI01-5 HI01-6 HI01-7 HI01-8 HI01-9 HI02 HI02-1 HI02-2 HI02-3 HI02-4 HI02-5 HI02-6 HI02-7 HI02-8 HI02-9 HI03 HI03-1 HI03-2 HI03-3 HI03-4 HI03-5 HI03-6 HI03-7 HI03-8 HI03-9 HI04 HI04-1 HI04-2
Quantity Version Identifier Industry code Present on Admission indicator ADMITTING DISGNOSIS HEALTH CARE CODE INFORMATION Diagnosis Type Code Admitting Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code
Page 25 of 93
R AN AN
1-15 1-30 1-30
N/U N/U N/U
ID
1-1
N/U
1
R
ID AN
1-3 1-30
R R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
N/U N/U N/U
New Element New Element New Element New Element
New Segment
2300
ABJ, BJ
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1
ID
Min. Max.
Usage Reg.
837-I 5010 HI04-3 HI04-4 HI04-5 HI04-6 HI04-7 HI04-8 HI04-9 HI05 HI05-1 HI05-2 HI05-3 HI05-4 HI05-5 HI05-6 HI05-7 HI05-8 HI05-9 HI06 HI06-1 HI06-2 HI06-3 HI06-4 HI06-5 HI06-6 HI06-7 HI06-8 HI06-9 HI07 HI07-1 HI07-2 HI07-3 HI07-4 HI07-5 HI07-6 HI07-7 HI07-8 HI07-9 HI08
Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION
Page 26 of 93
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U N/U
Loop
Loop Repeat
Values
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Min. Max.
Usage Reg.
Description
ID
Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator
ID AN
1-3 1-30
N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
837-I 4010A1
837-I 5010 HI08-1 HI08-2 HI08-3 HI08-4 HI08-5 HI08-6 HI08-7 HI08-8 HI08-9 HI09 HI09-1 HI09-2 HI09-3 HI09-4 HI09-5 HI09-6 HI09-7 HI09-8 HI09-9 HI10 HI10-1 HI10-2 HI10-3 HI10-4 HI10-5 HI10-6 HI10-7 HI10-8 HI10-9 HI11 HI11-1 HI11-2 HI11-3 HI11-4 HI11-5 HI11-6 HI11-7 HI11-8 HI11-9
Page 27 of 93
Loop
Loop Repeat
Values
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1
ID
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010 HI12 HI12-1 HI12-2 HI12-3 HI12-4 HI12-5 HI12-6 HI12-7 HI12-8 HI12-9
HI HI01 HI01-1 HI01-2 HI01-3 HI01-4 HI01-5 HI01-6 HI01-7 HI01-8 HI01-9 HI02 HI02-1 HI02-2 HI02-3 HI02-4 HI02-5 HI02-6 HI02-7 HI02-8 HI02-9 HI03 HI03-1 HI03-2 HI03-3 HI03-4 HI03-5
HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator PATIENT REASON FOR VISIT HEALTH CARE CODE INFORMATION Diagnosis Type Code Patient Reason For Visit Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Diagnosis Type Code Patient Reason For Visit Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Diagnosis Type Code Patient Reason For Visit Date Time Period Format Qualifier Date Time Period Monetary Amount
Page 28 of 93
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
1
R
ID AN
1-3 1-30
R R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN R
2-3 1-35 1-18
N/U N/U N/U
New Segment 2300
APR, PR
APR, PR
APR, PR
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1
ID
Min. Max.
Usage Reg.
837-I 5010 HI03-6 HI03-7 HI03-8 HI03-9 HI04 HI04-1 HI04-2 HI04-3 HI04-4 HI04-5 HI04-6 HI04-7 HI04-8 HI04-9 HI05 HI05-1 HI05-2 HI05-3 HI05-4 HI05-5 HI05-6 HI05-7 HI05-8 HI05-9 HI06 HI06-1 HI06-2 HI06-3 HI06-4 HI06-5 HI06-6 HI06-7 HI06-8 HI06-9 HI07 HI07-1 HI07-2 HI07-3
Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier
Page 29 of 93
R AN AN
1-15 1-30 1-30
N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID
2-3
N/U
Loop
Loop Repeat
Values
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Min. Max.
Usage Reg.
Description
ID
Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code
AN R R AN AN
1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
N/U N/U N/U
837-I 4010A1
837-I 5010 HI07-4 HI07-5 HI07-6 HI07-7 HI07-8 HI07-9 HI08 HI08-1 HI08-2 HI08-3 HI08-4 HI08-5 HI08-6 HI08-7 HI08-8 HI08-9 HI09 HI09-1 HI09-2 HI09-3 HI09-4 HI09-5 HI09-6 HI09-7 HI09-8 HI09-9 HI10 HI10-1 HI10-2 HI10-3 HI10-4 HI10-5 HI10-6 HI10-7 HI10-8 HI10-9 HI11 HI11-1 HI11-2
Page 30 of 93
Loop
Loop Repeat
Values
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1
ID
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010 HI11-3 HI11-4 HI11-5 HI11-6 HI11-7 HI11-8 HI11-9 HI12 HI12-1 HI12-2 HI12-3 HI12-4 HI12-5 HI12-6 HI12-7 HI12-8 HI12-9
HI HI01 HI01-1 HI01-2 HI01-3 HI01-4 HI01-5 HI01-6 HI01-7 HI01-8 HI01-9 HI02 HI02-1 HI02-2 HI02-3 HI02-4 HI02-5 HI02-6 HI02-7
Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator EXTERNAL CAUSE OF INJURY HEALTH CARE CODE INFORMATION Diagnosis Type Code External Cause of Injury Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code External Cause of Injury Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
Page 31 of 93
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
1
R
ID
1-3
R R
AN
1-30
R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
S
N, U, W, Y
ID
1-3
S R
ABN, BN
AN
1-30
R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
New Segment 2300
ABN, BN
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Min. Max.
Usage Reg.
Loop Repeat
Description
ID
Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code
AN
1-30
N/U
ID
1-1
S
N, U, W, Y
ID
1-3
S R
ABN, BN
External Cause of Injury Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code
AN
1-30
R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
S
N, U, W, Y
ID
1-3
S R
ABN, BN
AN
1-30
R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
N, U, W, Y
ID AN
1-3 1-30
S R R
ABN, BN
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
S
N, U, W, Y
ABN, BN
837-I 4010A1
Loop
Values
837-I 5010 HI02-8 HI02-9 HI03 HI03-1 HI03-2 HI03-3 HI03-4 HI03-5 HI03-6 HI03-7 HI03-8 HI03-9 HI04 HI04-1
HI06 HI06-1
External Cause of Injury Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code
ID
1-3
S R
HI06-2
External Cause of Injury Code AN
1-30
R
HI04-2 HI04-3 HI04-4 HI04-5 HI04-6 HI04-7 HI04-8 HI04-9 HI05 HI05-1 HI05-2 HI05-3 HI05-4 HI05-5 HI05-6 HI05-7 HI05-8 HI05-9
Page 32 of 93
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1
ID
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010 HI06-3 HI06-4 HI06-5 HI06-6 HI06-7 HI06-8 HI06-9 HI07 HI07-1 HI07-2 HI07-3 HI07-4 HI07-5 HI07-6 HI07-7 HI07-8 HI07-9 HI08 HI08-1 HI08-2 HI08-3 HI08-4 HI08-5 HI08-6 HI08-7 HI08-8 HI08-9 HI09 HI09-1 HI09-2 HI09-3 HI09-4 HI09-5 HI09-6 HI09-7 HI09-8
Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code External Cause of Injury Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code External Cause of Injury Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code External Cause of Injury Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code
Page 33 of 93
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
S
N, U, W, Y
ID
1-3
S R
ABN, BN
AN
1-30
R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
S
N, U, W, Y
ID
1-3
S R
ABN, BN
AN
1-30
R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
S
N, U, W, Y
ID
1-3
S R
ABN, BN
AN
1-30
R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1
HI10 HI10-1 HI10-2 HI10-3 HI10-4 HI10-5 HI10-6 HI10-7 HI10-8 HI10-9 HI11 HI11-1 HI11-2 HI11-3 HI11-4 HI11-5 HI11-6 HI11-7 HI11-8 HI11-9 HI12 HI12-1
R
2300
External Cause of Injury Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code External Cause of Injury Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code
HI12-9
HI
DIAGNOSIS RELATED GROUP (DRG) INFORMATION
HI12-3 HI12-4 HI12-5 HI12-6 HI12-7 HI12-8
1
Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code
External Cause of Injury Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator
HI12-2
HI
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010 HI09-9
DIAGNOSIS RELATED GROUP (DRG) INFORMATION
ID
Page 34 of 93
ID
1-1
S
N, U, W, Y
ID
1-3
S R
ABN, BN
AN
1-30
R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
S
N, U, W, Y
ID
1-3
S R
ABN, BN
AN
1-30
R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
S
N, U, W, Y
ID
1-3
S R
ABN, BN
AN
1-30
R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
S
1
R
N, U, W, Y
2300
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1 HI01 HI01-1 HI01-2 HI01-3 HI01-4 HI01-5 HI01-6 HI01-7
HEALTH CARE CODE INFORMATION Code List Qualifier Code DRG Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
ID AN
1-3 1-30
R R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
HI02
S
DR
HI01 HI01-1 HI01-2 HI01-3 HI01-4 HI01-5 HI01-6 HI01-7 HI01-8
HI02 HI02-1 HI02-2 HI02-3 HI02-4 HI02-5 HI02-6 HI02-7 HI02-8 HI02-9
HI03
HEALTH CARE CODE INFORMATION
N/U
HI03 HI03-1 HI03-2 HI03-3 HI03-4 HI03-5 HI03-6 HI03-7 HI03-8 HI03-9
HI04
HEALTH CARE CODE INFORMATION
N/U
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010
HI01-9 HEALTH CARE CODE INFORMATION
ID
HI04 HI04-1 HI04-2 HI04-3 HI04-4 HI04-5 HI04-6 HI04-7 HI04-8
HEALTH CARE CODE INFORMATION Qualifier DRG Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code
Page 35 of 93
ID AN
1-3 1-30
R R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
DR
Name Change
New Element New Element
New Element New Element New Element New Element New Element New Element New Element New Element New Element
New Element New Element New Element New Element New Element New Element New Element New Element New Element
New Element New Element New Element New Element New Element New Element New Element New Element
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1 HEALTH CARE CODE INFORMATION
N/U
HI05 HI05-1 HI05-2 HI05-3 HI05-4 HI05-5 HI05-6 HI05-7 HI05-8 HI05-9
HI06
HEALTH CARE CODE INFORMATION
N/U
HI06 HI06-1 HI06-2 HI06-3 HI06-4 HI06-5 HI06-6 HI06-7 HI06-8 HI06-9
HI07
HEALTH CARE CODE INFORMATION
N/U
HI07 HI07-1 HI07-2 HI07-3 HI07-4 HI07-5 HI07-6 HI07-7 HI07-8 HI07-9
HI08
HEALTH CARE CODE INFORMATION
N/U
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010 HI04-9
HI05
ID
HI08 HI08-1 HI08-2 HI08-3 HI08-4 HI08-5 HI08-6
Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity
Page 36 of 93
New Element ID
1-1
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R
2-3 1-35 1-18 1-15
N/U N/U N/U N/U
New Element New Element New Element New Element New Element New Element New Element New Element New Element
New Element New Element New Element New Element New Element New Element New Element New Element New Element
New Element New Element New Element New Element New Element New Element New Element New Element New Element
New Element New Element New Element New Element New Element New Element
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period
AN AN
1-30 1-30
N/U N/U
ID
1-1
N/U
HI08-9 N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
HI09 HI09-1 HI09-2 HI09-3 HI09-4 HI09-5 HI09-6 HI09-7 HI09-8 HI09-9
HI10
HEALTH CARE CODE INFORMATION
ID
1-1
N/U
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
HI10 HI10-1 HI10-2 HI10-3 HI10-4 HI10-5 HI10-6 HI10-7 HI10-8 HI10-9
HI11
HEALTH CARE CODE INFORMATION
ID
1-1
N/U
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
HI11 HI11-1 HI11-2 HI11-3 HI11-4 HI11-5 HI11-6 HI11-7 HI11-8 HI11-9
HI12
HEALTH CARE CODE INFORMATION
ID
1-1
N/U
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN
2-3 1-35
N/U N/U
Loop
Loop Repeat
Values
837-I 5010 HI08-7 HI08-8
HI09
Usage Reg.
ID
837-I 4010A1
HEALTH CARE CODE INFORMATION
Min. Max.
Description
HI12 HI12-1 HI12-2 HI12-3 HI12-4
Page 37 of 93
New Element New Element New Element
New Element New Element New Element New Element New Element New Element New Element New Element New Element
New Element New Element New Element New Element New Element New Element New Element New Element New Element
New Element New Element New Element New Element New Element New Element New Element New Element New Element
New Element New Element New Element New Element
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1
HI12-9
HI01 HI01-1 HI01-2 HI01-3 HI01-4 HI01-5 HI01-6 HI01-7
OTHER DIAGNOSIS INFORMATION HEALTH CARE CODE INFORMATION Code List Qualifier Code Other Diagnosis Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
2
R
2300
HI
R ID AN
1-3 1-30
R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
HI01 BF
HI01-1 HI01-2 HI01-3 HI01-4 HI01-5 HI01-6 HI01-7 HI01-8 HI01-9
HI02 HI02-1 HI02-2 HI02-3 HI02-4 HI02-5 HI02-6 HI02-7
HEALTH CARE CODE INFORMATION Code List Qualifier Code Other Diagnosis Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
S ID AN
1-3 1-30
R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
HI02 BF
HI02-1 HI02-2 HI02-3 HI02-4 HI02-5 HI02-6 HI02-7 HI02-8 HI02-9
HI03 HI03-1 HI03-2 HI03-3 HI03-4 HI03-5 HI03-6 HI03-7
HEALTH CARE CODE INFORMATION Code List Qualifier Code Other Diagnosis Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
S ID AN
1-3 1-30
R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010 HI12-5 HI12-6 HI12-7 HI12-8
HI
ID
HI03 BF
HI03-1 HI03-2 HI03-3 HI03-4 HI03-5 HI03-6 HI03-7 HI03-8
Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator
R R AN AN
1-18 1-15 1-30 1-30
N/U N/U N/U N/U
ID
1-1
N/U
2
R
OTHER DIAGNOSIS INFORMATION HEALTH CARE CODE INFORMATION
2300
R
Diagnosis Type Code Other Diagnosis Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION
ID AN
1-3 1-30
R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
S
Diagnosis Type Code Other Diagnosis Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION
ID AN
1-3 1-30
R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
Diagnosis Type Code Other Diagnosis Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code
ID AN
1-3 1-30
R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
Page 38 of 93
New Element New Element New Element New Element New Element
ABF, BF
Name Change Code Added
New Element New Element N, U, W, Y
S ABF, BF
Name Change Code Added
New Element New Element N, U, W, Y
S ABF, BF
Name Change Code Added
New Element
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1
HI04-1 HI04-2 HI04-3 HI04-4 HI04-5 HI04-6 HI04-7
HEALTH CARE CODE INFORMATION Code List Qualifier Code Other Diagnosis Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
S ID AN
1-3 1-30
R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
HI04 BF
HI05 HI05-1 HI05-2 HI05-3 HI05-4 HI05-5 HI05-6 HI05-7
Code List Qualifier Code Other Diagnosis Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
1-3 1-30
R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
HI06 HI06-1 HI06-2 HI06-3 HI06-4 HI06-5 HI06-6 HI06-7
Code List Qualifier Code Other Diagnosis Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
ID AN
1-3 1-30
R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
Diagnosis Type Code Other Diagnosis Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION
ID AN
1-3 1-30
R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
HI07
Diagnosis Type Code Other Diagnosis Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION
HI07-1 HI07-2
Diagnosis Type Code Other Diagnosis
ID AN
HI05-1 HI05-2
HI06-1 HI06-2 HI06-3 HI06-4 HI06-5 HI06-6 HI06-7 HI06-8 HI06-9
HI07
HEALTH CARE CODE INFORMATION
HI07-1 HI07-2
Code List Qualifier Code Other Diagnosis
S ID AN
1-3 1-30
R R
Loop Repeat
Values
BF
Page 39 of 93
N, U, W, Y
S
2-3 1-35 1-18 1-15 1-30 1-30
HI06 BF
N/U
ID AN R R AN AN
HI05-3 HI05-4 HI05-5 HI05-6 HI05-7 HI05-8
S
1-1
R R
HI05-9 HEALTH CARE CODE INFORMATION
Loop
New Element ID
1-3 1-30
HI05 BF
Present on Admission indicator HEALTH CARE CODE INFORMATION
ID AN
HI04-3 HI04-4 HI04-5 HI04-6 HI04-7 HI04-8
S ID AN
Usage Reg.
Diagnosis Type Code Other Diagnosis Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION
HI04-1 HI04-2
HI04-9 HEALTH CARE CODE INFORMATION
Min. Max.
837-I 5010 HI03-9
HI04
ID
ABF, BF
Name Change Code Added
New Element New Element N, U, W, Y
S ABF, BF
Name Change Code Added
New Element New Element N, U, W, Y
S ABF, BF
Name Change Code Added
New Element New Element N, U, W, Y
S 1-3 1-30
R R
ABF, BF
Name Change Code Added
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
HI07-3 HI07-4 HI07-5 HI07-6 HI07-7
Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1 ID AN R R AN
2-3 1-35 1-18 1-15 1-30
HI08 HI08-1 HI08-2 HI08-3 HI08-4 HI08-5 HI08-6 HI08-7
Code List Qualifier Code Other Diagnosis Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
N/U N/U N/U N/U N/U
HI07-3 HI07-4 HI07-5 HI07-6 HI07-7 HI07-8
S ID AN
1-3 1-30
R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
HI08 BF
HI08-1 HI08-2 HI08-3 HI08-4 HI08-5 HI08-6 HI08-7 HI08-8 HI08-9
HI09 HI09-1 HI09-2 HI09-3 HI09-4 HI09-5 HI09-6 HI09-7
HEALTH CARE CODE INFORMATION Code List Qualifier Code Other Diagnosis Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
S ID AN
1-3 1-30
R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
HI09 BF
HI09-1 HI09-2 HI09-3 HI09-4 HI09-5 HI09-6 HI09-7 HI09-8 HI09-9
HI10 HI10-1 HI10-2 HI10-3 HI10-4 HI10-5 HI10-6 HI10-7
HEALTH CARE CODE INFORMATION Code List Qualifier Code Other Diagnosis Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
S ID AN
1-3 1-30
R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010
HI07-9 HEALTH CARE CODE INFORMATION
ID
HI10 BF
HI10-1 HI10-2 HI10-3 HI10-4 HI10-5 HI10-6 HI10-7 HI10-8
Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
N, U, W, Y
S
Diagnosis Type Code Other Diagnosis Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION
ID AN
1-3 1-30
R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
Diagnosis Type Code Other Diagnosis Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION
ID AN
1-3 1-30
R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
Diagnosis Type Code Other Diagnosis Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code
ID AN
1-3 1-30
R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
Page 40 of 93
New Element New Element
ABF, BF
Name Change Code Added
New Element New Element N, U, W, Y
S ABF, BF
Name Change Code Added
New Element New Element N, U, W, Y
S ABF, BF
Name Change Code Added
New Element
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1
HI11-1 HI11-2 HI11-3 HI11-4 HI11-5 HI11-6 HI11-7
HEALTH CARE CODE INFORMATION Code List Qualifier Code Other Diagnosis Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
S ID AN
1-3 1-30
R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
HI11 BF
HI11-1 HI11-2 HI11-3 HI11-4 HI11-5 HI11-6 HI11-7 HI11-8 HI11-9
HI12 HI12-1 HI12-2 HI12-3 HI12-4 HI12-5 HI12-6 HI12-7
HEALTH CARE CODE INFORMATION Code List Qualifier Code Other Diagnosis Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
S ID AN
1-3 1-30
R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
HI12 BF
HI12-1 HI12-2 HI12-3 HI12-4 HI12-5 HI12-6 HI12-7 HI12-8 HI12-9
HI HI01
PRINCIPAL PROCEDURE INFORMATION HEALTH CARE CODE INFORMATION
1
R
2300
HI
R
HI01
ID AN
1-3 1-30
R R
BP
HI01-1 HI01-2
HI01-3
Code List Qualifier Code Principal Procedure Code Date Time Period Format Qualifier
ID
2-3
S
D8
HI01-3
HI01-4 HI01-5 HI01-6 HI01-7
Date Time Period Monetary Amount Quantity Version Identifier
AN R R AN
1-35 1-18 1-15 1-30
S N/U N/U N/U
HI01-1 HI01-2
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010 HI10-9
HI11
ID
Present on Admission indicator HEALTH CARE CODE INFORMATION
New Element ID
1-1
N, U, W, Y
N/U S
Diagnosis Type Code Other Diagnosis Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION
ID AN
1-3 1-30
R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
Diagnosis Type Code Other Diagnosis Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator
ID AN
1-3 1-30
R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
1
R
ABF, BF
Name Change Code Added
New Element New Element N, U, W, Y
S
PRINCIPAL PROCEDURE INFORMATION HEALTH CARE CODE INFORMATION
ABF, BF
Name Change Code Added
New Element New Element N, U, W, Y
2300
R
Qualifier Principal Procedure Code Date Time Period Format Qualifier
ID AN
1-3 1-30
R R
ID
2-3
N/U
Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION
AN R R AN AN
1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U
ID
1-1
N/U
BBR, BR
Name Change Code Change Usage change to Not Used Usage change to Not Used
HI01-4 HI01-5 HI01-6 HI01-7 HI01-8 HI01-9
HI02
HEALTH CARE CODE INFORMATION
N/U
HI02
Page 41 of 93
N/U
New Element New Element
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator
ID AN
1-3 1-30
N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
HI02-3 HI02-4 HI02-5 HI02-6 HI02-7 HI02-8 HI02-9 N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
HI03 HI03-1 HI03-2 HI03-3 HI03-4 HI03-5 HI03-6 HI03-7 HI03-8 HI03-9
HI04
HEALTH CARE CODE INFORMATION
ID
1-1
N/U
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
HI04 HI04-1 HI04-2 HI04-3 HI04-4 HI04-5 HI04-6 HI04-7 HI04-8 HI04-9
HI05
HEALTH CARE CODE INFORMATION
ID
1-1
N/U
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
Loop
Loop Repeat
Values
837-I 5010 HI02-1 HI02-2
HI03
Usage Reg.
ID
837-I 4010A1
HEALTH CARE CODE INFORMATION
Min. Max.
Description
HI05 HI05-1 HI05-2 HI05-3 HI05-4 HI05-5 HI05-6 HI05-7 HI05-8 HI05-9
Page 42 of 93
New Element New Element New Element New Element New Element New Element New Element New Element New Element
New Element New Element New Element New Element New Element New Element New Element New Element New Element
New Element New Element New Element New Element New Element New Element New Element New Element New Element
New Element New Element New Element New Element New Element New Element New Element New Element New Element
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
HI06
HEALTH CARE CODE INFORMATION
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1 N/U
HI06 HI06-1 HI06-2
HI06-9 HI07
N/U
HI07 HI07-1 HI07-2 HI07-3 HI07-4 HI07-5 HI07-6 HI07-7 HI07-8 HI07-9
HI08
HEALTH CARE CODE INFORMATION
N/U
HI08 HI08-1 HI08-2 HI08-3 HI08-4 HI08-5 HI08-6 HI08-7 HI08-8 HI08-9
HI09
HEALTH CARE CODE INFORMATION
N/U
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010
HI06-3 HI06-4 HI06-5 HI06-6 HI06-7 HI06-8
HEALTH CARE CODE INFORMATION
ID
HI09 HI09-1 HI09-2 HI09-3 HI09-4 HI09-5 HI09-6 HI09-7 HI09-8
HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code
Page 43 of 93
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
New Element New Element New Element New Element New Element New Element New Element New Element New Element
New Element New Element New Element New Element New Element New Element New Element New Element New Element
New Element New Element New Element New Element New Element New Element New Element New Element New Element
New Element New Element New Element New Element New Element New Element New Element New Element
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1 HEALTH CARE CODE INFORMATION
N/U
HI10 HI10-1 HI10-2 HI10-3 HI10-4 HI10-5 HI10-6 HI10-7 HI10-8 HI10-9
HI11
HEALTH CARE CODE INFORMATION
N/U
HI11 HI11-1 HI11-2 HI11-3 HI11-4 HI11-5 HI11-6 HI11-7 HI11-8 HI11-9
HI12
HEALTH CARE CODE INFORMATION
N/U
HI12 HI12-1 HI12-2 HI12-3 HI12-4 HI12-5 HI12-6 HI12-7 HI12-8 HI12-9
HI01
OTHER PROCEDURE INFORMATION HEALTH CARE CODE INFORMATION
HI01-1 HI01-2
Code List Qualifier Code Procedure Code
HI
2
R
2300
1-3 1-30
R R
BO, BQ
Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator HEALTH CARE CODE INFORMATION Diagnosis Type Code Principal Diagnosis Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Present on Admission indicator
HI01
OTHER PROCEDURE INFORMATION HEALTH CARE CODE INFORMATION
HI01-1 HI01-2
Qualifier Code Procedure Code
HI
R ID AN
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010 HI09-9
HI10
ID
Page 44 of 93
New Element ID
1-1
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
2
R
New Element New Element New Element New Element New Element New Element New Element New Element New Element
New Element New Element New Element New Element New Element New Element New Element New Element New Element
New Element New Element New Element New Element New Element New Element New Element New Element New Element
2300
R ID AN
1-3 1-30
R R
BBQ, BQ
Name Change Code Change
INSTITUTIONAL CLAIM
4010A1 Description
HI01-3
Date Time Period Format Qualifier
ID
2-3
S
HI01-4 HI01-5 HI01-6 HI01-7
Date Time Period Monetary Amount Quantity Version Identifier
AN R R AN
1-35 1-18 1-15 1-30
S N/U N/U N/U
ID
Min. Max.
Usage Reg.
Element Identifier
5010 Loop
Loop Repeat
Element Identifier
Description
D8
HI01-3
Date Time Period Format Qualifier
CCYYMMDD
HI01-4 HI01-5 HI01-6 HI01-7 HI01-8
Values
837-I 4010A1
ID
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010 Usage change to Required ID
2-3
R
D8
Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION
AN R R AN AN
1-35 1-18 1-15 1-30 1-30
R N/U N/U N/U N/U
CCYYMMDD
ID
1-1
N/U
Qualifier Code Procedure Code Date Time Period Format Qualifier
ID AN
1-3 1-30
R R
BBQ, BQ
ID
2-3
R
D8
Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION
AN R R AN AN
1-35 1-18 1-15 1-30 1-30
R N/U N/U N/U N/U
CCYYMMDD
ID
1-1
N/U
Qualifier Code Procedure Code Date Time Period Format Qualifier
ID AN
1-3 1-30
R R
BBQ, BQ
ID
2-3
R
D8
Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION
AN R R AN AN
1-35 1-18 1-15 1-30 1-30
R N/U N/U N/U N/U
CCYYMMDD
ID
1-1
N/U
ID AN
1-3 1-30
R R
BBQ, BQ
ID
2-3
R
D8
AN R
1-35 1-18
R N/U
CCYYMMDD
Usage change to Required
HI01-9 HI02
HEALTH CARE CODE INFORMATION
S
HI02
ID AN
1-3 1-30
R R
BO, BQ
HI02-1 HI02-2
HI02-3
Code List Qualifier Code Procedure Code Date Time Period Format Qualifier
ID
2-3
S
D8
HI02-3
HI02-4 HI02-5 HI02-6 HI02-7
Date Time Period Monetary Amount Quantity Version Identifier
AN R R AN
1-35 1-18 1-15 1-30
S N/U N/U N/U
CCYYMMDD
HI02-4 HI02-5 HI02-6 HI02-7 HI02-8
HI02-1 HI02-2
New Element New Element
S Name Change Code Change Usage change to Required Usage change to Required
HI02-9 HI03
HEALTH CARE CODE INFORMATION
S
HI03
ID AN
1-3 1-30
R R
BO, BQ
HI03-1 HI03-2
HI03-3
Code List Qualifier Code Procedure Code Date Time Period Format Qualifier
ID
2-3
S
D8
HI03-3
HI03-4 HI03-5 HI03-6 HI03-7
Date Time Period Monetary Amount Quantity Version Identifier
AN R R AN
1-35 1-18 1-15 1-30
S N/U N/U N/U
CCYYMMDD
HI03-4 HI03-5 HI03-6 HI03-7 HI03-8
HI03-1 HI03-2
New Element New Element
S Name Change Code Change Usage change to Required Usage change to Required
HI03-9 HI04
HEALTH CARE CODE INFORMATION
S
HI04
ID AN
1-3 1-30
R R
BO, BQ
HI04-1 HI04-2
HI04-3
Code List Qualifier Code Procedure Code Date Time Period Format Qualifier
ID
2-3
S
D8
HI04-3
Qualifier Code Procedure Code Date Time Period Format Qualifier
HI04-4 HI04-5
Date Time Period Monetary Amount
AN R
1-35 1-18
S N/U
CCYYMMDD
HI04-4 HI04-5
Date Time Period Monetary Amount
HI04-1 HI04-2
New Element New Element
S Name Change Code Change Usage change to Required Usage change to Required
Page 45 of 93
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
HI04-6 HI04-7
Quantity Version Identifier
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1 R AN
1-15 1-30
HI05
HI04-6 HI04-7 HI04-8
S
HI05
ID AN
1-3 1-30
R R
BO, BQ
HI05-1 HI05-2
HI05-3
Code List Qualifier Code Procedure Code Date Time Period Format Qualifier
ID
2-3
S
D8
HI05-3
HI05-4 HI05-5 HI05-6 HI05-7
Date Time Period Monetary Amount Quantity Version Identifier
AN R R AN
1-35 1-18 1-15 1-30
S N/U N/U N/U
CCYYMMDD
HI05-4 HI05-5 HI05-6 HI05-7 HI05-8
HI05-1 HI05-2
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010
N/U N/U
HI04-9 HEALTH CARE CODE INFORMATION
ID
Quantity R Version Identifier AN Industry code AN Yes/No Condition or response Code ID HEALTH CARE CODE INFORMATION
1-15 1-30 1-30
N/U N/U N/U
1-1
N/U
New Element New Element
S
Qualifier Code Procedure Code Date Time Period Format Qualifier
ID AN
1-3 1-30
R R
BBQ, BQ
ID
2-3
R
D8
Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION
AN R R AN AN
1-35 1-18 1-15 1-30 1-30
R N/U N/U N/U N/U
CCYYMMDD
ID
1-1
N/U
Qualifier Code Procedure Code Date Time Period Format Qualifier
ID AN
1-3 1-30
R R
BBQ, BQ
ID
2-3
R
D8
Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION
AN R R AN AN
1-35 1-18 1-15 1-30 1-30
R N/U N/U N/U N/U
CCYYMMDD
ID
1-1
N/U
Qualifier Code Procedure Code Date Time Period Format Qualifier
ID AN
1-3 1-30
R R
BBQ, BQ
ID
2-3
R
D8
Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code
AN R R AN AN
1-35 1-18 1-15 1-30 1-30
R N/U N/U N/U N/U
CCYYMMDD
ID
1-1
N/U
Name Change Code Change Usage change to Required Usage change to Required
HI05-9 HI06
HEALTH CARE CODE INFORMATION
S
HI06
ID AN
1-3 1-30
R R
BO, BQ
HI06-1 HI06-2
HI06-3
Code List Qualifier Code Procedure Code Date Time Period Format Qualifier
ID
2-3
S
D8
HI06-3
HI06-4 HI06-5 HI06-6 HI06-7
Date Time Period Monetary Amount Quantity Version Identifier
AN R R AN
1-35 1-18 1-15 1-30
S N/U N/U N/U
CCYYMMDD
HI06-4 HI06-5 HI06-6 HI06-7 HI06-8
HI06-1 HI06-2
New Element New Element
S Name Change Code Change Usage change to Required Usage change to Required
HI06-9 HI07
HEALTH CARE CODE INFORMATION
S
HI07
ID AN
1-3 1-30
R R
BO, BQ
HI07-1 HI07-2
HI07-3
Code List Qualifier Code Procedure Code Date Time Period Format Qualifier
ID
2-3
S
D8
HI07-3
HI07-4 HI07-5 HI07-6 HI07-7
Date Time Period Monetary Amount Quantity Version Identifier
AN R R AN
1-35 1-18 1-15 1-30
S N/U N/U N/U
CCYYMMDD
HI07-4 HI07-5 HI07-6 HI07-7 HI07-8
HI07-1 HI07-2
New Element New Element
S Name Change Code Change Usage change to Required Usage change to Required
HI07-9
Page 46 of 93
New Element New Element
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
HI08
HEALTH CARE CODE INFORMATION
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
HI08
HEALTH CARE CODE INFORMATION
837-I 4010A1
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010
S ID AN
1-3 1-30
R R
BO, BQ
HI08-1 HI08-2
HI08-3
Code List Qualifier Code Procedure Code Date Time Period Format Qualifier
ID
2-3
S
D8
HI08-3
HI08-4 HI08-5 HI08-6 HI08-7
Date Time Period Monetary Amount Quantity Version Identifier
AN R R AN
1-35 1-18 1-15 1-30
S N/U N/U N/U
CCYYMMDD
HI08-4 HI08-5 HI08-6 HI08-7 HI08-8
HI08-1 HI08-2
ID
S
Qualifier Code Procedure Code Date Time Period Format Qualifier
ID AN
1-3 1-30
R R
BBQ, BQ
ID
2-3
R
D8
Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION
AN R R AN AN
1-35 1-18 1-15 1-30 1-30
R N/U N/U N/U N/U
CCYYMMDD
ID
1-1
N/U
Qualifier Code Procedure Code Date Time Period Format Qualifier
ID AN
1-3 1-30
R R
BBQ, BQ
ID
2-3
R
D8
Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION
AN R R AN AN
1-35 1-18 1-15 1-30 1-30
R N/U N/U N/U N/U
CCYYMMDD
ID
1-1
N/U
Qualifier Code Procedure Code Date Time Period Format Qualifier
ID AN
1-3 1-30
R R
BBQ, BQ
ID
2-3
R
D8
AN R R AN AN
1-35 1-18 1-15 1-30 1-30
R N/U N/U N/U N/U
CCYYMMDD
ID
1-1
N/U
HI11
Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION
HI11-1 HI11-2
Qualifier Code Procedure Code
ID AN
Name Change Code Change Usage change to Required Usage change to Required
HI08-9 HI09
HEALTH CARE CODE INFORMATION
S
HI09
ID AN
1-3 1-30
R R
BO, BQ
HI09-1 HI09-2
HI09-3
Code List Qualifier Code Procedure Code Date Time Period Format Qualifier
ID
2-3
S
D8
HI09-3
HI09-4 HI09-5 HI09-6 HI09-7
Date Time Period Monetary Amount Quantity Version Identifier
AN R R AN
1-35 1-18 1-15 1-30
S N/U N/U N/U
CCYYMMDD
HI09-4 HI09-5 HI09-6 HI09-7 HI09-8
HI09-1 HI09-2
New Element New Element
S Name Change Code Change Usage change to Required Usage change to Required
HI09-9 HI10
HEALTH CARE CODE INFORMATION
S
HI10
ID AN
1-3 1-30
R R
BO, BQ
HI10-1 HI10-2
HI10-3
Code List Qualifier Code Procedure Code Date Time Period Format Qualifier
ID
2-3
S
D8
HI10-3
HI10-4 HI10-5 HI10-6 HI10-7
Date Time Period Monetary Amount Quantity Version Identifier
AN R R AN
1-35 1-18 1-15 1-30
S N/U N/U N/U
CCYYMMDD
HI10-4 HI10-5 HI10-6 HI10-7 HI10-8
HI10-1 HI10-2
New Element New Element
S Name Change Code Change Usage change to Required Usage change to Required
HI10-9 HI11
HEALTH CARE CODE INFORMATION
HI11-1 HI11-2
Code List Qualifier Code Procedure Code
S ID AN
1-3 1-30
R R
BO, BQ
Page 47 of 93
New Element New Element
S 1-3 1-30
R R
BBQ, BQ
Name Change Code Change
INSTITUTIONAL CLAIM
4010A1 Description
HI11-3
Date Time Period Format Qualifier
ID
2-3
S
HI11-4 HI11-5 HI11-6 HI11-7
Date Time Period Monetary Amount Quantity Version Identifier
AN R R AN
1-35 1-18 1-15 1-30
S N/U N/U N/U
ID
Min. Max.
Usage Reg.
Element Identifier
5010 Loop
Loop Repeat
Element Identifier
Description
D8
HI11-3
Date Time Period Format Qualifier
CCYYMMDD
HI11-4 HI11-5 HI11-6 HI11-7 HI11-8
Values
837-I 4010A1
ID
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010 Usage change to Required ID
2-3
R
D8
Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION
AN R R AN AN
1-35 1-18 1-15 1-30 1-30
R N/U N/U N/U N/U
CCYYMMDD
ID
1-1
N/U
Qualifier Code Procedure Code Date Time Period Format Qualifier
ID AN
1-3 1-30
R R
BBQ, BQ
ID
2-3
R
D8
Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code
AN R R AN AN
1-35 1-18 1-15 1-30 1-30
R N/U N/U N/U N/U
CCYYMMDD
ID
1-1
N/U
2
R
ID AN
1-3 1-30
R R R
ID
2-3
R
AN R R AN AN
1-35 1-18 1-15 1-30 1-30
R N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
HI02-3
Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Occurrence Span Code Date Time Period Format Qualifier
ID
2-3
R
HI02-4
Date Time Period
AN
1-35
R
Usage change to Required
HI11-9 HI12
HEALTH CARE CODE INFORMATION
S
HI12
ID AN
1-3 1-30
R R
BO, BQ
HI12-1 HI12-2
HI12-3
Code List Qualifier Code Procedure Code Date Time Period Format Qualifier
ID
2-3
S
D8
HI12-3
HI12-4 HI12-5 HI12-6 HI12-7
Date Time Period Monetary Amount Quantity Version Identifier
AN R R AN
1-35 1-18 1-15 1-30
S N/U N/U N/U
CCYYMMDD
HI12-4 HI12-5 HI12-6 HI12-7 HI12-8
HI12-1 HI12-2
New Element New Element
S Name Change Code Change Usage change to Required Usage change to Required
HI12-9
HI01-3
OCCURRENCE SPAN INFORMATION HEALTH CARE CODE INFORMATION Code List Qualifier Code Occurrence Span Code Date Time Period Format Qualifier
HI01-4 HI01-5 HI01-6 HI01-7
Date Time Period Monetary Amount Quantity Version Identifier
HI HI01 HI01-1 HI01-2
2
S
ID AN
1-3 1-30
R R R
ID
2-3
R
AN R R AN
1-35 1-18 1-15 1-30
R N/U N/U N/U
2300
HI
BI
RD8 CCYYMMDDCCYYMMDD
HI01 HI01-1 HI01-2 HI01-3 HI01-4 HI01-5 HI01-6 HI01-7 HI01-8 HI01-9
ID AN
1-3 1-30
S R R
HI02-3
HEALTH CARE CODE INFORMATION Code List Qualifier Code Occurrence Span Code Date Time Period Format Qualifier
ID
2-3
R
HI02-4
Date Time Period
AN
1-35
R
HI02 HI02-1 HI02-2
BI
RD8 CCYYMMDDCCYYMMDD
HI02 HI02-1 HI02-2
OCCURRENCE SPAN INFORMATION HEALTH CARE CODE INFORMATION Qualifier Occurrence Span Code Date Time Period Format Qualifier
Page 48 of 93
New Element New Element
Usage change to Required 2300
BI
Name Change
RD8 CCYYMMDDCCYYMMDD
New Element New Element
BI
RD8 CCYYMMDDCCYYMMDD
Name Change
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
HI02-5 HI02-6 HI02-7
Monetary Amount Quantity Version Identifier
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1 R R AN
1-18 1-15 1-30
HI03 HI03-1 HI03-2
ID AN
1-3 1-30
S R R
ID
2-3
R
AN R R AN AN
1-35 1-18 1-15 1-30 1-30
R N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
HI04-3
Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Code List Qualifier Code Occurrence Span Code Date Time Period Format Qualifier
ID
2-3
R
HI04-4 HI04-5 HI04-6 HI04-7
Date Time Period Monetary Amount Quantity Version Identifier
AN R R AN
1-35 1-18 1-15 1-30
R N/U N/U N/U
HI03-3 HI03-4 HI03-5 HI03-6 HI03-7 HI03-8 HI03-9 HI04 HI04-1 HI04-2
HI02-5 HI02-6 HI02-7 HI02-8
BI
RD8 CCYYMMDDCCYYMMDD
HI03 HI03-1 HI03-2 HI03-3 HI03-4 HI03-5 HI03-6 HI03-7 HI03-8 HI03-9
BI
RD8 CCYYMMDDCCYYMMDD
HI04 HI04-1 HI04-2 HI04-3 HI04-4 HI04-5 HI04-6 HI04-7 HI04-8 HI04-9
ID AN
1-3 1-30
S R R
HI05-3
HEALTH CARE CODE INFORMATION Code List Qualifier Code Occurrence Span Code Date Time Period Format Qualifier
ID
2-3
R
HI05-4 HI05-5 HI05-6 HI05-7
Date Time Period Monetary Amount Quantity Version Identifier
AN R R AN
1-35 1-18 1-15 1-30
R N/U N/U N/U
HI05 HI05-1 HI05-2
BI
RD8 CCYYMMDDCCYYMMDD
HI05 HI05-1 HI05-2 HI05-3 HI05-4 HI05-5 HI05-6 HI05-7 HI05-8 HI05-9
HI06
HEALTH CARE CODE INFORMATION
S
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010
N/U N/U N/U
HI02-9 HEALTH CARE CODE INFORMATION Code List Qualifier Code Occurrence Span Code Date Time Period Format Qualifier
ID
HI06
Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Occurrence Span Code Date Time Period Format Qualifier
R R AN AN
1-18 1-15 1-30 1-30
N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID
2-3
R
Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Occurrence Span Code Date Time Period Format Qualifier
AN R R AN AN
1-35 1-18 1-15 1-30 1-30
R N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID
2-3
R
Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Occurrence Span Code Date Time Period Format Qualifier
AN R R AN AN
1-35 1-18 1-15 1-30 1-30
R N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID
2-3
R
Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION
AN R R AN AN
1-35 1-18 1-15 1-30 1-30
R N/U N/U N/U N/U
ID
1-1
N/U
Page 49 of 93
S
New Element New Element
BI
Name Change
RD8 CCYYMMDDCCYYMMDD
New Element New Element
BI
Name Change
RD8 CCYYMMDDCCY YMMDD
New Element New Element
BI
Name Change
RD8 CCYYMMDDCCYYMMDD
New Element New Element
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
ID AN
1-3 1-30
R R
BI
ID
2-3
R
Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Occurrence Span Code Date Time Period Format Qualifier
AN R R AN AN
1-35 1-18 1-15 1-30 1-30
R N/U N/U N/U N/U
RD8 CCYYMMDDCCYYMMDD
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID
2-3
R
Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Occurrence Span Code Date Time Period Format Qualifier
AN R R AN AN
1-35 1-18 1-15 1-30 1-30
R N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID
2-3
R
AN R R AN AN
1-35 1-18 1-15 1-30 1-30
R N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
HI09-3
Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Occurrence Span Code Date Time Period Format Qualifier
ID
2-3
R
HI09-4 HI09-5 HI09-6
Date Time Period Monetary Amount Quantity
AN R R
1-35 1-18 1-15
R N/U N/U
1-3 1-30
R R
BI
HI06-1 HI06-2
HI06-3
ID
2-3
R
HI06-3
HI06-4 HI06-5 HI06-6 HI06-7
Date Time Period Monetary Amount Quantity Version Identifier
AN R R AN
1-35 1-18 1-15 1-30
R N/U N/U N/U
RD8 CCYYMMDDCCYYMMDD
HI06-4 HI06-5 HI06-6 HI06-7 HI06-8 HI06-9
ID AN
1-3 1-30
S R R
HI07-3
ID
2-3
R
HI07-4 HI07-5 HI07-6 HI07-7
Date Time Period Monetary Amount Quantity Version Identifier
AN R R AN
1-35 1-18 1-15 1-30
R N/U N/U N/U
BI
RD8 CCYYMMDDCCYYMMDD
HI07 HI07-1 HI07-2 HI07-3 HI07-4 HI07-5 HI07-6 HI07-7 HI07-8 HI07-9
ID AN
1-3 1-30
S R R
HI08-3
HEALTH CARE CODE INFORMATION Code List Qualifier Code Occurrence Span Code Date Time Period Format Qualifier
ID
2-3
R
HI08-4 HI08-5 HI08-6 HI08-7
Date Time Period Monetary Amount Quantity Version Identifier
AN R R AN
1-35 1-18 1-15 1-30
R N/U N/U N/U
HI08 HI08-1 HI08-2
BI
RD8 CCYYMMDDCCYYMMDD
HI08 HI08-1 HI08-2 HI08-3 HI08-4 HI08-5 HI08-6 HI08-7 HI08-8 HI08-9
ID AN
1-3 1-30
S R R
HI09-3
HEALTH CARE CODE INFORMATION Code List Qualifier Code Occurrence Span Code Date Time Period Format Qualifier
ID
2-3
R
HI09-4 HI09-5 HI09-6
Date Time Period Monetary Amount Quantity
AN R R
1-35 1-18 1-15
R N/U N/U
HI09 HI09-1 HI09-2
Loop
Values
837-I 5010
ID AN
HI07 HI07-1 HI07-2
Loop Repeat
Qualifier Occurrence Span Code Date Time Period Format Qualifier
837-I 4010A1
HEALTH CARE CODE INFORMATION Code List Qualifier Code Occurrence Span Code Date Time Period Format Qualifier
Usage Reg.
ID
Code List Qualifier Code Occurrence Span Code Date Time Period Format Qualifier
HI06-1 HI06-2
Min. Max.
Description
BI
RD8 CCYYMMDDCCYYMMDD
HI09 HI09-1 HI09-2
Page 50 of 93
Name Change
New Element New Element
BI
Name Change
RD8 CCYYMMDDCCYYMMDD
New Element New Element
BI
Name Change
RD8 CCYYMMDDCCYYMMDD
New Element New Element
BI
RD8 CCYYMMDDCCYYMMDD
Name Change
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
HI09-7
Version Identifier
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
1-30
Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Occurrence Span Code Date Time Period Format Qualifier
AN AN
1-30 1-30
N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID
2-3
R
Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Occurrence Span Code Date Time Period Format Qualifier
AN R R AN AN
1-35 1-18 1-15 1-30 1-30
R N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID
2-3
R
Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Occurrence Span Code Date Time Period Format Qualifier
AN R R AN AN
1-35 1-18 1-15 1-30 1-30
R N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID
2-3
R
AN R R AN AN
1-35 1-18 1-15 1-30 1-30
R N/U N/U N/U N/U
HI12-9
Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code
ID
1-1
N/U
HI
OCCURRENCE INFORMATION
2
R
HI09-7 HI09-8 HI09-9
ID AN
1-3 1-30
S R R
HI10-3
ID
2-3
R
HI10-4 HI10-5 HI10-6 HI10-7
Date Time Period Monetary Amount Quantity Version Identifier
AN R R AN
1-35 1-18 1-15 1-30
R N/U N/U N/U
HI10 HI10-1 HI10-2
BI
RD8 CCYYMMDDCCYYMMDD
HI10 HI10-1 HI10-2 HI10-3 HI10-4 HI10-5 HI10-6 HI10-7 HI10-8 HI10-9
ID AN
1-3 1-30
S R R
HI11-3
HEALTH CARE CODE INFORMATION Code List Qualifier Code Occurrence Span Code Date Time Period Format Qualifier
ID
2-3
R
HI11-4 HI11-5 HI11-6 HI11-7
Date Time Period Monetary Amount Quantity Version Identifier
AN R R AN
1-35 1-18 1-15 1-30
R N/U N/U N/U
HI11 HI11-1 HI11-2
BI
RD8 CCYYMMDDCCYYMMDD
HI11 HI11-1 HI11-2 HI11-3 HI11-4 HI11-5 HI11-6 HI11-7 HI11-8 HI11-9
ID AN
1-3 1-30
S R R
HI12-3
HEALTH CARE CODE INFORMATION Code List Qualifier Code Occurrence Span Code Date Time Period Format Qualifier
ID
2-3
R
HI12-4 HI12-5 HI12-6 HI12-7
Date Time Period Monetary Amount Quantity Version Identifier
AN R R AN
1-35 1-18 1-15 1-30
R N/U N/U N/U
HI12 HI12-1 HI12-2
HI
OCCURRENCE INFORMATION
2
R
Loop
Loop Repeat
Values
837-I 5010
N/U
HEALTH CARE CODE INFORMATION Code List Qualifier Code Occurrence Span Code Date Time Period Format Qualifier
Usage Reg.
ID
837-I 4010A1 AN
Min. Max.
Description
BI
RD8 CCYYMMDDCCYYMMDD
2300
HI12 HI12-1 HI12-2 HI12-3 HI12-4 HI12-5 HI12-6 HI12-7 HI12-8
Page 51 of 93
New Element New Element
BI
Name Change
RD8 CCYYMMDDCCYYMMDD
New Element New Element
BI
Name Change
RD8 CCYYMMDDCCYYMMDD
New Element New Element
BI
Name Change
RD8 CCYYMMDDCCYYMMDD
New Element New Element
2300
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1 HI01 HI01-1 HI01-2 HI01-3 HI01-4 HI01-5 HI01-6 HI01-7
HEALTH CARE CODE INFORMATION Code List Qualifier Code Occurrence Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
ID AN
1-3 1-30
R R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
R R N/U N/U N/U
HI02 HI02-1 HI02-2 HI02-3 HI02-4 HI02-5 HI02-6 HI02-7
ID AN
1-3 1-30
S R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
R R N/U N/U N/U
BH
D8 CCYYMMDD
HI01 HI01-1 HI01-2 HI01-3 HI01-4 HI01-5 HI01-6 HI01-7 HI01-8
BH
D8 CCYYMMDD
HI02 HI02-1 HI02-2 HI02-3 HI02-4 HI02-5 HI02-6 HI02-7 HI02-8 HI02-9
HI03 HI03-1 HI03-2 HI03-3 HI03-4 HI03-5 HI03-6 HI03-7
HEALTH CARE CODE INFORMATION Code List Qualifier Code Occurrence Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
ID AN
1-3 1-30
S R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
R R N/U N/U N/U
BH
D8 CCYYMMDD
HI03 HI03-1 HI03-2 HI03-3 HI03-4 HI03-5 HI03-6 HI03-7 HI03-8 HI03-9
HI04 HI04-1 HI04-2 HI04-3 HI04-4 HI04-5 HI04-6 HI04-7
HEALTH CARE CODE INFORMATION Code List Qualifier Code Occurrence Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
ID AN
1-3 1-30
S R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
R R N/U N/U N/U
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010
HI01-9 HEALTH CARE CODE INFORMATION Code List Qualifier Code Occurrence Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
ID
BH
D8 CCYYMMDD
HI04 HI04-1 HI04-2 HI04-3 HI04-4 HI04-5 HI04-6 HI04-7 HI04-8
HEALTH CARE CODE INFORMATION Qualifier Occurrence Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Occurrence Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Occurrence Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Occurrence Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code
Page 52 of 93
ID AN
1-3 1-30
R R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
R R N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
R R N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
R R N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
R R N/U N/U N/U N/U
BH
Name Change
D8 CCYYMMDD
New Element New Element
BH
Name Change
D8 CCYYMMDD
New Element New Element
BH
Name Change
D8 CCYYMMDD
New Element New Element
BH
Name Change
D8 CCYYMMDD
New Element
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1
HI05-3 HI05-4 HI05-5 HI05-6 HI05-7
HEALTH CARE CODE INFORMATION Code List Qualifier Code Occurrence Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
ID AN
1-3 1-30
S R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
R R N/U N/U N/U
BH
D8 CCYYMMDD
HI05 HI05-1 HI05-2 HI05-3 HI05-4 HI05-5 HI05-6 HI05-7 HI05-8 HI05-9
HI06 HI06-1 HI06-2 HI06-3 HI06-4 HI06-5 HI06-6 HI06-7
HEALTH CARE CODE INFORMATION Code List Qualifier Code Occurrence Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
ID AN
1-3 1-30
S R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
R R N/U N/U N/U
BH
D8 CCYYMMDD
HI06 HI06-1 HI06-2 HI06-3 HI06-4 HI06-5 HI06-6 HI06-7 HI06-8 HI06-9
HI07 HI07-1 HI07-2 HI07-3 HI07-4 HI07-5 HI07-6 HI07-7
HEALTH CARE CODE INFORMATION Code List Qualifier Code Occurrence Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
ID AN
1-3 1-30
S R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
R R N/U N/U N/U
BH
D8 CCYYMMDD
HI07 HI07-1 HI07-2 HI07-3 HI07-4 HI07-5 HI07-6 HI07-7 HI07-8 HI07-9
HI08 HI08-1 HI08-2 HI08-3 HI08-4 HI08-5 HI08-6
HEALTH CARE CODE INFORMATION Code List Qualifier Code Occurrence Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity
ID AN
1-3 1-30
S R R
ID AN R R
2-3 1-35 1-18 1-15
R R N/U N/U
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010 HI04-9
HI05 HI05-1 HI05-2
ID
BH
D8 CCYYMMDD
HI08 HI08-1 HI08-2 HI08-3 HI08-4 HI08-5 HI08-6
Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Occurrence Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Occurrence Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Occurrence Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Occurrence Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity
Page 53 of 93
New Element ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
R R N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
R R N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
R R N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN R R
2-3 1-35 1-18 1-15
R R N/U N/U
BH
Name Change
D8 CCYYMMDD
New Element New Element
BH
Name Change
D8 CCYYMMDD
New Element New Element
BH
Name Change
D8 CCYYMMDD
New Element New Element
BH
D8 CCYYMMDD
Name Change
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
HI08-7
Version Identifier
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
1-30
HI09 HI09-1 HI09-2 HI09-3 HI09-4 HI09-5 HI09-6 HI09-7
ID AN
1-3 1-30
S R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
R R N/U N/U N/U
HI08-7 HI08-8
BH
D8 CCYYMMDD
HI09 HI09-1 HI09-2 HI09-3 HI09-4 HI09-5 HI09-6 HI09-7 HI09-8 HI09-9
HI10 HI10-1 HI10-2 HI10-3 HI10-4 HI10-5 HI10-6 HI10-7
HEALTH CARE CODE INFORMATION Code List Qualifier Code Occurrence Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
ID AN
1-3 1-30
S R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
R R N/U N/U N/U
BH
D8 CCYYMMDD
HI10 HI10-1 HI10-2 HI10-3 HI10-4 HI10-5 HI10-6 HI10-7 HI10-8 HI10-9
HI11 HI11-1 HI11-2 HI11-3 HI11-4 HI11-5 HI11-6 HI11-7
HEALTH CARE CODE INFORMATION Code List Qualifier Code Occurrence Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
ID AN
1-3 1-30
S R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
R R N/U N/U N/U
BH
D8 CCYYMMDD
HI11 HI11-1 HI11-2 HI11-3 HI11-4 HI11-5 HI11-6 HI11-7 HI11-8 HI11-9
HI12 HI12-1 HI12-2 HI12-3 HI12-4
HEALTH CARE CODE INFORMATION Code List Qualifier Code Occurrence Code Date Time Period Format Qualifier Date Time Period
Loop Repeat
Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Occurrence Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Occurrence Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Occurrence Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Occurrence Code Date Time Period Format Qualifier Date Time Period
AN AN
1-30 1-30
N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
R R N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
R R N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
R R N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
BH
ID AN
2-3 1-35
R R
D8 CCYYMMDD
Loop
Values
837-I 5010
N/U
HI08-9 HEALTH CARE CODE INFORMATION Code List Qualifier Code Occurrence Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
Usage Reg.
ID
837-I 4010A1 AN
Min. Max.
Description
ID AN
1-3 1-30
S R R
BH
HI12 HI12-1 HI12-2
ID AN
2-3 1-35
R R
D8 CCYYMMDD
HI12-3 HI12-4
Page 54 of 93
New Element New Element
BH
Name Change
D8 CCYYMMDD
New Element New Element
BH
Name Change
D8 CCYYMMDD
New Element New Element
BH
Name Change
D8 CCYYMMDD
New Element New Element
Name Change
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
HI12-5 HI12-6 HI12-7
Monetary Amount Quantity Version Identifier
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1 R R AN
1-18 1-15 1-30
HI01 HI01-1 HI01-2 HI01-3 HI01-4 HI01-5 HI01-6 HI01-7
VALUE INFORMATION HEALTH CARE CODE INFORMATION Code List Qualifier Code Value Code Date Time Period Format Qualifier Date Time Period Value Code Associated Amount Quantity Version Identifier
HI12-5 HI12-6 HI12-7 HI12-8
2
R
2300
HI
ID AN
1-3 1-30
R R R
ID AN
2-3 1-35
N/U N/U
HI01-3 HI01-4
R R AN
1-18 1-15 1-30
R N/U N/U
HI01-5 HI01-6 HI01-7 HI01-8
BE
HI01 HI01-1 HI01-2
HI02 HI02-1 HI02-2 HI02-3 HI02-4 HI02-5 HI02-6 HI02-7
ID AN
1-3 1-30
S R R
ID AN
2-3 1-35
N/U N/U
HI02-3 HI02-4
R R AN
1-18 1-15 1-30
R N/U N/U
HI02-5 HI02-6 HI02-7 HI02-8
BE
HI02 HI02-1 HI02-2
HI03 HI03-1 HI03-2 HI03-3 HI03-4 HI03-5 HI03-6 HI03-7
Loop
Loop Repeat
Values
Monetary Amount R Quantity R Version Identifier AN Industry code AN Yes/No Condition or response Code ID
1-18 1-15 1-30 1-30
N/U N/U N/U N/U
1-1
N/U
2
R
ID AN
1-3 1-30
R R R
ID AN
2-3 1-35
N/U N/U
R R AN AN
1-18 1-15 1-30 1-30
R N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN
2-3 1-35
N/U N/U
R R AN AN
1-18 1-15 1-30 1-30
R N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN
2-3 1-35
N/U N/U
Value Code Amount R Quantity R Version Identifier AN Industry code AN Yes/No Condition or response Code ID
1-18 1-15 1-30 1-30
R N/U N/U N/U
1-1
N/U
VALUE INFORMATION HEALTH CARE CODE INFORMATION Qualifier Value Code Date Time Period Format Qualifier Date Time Period
New Element New Element
2300
BE
Name Change
Value Code Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Value Code Date Time Period Format Qualifier Date Time Period
New Element New Element
BE
Name Change
Name Change
HI02-9 HEALTH CARE CODE INFORMATION Code List Qualifier Code Value Code Date Time Period Format Qualifier Date Time Period Value Code Associated Amount Quantity Version Identifier
Usage Reg.
Name Change
HI01-9 HEALTH CARE CODE INFORMATION Code List Qualifier Code Value Code Date Time Period Format Qualifier Date Time Period Value Code Associated Amount Quantity Version Identifier
Min. Max.
837-I 5010
N/U N/U N/U
HI12-9 HI
ID
ID AN
1-3 1-30
S R R
ID AN
2-3 1-35
N/U N/U
HI03-3 HI03-4
R R AN
1-18 1-15 1-30
R N/U N/U
HI03-5 HI03-6 HI03-7 HI03-8
BE
HI03 HI03-1 HI03-2
Value Code Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Value Code Date Time Period Format Qualifier Date Time Period
New Element New Element
BE
Name Change
Name Change
HI03-9
Page 55 of 93
New Element New Element
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1 HI04 HI04-1 HI04-2 HI04-3 HI04-4 HI04-5 HI04-6 HI04-7
HEALTH CARE CODE INFORMATION Code List Qualifier Code Value Code Date Time Period Format Qualifier Date Time Period Value Code Associated Amount Quantity Version Identifier
HI05 HI05-1 HI05-2 HI05-3 HI05-4 HI05-5 HI05-6 HI05-7
ID AN
1-3 1-30
S R R
ID AN
2-3 1-35
N/U N/U
HI04-3 HI04-4
R R AN
1-18 1-15 1-30
R N/U N/U
HI04-5 HI04-6 HI04-7 HI04-8
BE
HI04 HI04-1 HI04-2
HI06 HI06-1 HI06-2 HI06-3 HI06-4 HI06-5 HI06-6 HI06-7
ID AN
1-3 1-30
S R R
ID AN
2-3 1-35
N/U N/U
HI05-3 HI05-4
R R AN
1-18 1-15 1-30
R N/U N/U
HI05-5 HI05-6 HI05-7 HI05-8
BE
HI05 HI05-1 HI05-2
HI07 HI07-1 HI07-2 HI07-3 HI07-4
Loop
Loop Repeat
Values
HEALTH CARE CODE INFORMATION Qualifier Value Code Date Time Period Format Qualifier Date Time Period
ID AN
1-3 1-30
S R R
ID AN
2-3 1-35
N/U N/U
R R AN AN
1-18 1-15 1-30 1-30
R N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN
2-3 1-35
N/U N/U
R R AN AN
1-18 1-15 1-30 1-30
R N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN
2-3 1-35
N/U N/U
R R AN AN
1-18 1-15 1-30 1-30
R N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN
2-3 1-35
N/U N/U
BE
Name Change
Value Code Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Value Code Date Time Period Format Qualifier Date Time Period
New Element New Element
BE
Name Change
Name Change
ID AN
1-3 1-30
S R R
ID AN
2-3 1-35
N/U N/U
HI06-3 HI06-4
R R AN
1-18 1-15 1-30
R N/U N/U
HI06-5 HI06-6 HI06-7 HI06-8
BE
HI06 HI06-1 HI06-2
Value Code Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Value Code Date Time Period Format Qualifier Date Time Period
New Element New Element
BE
Name Change
Name Change
HI06-9 HEALTH CARE CODE INFORMATION Code List Qualifier Code Value Code Date Time Period Format Qualifier Date Time Period
Usage Reg.
Name Change
HI05-9 HEALTH CARE CODE INFORMATION Code List Qualifier Code Value Code Date Time Period Format Qualifier Date Time Period Value Code Associated Amount Quantity Version Identifier
Min. Max.
837-I 5010
HI04-9 HEALTH CARE CODE INFORMATION Code List Qualifier Code Value Code Date Time Period Format Qualifier Date Time Period Value Code Associated Amount Quantity Version Identifier
ID
ID AN
1-3 1-30
S R R
ID AN
2-3 1-35
N/U N/U
BE
HI07 HI07-1 HI07-2 HI07-3 HI07-4
Value Code Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Value Code Date Time Period Format Qualifier Date Time Period
Page 56 of 93
New Element New Element
BE
Name Change
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
HI07-5 HI07-6 HI07-7
Value Code Associated Amount Quantity Version Identifier
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1
HI08 HI08-1 HI08-2 HI08-3 HI08-4 HI08-5 HI08-6 HI08-7
HI09 HI09-1 HI09-2 HI09-3 HI09-4 HI09-5 HI09-6 HI09-7
1-18 1-15 1-30
R N/U N/U
HI07-5 HI07-6 HI07-7 HI07-8
ID AN
1-3 1-30
S R R
ID AN
2-3 1-35
N/U N/U
HI08-3 HI08-4
R R AN
1-18 1-15 1-30
R N/U N/U
HI08-5 HI08-6 HI08-7 HI08-8
BE
HI08 HI08-1 HI08-2
HI10 HI10-1 HI10-2 HI10-3 HI10-4 HI10-5 HI10-6 HI10-7
Loop
Loop Repeat
Values
Value Code Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Value Code Date Time Period Format Qualifier Date Time Period
R R AN AN
1-18 1-15 1-30 1-30
R N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN
2-3 1-35
N/U N/U
Value Code Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Value Code Date Time Period Format Qualifier Date Time Period
R R AN AN
1-18 1-15 1-30 1-30
R N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN
2-3 1-35
N/U N/U
R R AN AN
1-18 1-15 1-30 1-30
R N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN
2-3 1-35
N/U N/U
Value Code Amount R Quantity R Version Identifier AN Industry code AN Yes/No Condition or response Code ID
1-18 1-15 1-30 1-30
R N/U N/U N/U
1-1
N/U
New Element New Element
BE
Name Change
Name Change
ID AN
1-3 1-30
S R R
ID AN
2-3 1-35
N/U N/U
HI09-3 HI09-4
R R AN
1-18 1-15 1-30
R N/U N/U
HI09-5 HI09-6 HI09-7 HI09-8
BE
HI09 HI09-1 HI09-2
New Element New Element
BE
Name Change
Name Change
HI09-9 HEALTH CARE CODE INFORMATION Code List Qualifier Code Value Code Date Time Period Format Qualifier Date Time Period Value Code Associated Amount Quantity Version Identifier
Usage Reg.
Name Change R R AN
HI08-9 HEALTH CARE CODE INFORMATION Code List Qualifier Code Value Code Date Time Period Format Qualifier Date Time Period Value Code Associated Amount Quantity Version Identifier
Min. Max.
837-I 5010
HI07-9 HEALTH CARE CODE INFORMATION Code List Qualifier Code Value Code Date Time Period Format Qualifier Date Time Period Value Code Associated Amount Quantity Version Identifier
ID
ID AN
1-3 1-30
S R R
ID AN
2-3 1-35
N/U N/U
HI10-3 HI10-4
R R AN
1-18 1-15 1-30
R N/U N/U
HI10-5 HI10-6 HI10-7 HI10-8
BE
HI10 HI10-1 HI10-2
Value Code Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Value Code Date Time Period Format Qualifier Date Time Period
New Element New Element
BE
Name Change
Name Change
HI10-9
Page 57 of 93
New Element New Element
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1 HI11 HI11-1 HI11-2 HI11-3 HI11-4 HI11-5 HI11-6 HI11-7
HEALTH CARE CODE INFORMATION Code List Qualifier Code Value Code Date Time Period Format Qualifier Date Time Period Value Code Associated Amount Quantity Version Identifier
HI12 HI12-1 HI12-2 HI12-3 HI12-4 HI12-5 HI12-6 HI12-7
ID AN
1-3 1-30
S R R
ID AN
2-3 1-35
N/U N/U
HI11-3 HI11-4
R R AN
1-18 1-15 1-30
R N/U N/U
HI11-5 HI11-6 HI11-7 HI11-8
BE
HI11 HI11-1 HI11-2
HI01 HI01-1 HI01-2 HI01-3 HI01-4 HI01-5 HI01-6 HI01-7
CONDITION INFORMATION HEALTH CARE CODE INFORMATION Code List Qualifier Code Condition Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
ID AN
1-3 1-30
S R R
ID AN
2-3 1-35
N/U N/U
HI12-3 HI12-4
R R AN
1-18 1-15 1-30
R N/U N/U
HI12-5 HI12-6 HI12-7 HI12-8
BE
HI12 HI12-1 HI12-2
HI02 HI02-1 HI02-2 HI02-3
Loop
Loop Repeat
Values
HEALTH CARE CODE INFORMATION Qualifier Value Code Date Time Period Format Qualifier Date Time Period
ID AN
1-3 1-30
S R R
ID AN
2-3 1-35
N/U N/U
R R AN AN
1-18 1-15 1-30 1-30
R N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN
2-3 1-35
N/U N/U
Value Code Amount R Quantity R Version Identifier AN Industry code AN Yes/No Condition or response Code ID
1-18 1-15 1-30 1-30
R N/U N/U N/U
1-1
N/U
2
R
ID AN
1-3 1-30
R R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID
2-3
N/U
BE
Name Change
Value Code Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Value Code Date Time Period Format Qualifier Date Time Period
New Element New Element
BE
Name Change
Name Change
2
R
ID AN
1-3 1-30
R R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
2300
HI
BG
HI01 HI01-1 HI01-2 HI01-3 HI01-4 HI01-5 HI01-6 HI01-7 HI01-8 HI01-9
HEALTH CARE CODE INFORMATION Code List Qualifier Code Condition Code Date Time Period Format Qualifier
Usage Reg.
Name Change
HI12-9
HI
Min. Max.
837-I 5010
HI11-9 HEALTH CARE CODE INFORMATION Code List Qualifier Code Value Code Date Time Period Format Qualifier Date Time Period Value Code Associated Amount Quantity Version Identifier
ID
ID AN
1-3 1-30
S R R
ID
2-3
N/U
BG
HI02 HI02-1 HI02-2 HI02-3
CONDITION INFORMATION HEALTH CARE CODE INFORMATION Qualifier Condition Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Condition Code Date Time Period Format Qualifier
Page 58 of 93
New Element New Element
2300
BG
Name Change
New Element New Element
BG
Name Change
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
HI02-4 HI02-5 HI02-6 HI02-7
Date Time Period Monetary Amount Quantity Version Identifier
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
1-35 1-18 1-15 1-30
Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Condition Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Condition Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Condition Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Condition Code
AN R R AN AN
1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U
ID
1-1
N/U
HI03 HI03-1 HI03-2 HI03-3 HI03-4 HI03-5 HI03-6 HI03-7
ID AN
1-3 1-30
S R R
ID AN
1-3 1-30
S R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
HI02-4 HI02-5 HI02-6 HI02-7 HI02-8
BG
HI03 HI03-1 HI03-2 HI03-3 HI03-4 HI03-5 HI03-6 HI03-7 HI03-8 HI03-9
HI04 HI04-1 HI04-2 HI04-3 HI04-4 HI04-5 HI04-6 HI04-7
HEALTH CARE CODE INFORMATION Code List Qualifier Code Condition Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN
1-3 1-30
S R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
BG
HI04 HI04-1 HI04-2 HI04-3 HI04-4 HI04-5 HI04-6 HI04-7 HI04-8 HI04-9
HI05 HI05-1 HI05-2 HI05-3 HI05-4 HI05-5 HI05-6 HI05-7
HEALTH CARE CODE INFORMATION Code List Qualifier Code Condition Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN
1-3 1-30
S R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
BG
HI05 HI05-1 HI05-2 HI05-3 HI05-4 HI05-5 HI05-6 HI05-7 HI05-8 HI05-9
HI06 HI06-1 HI06-2
HEALTH CARE CODE INFORMATION Code List Qualifier Code Condition Code
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN
1-3 1-30
S R R
Loop
Loop Repeat
Values
837-I 5010
N/U N/U N/U N/U
HI02-9 HEALTH CARE CODE INFORMATION Code List Qualifier Code Condition Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
Usage Reg.
ID
837-I 4010A1 AN R R AN
Min. Max.
Description
BG
HI06 HI06-1 HI06-2
Page 59 of 93
New Element New Element
BG
Name Change
New Element New Element
BG
Name Change
New Element New Element
BG
Name Change
New Element New Element
BG
Name Change
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
HI06-3 HI06-4 HI06-5 HI06-6 HI06-7
Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1 ID AN R R AN
2-3 1-35 1-18 1-15 1-30
HI07 HI07-1 HI07-2
N/U N/U N/U N/U N/U
HI07-3 HI07-4 HI07-5 HI07-6 HI07-7
ID AN
1-3 1-30
S R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
HI06-3 HI06-4 HI06-5 HI06-6 HI06-7 HI06-8
BG
HI07 HI07-1 HI07-2 HI07-3 HI07-4 HI07-5 HI07-6 HI07-7 HI07-8 HI07-9
HI08 HI08-1 HI08-2 HI08-3 HI08-4 HI08-5 HI08-6 HI08-7
HEALTH CARE CODE INFORMATION Code List Qualifier Code Condition Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
ID AN
1-3 1-30
S R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
BG
HI08 HI08-1 HI08-2 HI08-3 HI08-4 HI08-5 HI08-6 HI08-7 HI08-8 HI08-9
HI09 HI09-1 HI09-2 HI09-3 HI09-4 HI09-5 HI09-6 HI09-7
HEALTH CARE CODE INFORMATION Code List Qualifier Code Condition Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
ID AN
1-3 1-30
S R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
BG
HI09 HI09-1 HI09-2 HI09-3 HI09-4 HI09-5 HI09-6 HI09-7 HI09-8 HI09-9
HI10
HEALTH CARE CODE INFORMATION
S
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010
HI06-9 HEALTH CARE CODE INFORMATION Code List Qualifier Code Condition Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
ID
HI10
Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Condition Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Condition Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Condition Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION
Page 60 of 93
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U S
New Element New Element
BG
Name Change
New Element New Element
BG
Name Change
New Element New Element
BG
Name Change
New Element New Element
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
HI10-3 HI10-4 HI10-5 HI10-6 HI10-7
Code List Qualifier Code Condition Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
ID AN
1-3 1-30
R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
Qualifier Condition Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Condition Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Condition Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code
ID AN
1-3 1-30
R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
HI11 HI11-1 HI11-2 HI11-3 HI11-4 HI11-5 HI11-6 HI11-7
ID AN
1-3 1-30
S R R
ID AN
1-3 1-30
S R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
HI10-1 HI10-2 HI10-3 HI10-4 HI10-5 HI10-6 HI10-7 HI10-8
BG
HI11 HI11-1 HI11-2 HI11-3 HI11-4 HI11-5 HI11-6 HI11-7 HI11-8 HI11-9
HI12 HI12-1 HI12-2 HI12-3 HI12-4 HI12-5 HI12-6 HI12-7
HEALTH CARE CODE INFORMATION Code List Qualifier Code Condition Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN
1-3 1-30
S R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
BG
HI12 HI12-1 HI12-2 HI12-3 HI12-4 HI12-5 HI12-6 HI12-7 HI12-8 HI12-9
HI HI01 HI01-1 HI01-2 HI01-3 HI01-4 HI01-5 HI01-6 HI01-7
TREATMENT CODE INFORMATION HEALTH CARE CODE INFORMATION Code List Qualifier Code Treatment Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
2
R
2
R
ID AN
1-3 1-30
R R R
ID AN
1-3 1-30
R R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
Loop
Loop Repeat
Values
837-I 5010 BG
HI10-9 HEALTH CARE CODE INFORMATION Code List Qualifier Code Condition Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
Usage Reg.
ID
837-I 4010A1 HI10-1 HI10-2
Min. Max.
Description
2300
HI
TC
HI01 HI01-1 HI01-2 HI01-3 HI01-4 HI01-5 HI01-6 HI01-7
TREATMENT CODE INFORMATION HEALTH CARE CODE INFORMATION Qualifier Treatment Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
Page 61 of 93
BG
Name Change
New Element New Element
BG
Name Change
New Element New Element
BG
Name Change
New Element New Element
2300
TC
Name Change
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Treatment Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Treatment Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Treatment Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Treatment Code Date Time Period Format Qualifier Date Time Period Monetary Amount
AN
1-30
N/U
ID
1-1
N/U
HI01-9
HI02-3 HI02-4 HI02-5 HI02-6 HI02-7
ID AN
1-3 1-30
S R R
ID AN
1-3 1-30
S R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
TC
HI02 HI02-1 HI02-2 HI02-3 HI02-4 HI02-5 HI02-6 HI02-7 HI02-8 HI02-9
HI03 HI03-1 HI03-2 HI03-3 HI03-4 HI03-5 HI03-6 HI03-7
HEALTH CARE CODE INFORMATION Code List Qualifier Code Treatment Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN
1-3 1-30
S R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
TC
HI03 HI03-1 HI03-2 HI03-3 HI03-4 HI03-5 HI03-6 HI03-7 HI03-8 HI03-9
HI04 HI04-1 HI04-2 HI04-3 HI04-4 HI04-5 HI04-6 HI04-7
HEALTH CARE CODE INFORMATION Code List Qualifier Code Treatment Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN
1-3 1-30
S R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
TC
HI04 HI04-1 HI04-2 HI04-3 HI04-4 HI04-5 HI04-6 HI04-7 HI04-8 HI04-9
HI05 HI05-1 HI05-2 HI05-3 HI05-4 HI05-5
HEALTH CARE CODE INFORMATION Code List Qualifier Code Treatment Code Date Time Period Format Qualifier Date Time Period Monetary Amount
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN
1-3 1-30
S R R
ID AN R
2-3 1-35 1-18
N/U N/U N/U
ID AN R
2-3 1-35 1-18
N/U N/U N/U
Loop
Loop Repeat
Values
837-I 5010 HI01-8
HI02 HI02-1 HI02-2
Usage Reg.
ID
837-I 4010A1
HEALTH CARE CODE INFORMATION Code List Qualifier Code Treatment Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
Min. Max.
Description
TC
HI05 HI05-1 HI05-2 HI05-3 HI05-4 HI05-5
Page 62 of 93
New Element New Element
TC
Name Change
New Element New Element
TC
Name Change
New Element New Element
TC
Name Change
New Element New Element
TC
Name Change
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
HI05-6 HI05-7
Quantity Version Identifier
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1 R AN
1-15 1-30
HI06 HI06-1 HI06-2 HI06-3 HI06-4 HI06-5 HI06-6 HI06-7
ID AN
1-3 1-30
S R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
HI05-6 HI05-7 HI05-8
TC
HI06 HI06-1 HI06-2 HI06-3 HI06-4 HI06-5 HI06-6 HI06-7 HI06-8 HI06-9
HI07 HI07-1 HI07-2 HI07-3 HI07-4 HI07-5 HI07-6 HI07-7
HEALTH CARE CODE INFORMATION Code List Qualifier Code Treatment Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
ID AN
1-3 1-30
S R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
TC
HI07 HI07-1 HI07-2 HI07-3 HI07-4 HI07-5 HI07-6 HI07-7 HI07-8 HI07-9
HI08 HI08-1 HI08-2 HI08-3 HI08-4 HI08-5 HI08-6 HI08-7
HEALTH CARE CODE INFORMATION Code List Qualifier Code Treatment Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
ID AN
1-3 1-30
S R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
TC
HI08 HI08-1 HI08-2 HI08-3 HI08-4 HI08-5 HI08-6 HI08-7 HI08-8 HI08-9
HI09 HI09-1 HI09-2 HI09-3
HEALTH CARE CODE INFORMATION Code List Qualifier Code Treatment Code Date Time Period Format Qualifier
ID AN
1-3 1-30
S R R
ID
2-3
N/U
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010
N/U N/U
HI05-9 HEALTH CARE CODE INFORMATION Code List Qualifier Code Treatment Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
ID
TC
HI09 HI09-1 HI09-2 HI09-3
Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Treatment Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Treatment Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Treatment Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Treatment Code Date Time Period Format Qualifier
Page 63 of 93
R AN AN
1-15 1-30 1-30
N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID
2-3
N/U
New Element New Element
TC
Name Change
New Element New Element
TC
Name Change
New Element New Element
TC
Name Change
New Element New Element
TC
Name Change
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
HI09-4 HI09-5 HI09-6 HI09-7
Date Time Period Monetary Amount Quantity Version Identifier
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
1-35 1-18 1-15 1-30
Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Treatment Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Treatment Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code HEALTH CARE CODE INFORMATION Qualifier Treatment Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry code Yes/No Condition or response Code
AN R R AN AN
1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U
ID
1-1
N/U
HI10 HI10-1 HI10-2 HI10-3 HI10-4 HI10-5 HI10-6 HI10-7
ID AN
1-3 1-30
S R R
ID AN
1-3 1-30
S R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
HI09-4 HI09-5 HI09-6 HI09-7 HI09-8
TC
HI10 HI10-1 HI10-2 HI10-3 HI10-4 HI10-5 HI10-6 HI10-7 HI10-8 HI10-9
HI11 HI11-1 HI11-2 HI11-3 HI11-4 HI11-5 HI11-6 HI11-7
HEALTH CARE CODE INFORMATION Code List Qualifier Code Treatment Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN
1-3 1-30
S R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
TC
HI11 HI11-1 HI11-2 HI11-3 HI11-4 HI11-5 HI11-6 HI11-7 HI11-8 HI11-9
HI12 HI12-1 HI12-2 HI12-3 HI12-4 HI12-5 HI12-6 HI12-7
HEALTH CARE CODE INFORMATION Code List Qualifier Code Treatment Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN
1-3 1-30
S R R
ID AN R R AN
2-3 1-35 1-18 1-15 1-30
N/U N/U N/U N/U N/U
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
TC
HI12 HI12-1 HI12-2 HI12-3 HI12-4 HI12-5 HI12-6 HI12-7 HI12-8 HI12-9
QTY QTY01 QTY02
CLAIM QUANTITY Quantity Qualifier Claim Days Count
ID R
4 2-2 1-15
S R R
Loop
Loop Repeat
Values
837-I 5010
N/U N/U N/U N/U
HI09-9 HEALTH CARE CODE INFORMATION Code List Qualifier Code Treatment Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier
Usage Reg.
ID
837-I 4010A1 AN R R AN
Min. Max.
Description
New Element New Element
TC
Name Change
New Element New Element
TC
Name Change
New Element New Element
TC
Name Change
New Element New Element
Segment Deleted
2300 CA, CD, LA, NA
Page 64 of 93
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1
QTY03-13 QTY03-14 QTY03-15 QTY04
COMPOSITE UNIT OF MEASURE Unit or Basis for Measurement Code Exponent Multiplier Unit or Basis for Measurement Code Exponent Multiplier Unit or Basis for Measurement Code Exponent Multiplier Unit or Basis for Measurement Code Exponent Multiplier Unit or Basis for Measurement Code Exponent Multiplier Free-Form Message
HCP
CLAIM PRICING/REPRICING INFORMATION
QTY03 QTY03-1 QTY03-2 QTY03-3 QTY03-4 QTY03-5 QTY03-6 QTY03-7 QTY03-8 QTY03-9 QTY03-10 QTY03-11 QTY03-12
HCP06
Pricing Methodology Repriced Allowed Amount Repriced Saving Amount Repricing Organization Identifier Repricing Per Diem or Flat Rate Amount Repriced Approved DRG Code
HCP07 HCP08
HCP01 HCP02 HCP03
Usage Reg.
Loop
Loop Repeat
Values
R ID R R
2-2 1-15 1-10
R N/U N/U
ID R R
2-2 1-15 1-10
N/U N/U N/U
ID R R
2-2 1-15 1-10
N/U N/U N/U
ID R R
2-2 1-15 1-10
N/U N/U N/U
ID R R AN
2-2 1-15 1-10 1-30
N/U N/U N/U N/U
1
S
DA
2300
HCP 00, 01, 02, 03, 04, 05, 06, 07, 08, 09, 10 ,11, 12, 13, 14
CLAIM PRICING/REPRICING INFORMATION
HCP07 HCP08
Pricing Methodology Repriced Allowed Amount Repriced Saving Amount Repricing Organization Identifier Repricing Per Diem or Flat Rate Amount Ambulatory Patient Group Code Ambulatory Patient Group Amount Product/Service ID
HCP09 HCP10
2-2 1-18 1-18
R R S
AN
1-30
S
HCP04
R
1-9
S
HCP05
AN
1-30
S
HCP06
Repriced Approved Amount Product/Service ID
R AN
1-18 1-48
S S
HCP09
Product/Service ID Qualifier
ID
2-2
S
HCP10
Product/Service ID Unit or Basis for Measurement Code Quantity
AN
1-48
S
ID R
2-2 1-15
S S
HCP05
Min. Max.
837-I 5010
ID R R
HCP04
ID
HCP01 HCP02 HCP03
1
S
ID R R
2-2 1-18 1-18
R R S
AN
1-50
S
R
1-9
S
AN
1-50
S
R AN
1-18 1-48
S S
Product/Service ID Qualifier
ID
2-2
N/U
Product/Service ID Unit or Basis for Measurement Code Quantity
AN
1-48
N/U
ID R
2-2 1-15
S S
2300 00, 01, 02, 03, 04, 05, 06, 07, 08, 09, 10 ,11, 12, 13, 14
Increase from 30 - 50
Increase from 30 - 50 Name Change Name Change
Usage change to Not Used HC
Usage change to Not Used
HCP11 HCP12
DA, UN
HCP11 HCP12
Page 65 of 93
DA, UN
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1 HCP13 HCP14 HCP15
Reject Reason Code Policy Compliance Code Exception Code
CR7
HOME HEALTH CARE PLAN INFORMATION
CR701 CR702 CR703
HSD HSD01 HSD02 HSD03 HSD04 HSD05 HSD06
Disipline Type Code Vsits Prior to Recertification Date Count Total Visits Projected This Certification Count HOME CARE SERVICES DELIVERY Visits Number of Visits Frequency Period Frequency Count Duration of Visits Units Duration of Visits, Number of Units
HSD07 HSD08
Ship, Delivery or Caledar Pattern Code Delivery Pattern Time Code
NM1 NM101 NM102
ID ID ID
2-2 1-2 1-2
S S S
1
S
ID
2-2
R
NO
1-9
R
NO
1-9
R
ID R ID R ID
12 2-2 1-15 2-2 1-6 1-2
S S S S S S
NO
1-3
S
ID
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010 T1, T2, T3, T4, T5, T6 1, 2, 3, 4, 5 1, 2, 3, 4, 5, 6
HCP13 HCP14 HCP15
Reject Reason Code Policy Compliance Code Exception Code
ID ID ID
2-2 1-2 1-2
T1, T2, T3, T4, T5, T6 1, 2, 3, 4, 5 1, 2, 3, 4, 5, 6
S S S
Segment Deleted 2305
6 AI, MS, OT, PT, SN, ST
Segment Deleted
ID ID
1-2 1-1
S S
ATTENDING PHYSICIAN NAME Entity Identifier Code Entity Type Qualifier
ID ID
1 2-3 1-1
S R R
NM103
Name Last
AN
1-35
NM104 NM105 NM106 NM107
NameFirst Name Middle Name Prefix Name Suffix
AN AN AN AN
1-25 1-25 1-10 1-10
2305
DA, MO, Q1, WK 7, 35
1, 2, 3, 4, 5, 6, 7, 8, 9, A, B, C, D, E, F, G, J, K, L, N, O, S, SA, SB, SC, SD, SG, SL, SP, SX, SY, SZ, W, D, E, F
NM1 NM101 NM102
ATTENDING PROVIDER NAME Entity Identifier Code Entity Type Qualifier
R
NM103
S S N/U S
NM104 NM105 NM106 NM107
NM108
Identification Code Qualifier
ID
1-2
R
NM109 NM110 NM111
Provider Identifier Entity Relationship Code Entity Identifier Code
AN ID ID
2-80 2-2 2-3
R N/U N/U
2310A
1 71 1, 2
24, 34, XX
Name Change ID ID
1 2-3 1-1
S R R
Last Name
AN
1-60
R
First Name Middle Name Name Prefix Name Suffix
AN AN AN AN
1-35 1-25 1-10 1-10
S S N/U S
NM108
Identification Code Qualifier
ID
1-2
S
NM109 NM110 NM111
Provider Identifier Entity Relationship Code Entity Identifier Code
AN ID ID
2-80 2-2 2-3
S N/U N/U
Page 66 of 93
2310A
1 71 1
XX
Code Deleted Name Change Increase from 35 - 60 Name Change Increase 25 - 35 Name Change
Code Deleted Usage change to Situational Usage change to Situational
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
NM112
Name Last or Organization Name
837-I 4010A1
ID
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010 New Element AN
1-60
N/U Name Change
PRV PRV01 PRV02 PRV03 PRV04 PRV05
ATTENDING PHYSICIAN SPECIALTY INFORMATION Provider Code ID Reference Identification Qualifier ID Provider Taxonomy Code AN State or Province Code ID PROVIDER SPECIALTY INFORMATION
PRV06
Provider Organization Code
REF
ATTENDING PHYSICIAN SECONDARY IDENTIFICATION
ID
1 1-3
S R
2-3 1-30 2-2
R R N/U
3-3
5
REF02 REF03 REF04
Reference Identification Qualifier Attending Physician Secondary Identifier Description REFERENCE IDENTIFIER
NM1 NM101 NM102 NM103
OPERATING PHYSICIAN NAME Entity Identifier Code Entity Type Qualifier Last or Organization Name
ID ID AN
1 2-3 1-1 1-35
NM104 NM105 NM106 NM107
Name First Middle Name Name Prefix Name Suffix
AN AN AN AN
1-25 1-25 1-10 1-10
REF01
2310A AT, SU ZZ
PRV PRV01 PRV02 PRV03 PRV04
ATTENDING PROVIDER SPECIALTY INFORMATION Provider Code ID Reference Identification Qualifier ID Provider Taxonomy Code AN State or Province Code ID PROVIDER SPECIALTY INFORMATION
N/U
PRV05
N/U
PRV06
Provider Organization Code
REF
ATTENDING PROVIDER SECONDARY IDENTIFICATION
S
ID
2-3
R
AN AN
1-30 1-80
R N/U N/U
S R R R
R S N/U S
NM108
Identification Code Qualifier
ID
1-2
R
NM109 NM110 NM111
Identifier Entity Relationship Code Entity Identifier Code
AN ID ID
2-80 2-2 2-3
R N/U N/U
2310A 0B, 1A, 1B, 1C, 1D, 1G, 1H, EI, G2, LU, N5, SY, X5
2310B
1 72 1
24, 34, XX
ID
1 1-3
S R
2-3 1-50 2-2
R R N/U
2310A AT
Code Deleted Code Change
PXC Increase from 30 - 50
N/U 3-3
N/U Name Change # Repeats change to 4
4
S
2310A Code Deleted
REF01
Reference Identification Qualifier
REF02 REF03 REF04
Secondary Identifier Description REFERENCE IDENTIFIER
NM1 NM101 NM102 NM103
NM104 NM105 NM106 NM107
ID
2-3
R
AN AN
1-50 1-80
R N/U N/U
OPERATING PHYSICIAN NAME Entity Identifier Code Entity Type Qualifier Last or Organization Name
ID ID AN
1 2-3 1-1 1-60
S R R R
First Name Middle Name Name Prefix Name Suffix
AN AN AN AN
1-35 1-25 1-10 1-10
S S N/U S
NM108
Identification Code Qualifier
ID
1-2
S
NM109 NM110 NM111
Identifier Entity Relationship Code Entity Identifier Code Name Last or Organization Name
AN ID ID
2-80 2-2 2-3
S N/U N/U
AN
1-60
N/U
NM112
Page 67 of 93
0B, 1G, G2, LU Increase from 30 - 50 Name Change
2310B
1 72 1 Increase from 35 - 60 Increase from 25 - 35 Usage change to Situational
XX
Code Deleted Usage change to Situational Usage change to Situational
New Element
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
REF
OPERATING PHYSICIAN SECONDARY IDENTIFICATION
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
REF
OPERATING PHYSICIAN SECONDARY IDENTIFICATION
837-I 4010A1
REF01 REF02 REF03 REF04
Reference Identification Qualifier Secondary Identifier Description REFERENCE IDENTIFIER
NM1 NM101 NM102 NM103
NM104 NM105 NM106 NM107
NM108 NM109 NM110 NM111
REF
REF01 REF02 REF03 REF04
5
S
ID AN AN
2-3 1-30 1-80
R R N/U N/U
OTHER PROVIDER NAME Entity Identifier Code Entity Type Qualifier Last or Organization Name
ID ID AN
1 2-3 1-1 1-35
S R R R
First Name Middle Name Name Prefix Name Suffix
AN AN AN AN
1-25 1-25 1-10 1-10
R S N/U S
Identification Code Qualifier Identifier Entity Relationship Code Entity Identifier Code
ID AN ID ID
OTHER PROVIDER SECONDARY IDENTIFICATION
Reference Identification Qualifier Rendering Provider Secondary Identifier Description REFERENCE IDENTIFIER
1-2 2-80 2-2 2-3
5
ID
2-3
R
AN AN
1-30 1-80
R N/U N/U
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010 2310B 0B, 1A, 1B, 1C, 1D, 1G, 1H, EI, G2, LU, N5, SY, X5
2310C
1 73 1, 2
24, 34, XX
R S N/U N/U
S
ID
2310C 0B, 1A, 1B, 1C, 1D, 1G, 1H, EI, G2, LU, N5, SY, X5
# Repeats change to 4 4
S
2310B Code Deleted
REF01 REF02 REF03 REF04
Qualifier Secondary Identifier Description REFERENCE IDENTIFIER
NM1 NM101 NM102 NM103
NM104 NM105 NM106 NM107
ID AN AN
2-3 1-50 1-80
R R N/U N/U
OTHER OPERATING PHYSICIAN NAME Entity Identifier Code Entity Type Qualifier Last or Organization Name
ID ID AN
1 2-3 1-1 1-60
S R R R
First Name Middle Name Name Prefix Name Suffix
AN AN AN AN
1-35 1-25 1-10 1-10
S S N/U S
NM112
Identification Code Qualifier Identifier Entity Relationship Code Entity Identifier Code Name Last or Organization Name
REF
OPERATING PHYSICIAN SECONDARY IDENTIFICATION
NM108 NM109 NM110 NM111
0B, 1G, G2, LU Increase from 30 - 50
Name Change
ID AN ID ID
1-2 2-80 2-2 2-3
S S N/U N/U
AN
1-60
N/U
2310C
1 ZZ 1
XX
Code Change Code Deleted Increase from 35 - 60 Increase from 25 - 35 Usage change to Situational
Code Deleted Usage change to Situational
New Element
Name Chnge # of Repeats change to 4 4
S
2310C Code Deleted
REF01 REF02 REF03 REF04
NM1 NM101 NM102 NM103
Reference Identification Qualifier Rendering Provider Secondary Identifier Description REFERENCE IDENTIFIER RENDERING PHYSICIAN NAME Entity Identifier Code Entity Type Qualifier Rendering Provider Last or Organization Name
Page 68 of 93
ID
2-3
R
AN AN
1-50 1-80
R N/U N/U
ID ID
1 2-3 1-1
S R R
AN
1-60
R
0B, 1G, G2, LU Increase from 30 - 50
New Segment 2310D
1 82 1
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1
NM107 NM108
Identification Code Qualifier
ID
1-2
S
NM109 NM110 NM111
Rendering Provider Identifier Entity Relationship Code Entity Identifier Code Name Last or Organization Name
AN ID ID
2-80 2-2 2-3
S N/U N/U
AN
1-60
N/U
NM112
NM103 NM104 NM105 NM106 NM107
Laboratory or Facility Name Name First Name Middle Name Prefix Name Suffix
ID ID AN AN AN AN AN
1-35 1-25 1-25 1-10 1-10
R N/U N/U N/U N/U
Identification Code Qualifier ID Laboratory or Facility Primary Identifier AN Entity Relationship Code ID Entity Identifier Code ID
1-2
S
2-80 2-2 2-3
S N/U N/U
2310E
1 FA 2
1-35
S
AN AN
1-25 1-10
S N/U
AN
1-10
S
Loop
Loop Repeat
Values
XX
New Segment
REF02 REF03 REF04
NM1 NM101 NM102
SERVICE FACILITY LOCATION Entity Identifier Code Entity Type Qualifier
ID ID
1 2-3 1-1
NM103 NM104 NM105 NM106 NM107
Laboratory or Facility Name Name First Name Middle Name Prefix Name Suffix
AN AN AN AN AN
1-60 1-35 1-25 1-10 1-10
R N/U N/U N/U N/U
Identification Code Qualifier ID Laboratory or Facility Primary Identifier AN Entity Relationship Code ID Entity Identifier Code ID Name Last or Organization Name AN
1-2
S
2-80 2-2 2-3
S N/U N/U
1-60
N/U
1
R
1-55
R
REF01
S R R
AN
RENDERING PHYSICIAN SECONDARY IDENTIFICATION Reference Identification Qualifier Rendering Provider Secondary Identifier Description REFERENCE IDENTIFIER
REF
1 2-3 1-1
Usage Reg.
837-I 5010
NM105 NM106
SERVICE FACILITY NAME Entity Identifier Code Entity Type Qualifier
Min. Max.
Rendering Provider First Name Rendering Provider Middle Name Name Prefix Rendering Provider Name Suffix
NM104
NM1 NM101 NM102
ID
4
S
ID
2-3
R
AN AN
1-50 1-80
R N/U N/U
S R R
2310D 0B, 1G, G2, LU
Name Change 2310E
1 77 2
Code Change Increase from 35 - 60 Increase from 25 - 35
Code Deleted NM108 NM109 NM110 NM111
24, 34, XX
NM108 NM109 NM110 NM111 NM112
N3 N301
SERVICE FACILITY ADDRESS Laboratory or Facility Address Line AN
1
R
1-55
R
2310E
N3 N301
SERVICE FACILITY LOCATION ADDRESS Laboratory or Facility Address Line AN
Page 69 of 93
XX
New Element
Name Change 2310E
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1 N302
N4 N401 N402 N403 N404 N405 N406
REF
REF01 REF02 REF03 REF04
Laboratory or Facility Address Line AN SERVICE FACILITY CITY/STATE/ZIP CODE Laboratory or Facility City Name AN Laboratory or Facility State or Province Code ID Laboratory or Facility Postal Zone or ZIP Code ID Laboratory/Facility Country Code ID Location Qualifier ID Location Identifier AN
SERVICE FACILITY SECONDARY IDENTIFICATION
Reference Identification Qualifier Laboratory or Facility Secondary Identifier Description REFERENCE IDENTIFIER
S
1
R
2-30
R
N401
2-2
R
N402
3-15
R
N403
2-3 1-2 1-30
S N/U N/U
N404 N405 N406 N407
S
ID
2-3
R
AN AN
1-30 1-80
R N/U N/U
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010
1-55
5
ID
N302
2310E
N4
2310E
REF 0B, 1A, 1B, 1C, 1D, 1G, 1H, EI, G2, LU, N5, SY, X5
Laboratory or Facility Address Line AN SERVICE FACILITY LOCATION CITY/STATE/ZIP Laboratory or Facility City Name AN Laboratory or Facility State or Province Code ID Laboratory or Facility Postal Zone ZIP Code ID Laboratory/Facility Country Code ID Location Qualifier ID Location Identifier AN Country Subdivision Code ID
1-55
S
1
R
2-30
R
2-2
S
3-15
S
2-3 1-2 1-30 1-3
S N/U N/U S
3
S
Name Change 2310E
Usage change to Situational Usage change to Situational
New Element Name Change # of Repeats change to 3
SERVICE FACILITY LOCATION SECONDARY IDENTIFICATION
2310E Code Deleted
REF02 REF03 REF04
Reference Identification Qualifier Laboratory or Facility Secondary Identifier Description REFERENCE IDENTIFIER
NM1 NM101 NM102
REFERRING PROVIDER NAME Entity Identifier Code Entity Type Qualifier
REF01
ID
2-3
R
AN AN
1-50 1-80
R N/U N/U
ID ID
1 2-3 1-1
S R R
NM103
Referring Provider Last Name AN
1-60
R
NM104
AN
1-35
S
AN AN
1-25 1-10
S N/U
NM107
Referring Provider First Name Referring Provider Middle Name Name Prefix Referring Provider Name Suffix
AN
1-10
S
NM108
Identification Code Qualifier
ID
1-2
S
NM109 NM110 NM111
Referring Provider Identifier Entity Relationship Code Entity Identifier Code Name Last or Organization Name
AN ID ID
2-80 2-2 2-3
S N/U N/U
AN
1-60
N/U
NM105 NM106
NM112
Page 70 of 93
0B, G2, LU Increase from 30 - 50
New Segment 2310F
1 DN 1
XX
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1
REF01 REF02 REF03 REF04
SBR01
SBR02 SBR03 SBR04 SBR05 SBR06 SBR07 SBR08
SBR09
CAS CAS01 CAS02 CAS03 CAS04 CAS05 CAS06 CAS07 CAS08 CAS09
OTHER SUBSCRIBER INFORMATION Payer Responsibility Sequence Number Code
Individual Relationship Code Insured Group or Policy Number Other Insured Group Name Insurance Type Code
ID
1
S
2320
10
SBR
1-1
R
P, S, T
SBR01
01, 04, 05, 07, 10, 15, 17, 18, 19, 20, 21, 22, 23, 24, 29, 32, 33, 36, 39, 40, 41, 43, 53, G8
SBR02
ID
2-2
R
AN AN ID
1-30 1-60 1-3
S S N/U
SBR03 SBR04 SBR05
Coordination of Benefits Code ID Yes/No Condition or Response Code ID Employment Status Code ID
1-1
N/U
SBR06
1-1 2-2
N/U N/U
SBR07 SBR08
Claim Filing Indicator Code CLAIM LEVEL ADJUSTMENTS Claim Adjustment Group Code Adjustment Reason Code Adjustment Amount Adjustment Quantity Adjustment Reason Code Adjustment Amount Adjustment Quantity Adjustment Reason Code Adjustment Amount
ID
ID ID R R ID R R ID R
1-2
S
5
S
1-2 1-5 1-18 1-15 1-5 1-18 1-15 1-5 1-18
R R R S S S S S S
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010
REF
SBR
ID
09, 10, 11, 12, 13, 14, 15, 16, AM, BL, CH, CI, DS, HM, LI, LM, MA, MB, MC, OF, TV, VA, WC, ZZ
2320
SBR09
CAS CO, CR, OA, PI, PR
CAS01 CAS02 CAS03 CAS04 CAS05 CAS06 CAS07 CAS08 CAS09
REFERRING PROVIDER SECONDARY IDENTIFICATION Reference Identification Qualifier ID Referring Provider Secondary Identifier AN Description AN REFERENCE IDENTIFIER
New Segment 3
S
2-3
R
1-50 1-80
R N/U N/U
1
S
ID
1-1
R
ID
2-2
R
AN AN ID
1-50 1-60 1-3
S S N/U
Coordination of Benefits Code ID Yes/No Condition or Response Code ID Employment Status Code ID
1-1
N/U
1-1 2-2
N/U N/U
OTHER SUBSCRIBER INFORMATION Payer Responsibility Sequence Number Code
Individual Relationship Code Insured Group or Policy Number Other Insured Group Name Insurance Type Code
Claim Filing Indicator Code CLAIM LEVEL ADJUSTMENTS Claim Adjustment Group Code Adjustment Reason Code Adjustment Amount Adjustment Quantity Adjustment Reason Code Adjustment Amount Adjustment Quantity Adjustment Reason Code Adjustment Amount
Page 71 of 93
2310F 0B, 1G, G2
2320
10 A, B, C, D, E, F, Code Added G, H, P, S, T, U Code Deleted
01, 18, 19, 20, 21, 39, 40, 53, G8 Increase from 30 - 50
ID
ID ID R R ID R R ID R
1-2
S
5
S
1-2 1-5 1-18 1-15 1-5 1-18 1-15 1-5 1-18
R R R S S S S S S
11, 12, 13, 14, 15, 16, 17, AM, BL, CH, CI, DS, FI, HM, LM, MA, MB, MC, OF, TV, VA, WC, ZZ
2320 CO, CR, OA, PI, PR
Code Change
INSTITUTIONAL CLAIM
4010A1 Description
CAS10 CAS11 CAS12 CAS13 CAS14 CAS15 CAS16 CAS17 CAS18 CAS19
Adjustment Quantity Adjustment Reason Code Adjustment Amount Adjustment Quantity Adjustment Reason Code Adjustment Amount Adjustment Quantity Adjustment Reason Code Adjustment Amount Adjustment Quantity
AMT AMT01 AMT02 AMT03
PAYER PRIOR PAYMENT Amount Qualifier Code Other Payer Patient Paid Amount Credit/Debit Flag Code
AMT AMT01 AMT02 AMT03
COORDINATION OF BENEFITS (COB) TOTAL ALLOWED AMOUNT Amount Qualifier Code Allowed Amount Credit/Debit Flag Code
AMT AMT01
COORDINATION OF BENEFITS (COB) TOTAL SUBMITED CHARGES Amount Qualifier Code
ID
1 1-3
S R
AMT02 AMT03
Coordination of Benefits Total Submitted Charge Amount Credit/Debit Flag Code
R ID
1-18 1-1
R N/U
AMT AMT01 AMT02 AMT03
DIAGNOSTIC RELATED GROUP (DRG) OUTLIER AMOUNT Amount Qualifier Code Claim DRG Outlier Amount Credit/Debit Flag Code
AMT AMT01 AMT02 AMT03
COORDINATION OF BENEFITS (COB) TOTAL MEDICARE PAID AMOUNT Amount Qualifier Code Total Medicare Paid Amout Credit/Debit Flag Code
AMT
MEDICARE PAID AMOUNT 100%
ID
Min. Max.
Usage Reg.
Element Identifier
5010 Loop
Loop Repeat
Values
Element Identifier
Description
CAS10 CAS11 CAS12 CAS13 CAS14 CAS15 CAS16 CAS17 CAS18 CAS19
Adjustment Quantity Adjustment Reason Code Adjustment Amount Adjustment Quantity Adjustment Reason Code Adjustment Amount Adjustment Quantity Adjustment Reason Code Adjustment Amount Adjustment Quantity
AMT AMT01 AMT02 AMT03
837-I 4010A1 R ID R R ID R R ID R R
1-15 1-5 1-18 1-15 1-5 1-18 1-15 1-5 1-18 1-15
S S S S S S S S S S
ID
1 1-3
S R
R ID
1-18 1-1
R N/U
ID
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010 R ID R R ID R R ID R R
1-15 1-5 1-18 1-15 1-5 1-18 1-15 1-5 1-18 1-15
S S S S S S S S S S
COB PAYER PAID AMOUNT Amount Qualifier Code
ID
1 1-3
S R
Payer Paid Amount Credit/Debit Flag Code
R ID
1-18 1-1
R N/U
Name Change 2320 C4
2320 D
Code Change Name Change
Segment Deleted
ID R ID
1 1-3 1-18 1-1
S R R N/U
2320 B6
Segment Deleted 2320 T3
Segment Deleted
ID R ID
1 1-3 1-18 1-1
S R R N/U
2320 ZZ
Segment Deleted
ID R ID
1 1-3 1-18 1-1
S R R N/U
2320
1
S
2320
N1
Segment Deleted
Page 72 of 93
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1 AMT01 AMT02 AMT03
AMT AMT01 AMT02 AMT03
AMT AMT01 AMT02 AMT03
Amount Qualifier Code Medicare Paid at 100% Amount Credit/Debit Flag Code MEDICARE PAID AMOUNT 80% Amount Qualifier Code Medicare Paid at 80% Amount Credit/Debit Flag Code COORDINATION OF BENEFITS (COB) MEDICARE A TRUST FUND PAID AMOUNT Amount Qualifier Code Paid From Part A Medicare Trust Fund Amount Credit/Debit Flag Code
ID
1-3
R
R ID
1-18 1-1
R N/U
ID
1 1-3
S R
R ID
1-18 1-1
R N/U
ID
1 1-3
S R
R ID
1-18 1-1
R N/U
AMT AMT01
ID
1 1-3
S R
AMT02 AMT03
Non-Covered Charge Amount Credit/Debit Flag Code
R ID
1-18 1-1
R N/U
AMT02 AMT03
Loop
Loop Repeat
Values
837-I 5010 KF
2320 PG
2320 AA
Segment Deleted
COORDINATION OF BENEFITS (COB) TOTAL NON-COVERED AMOUNT Amount Qualifier Code
AMT AMT01
Usage Reg.
Segment Deleted
AMT02 AMT03
COORDINATION OF BENEFITS (COB) TOTAL DENIED AMOUNT Amount Qualifier Code Claim Total Denied Charge Amount Credit/Debit Flag Code
Min. Max.
Segment Deleted
COORDINATION OF BENEFITS (COB) MEDICARE B TRUST FUND PAID AMOUNT Amount Qualifier Code Paid From Part B Medicare Trust Fund Amount Credit/Debit Flag Code
AMT AMT01
ID
ID
1 1-3
S R
R ID
1-18 1-1
R N/U
2320 B1
Segment Deleted 2320 A8
Segment Deleted
ID
1 1-3
S R
R ID
1-18 1-1
R N/U
2320 YT
AMT AMT01
REMAINING PATIENT LIABILITY Amount Qualifier Code
Page 73 of 93
New Segment ID
1 1-3
S R
2320 EAF
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
AMT02 AMT03
Remaining Patient Liability Amount Credit/Debit Flag Code
AMT AMT01 AMT02 AMT03
COB TOTAL NONCOVERED AMOUNT Amount Qualifier Code Non-Covered Amount Credit/Debit Flag Code
837-I 4010A1
DMG DMG01 DMG02 DMG03 DMG04 DMG05 DMG06 DMG07 DMG08 DMG09
OTHER SUBSCRIBER DEMOGRAPHIC INFORMATION Date Time Period Format Qualifier Other Insured Birth Date Gender Code Marital Status Code Race or Ethnicity Code Citizenship Status Code Country Code Basis of Veification Code Quantity
1
S
ID AN ID ID ID ID ID ID R
2-3 1-35 1-1 1-1 1-1 1-2 2-3 1-2 1-15
R R R N/U N/U N/U N/U N/U N/U
ID
1 1-2
R N/U
ID
2-2
N/U
ID
1-1
R
OI04 OI05
ID ID
1-1 1-1
N/U N/U
OI06
Release of Information Code
ID
1-1
R
MIA
MEDICARE INPATIENT ADJUDICATION INFORMATION
1
S
MIA01
Covered Days or Visits Count
R
1-15
MIA02 MIA03
Lifetime Reserve Days Count Lifetime Psychiatric Days
R R
MIA04
Claim DRG Amount
R
OI02 OI03
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010 R ID
1-18 1-1
R N/U
ID R ID
1 1-3 1-18 1-1
S R R N/U
New Segment 2320 A8
Segment Deleted
OTHER INSURANCE COVERAGE INFORMATION Claim Filing Indicator Code Claim Submission Reason Code Benefits Assignment Certification Indicator Patient Signature Source Code Provider Agreement Code
OI OI01
ID
2320 D8 F, M, U
OI04 OI05
OTHER INSURANCE COVERAGE INFORMATION Claim Filing Indicator Code Claim Submission Reason Code Benefits Assignment Certification Indicator Patient Signature Source Code Provider Agreement Code
OI06
Release of Information Code
MIA
INPATIENT ADJUDICATION INFORMATION
R
MIA01
Covered Days or Visits Count
1-15 1-15
S S
MIA02 MIA03
1-18
S
MIA04
Amount Lifetime Psychiatric Days Remaining Patient Liability Amount
2320
OI OI01 OI02 N, Y
OI03
ID
1 1-2
R N/U
ID
2-2
N/U
ID
1-1
R
ID ID
1-1 1-1
N/U N/U
ID
1-1
R
1
S
R
1-15
S
R R
1-18 1-15
N/U S
R
1-18
S
2320
Code Added N, W, Y
Code Deleted A, I, M, N, O, Y
2320
Page 74 of 93
I, Y
2320 Usage change to Situational Usage change to Not Used Increase from 15 - 18 Name Change
Name Change
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1 MIA05 MIA06 MIA07 MIA08 MIA09 MIA10 MIA11 MIA12 MIA13 MIA14 MIA15 MIA16 MIA17 MIA18 MIA19
Remark Code AN Claim Disproportionate Share Amount R Claim MSP Pass-through Amount R Claim PPS Capital Amount R PPS-Capital FSP DRG Amount R PPS-Capital HSP DRG Amount R PPS-Capital DSH DRG Amount R Old Capital Amount R PPS-Capital IME Amount R PPS-Operating Hospital Specific DRG Amount R Cost Report Day Count R PPS-Operating Federal Specific DRG Amount R Claim PPS Capital Outlier Amount R Claim Indirect Teaching Amount R Non-Payable Professional Component Amount R
ID
Min. Max.
Usage Reg.
MIA19
Claim Payment Remark Code AN Claim Disproportionate Share Amount R Claim MSP Pass-through Amount R Claim PPS Capital Amount R PPS-Capital FSP DRG Amount R PPS-Capital HSP DRG Amount R PPS-Capital DSH DRG Amount R Old Capital Amount R PPS-Capital IME Amount R PPS-Operating Hospital Specific DRG Amount R Cost Report Day Count R PPS-Operating Federal Specific DRG Amount R Claim PPS Capital Outlier Amount R Claim Indirect Teaching Amount R Non-Payable Professional Component Billed Amount R
1-30
S
MIA05
1-18
S
MIA06
1-18 1-18
S S
MIA07 MIA08
1-18
S
MIA09
1-18
S
MIA10
1-18 1-18 1-18
S S S
MIA11 MIA12 MIA13
1-18 1-15
S S
MIA14 MIA15
1-18
S
MIA16
1-18
S
MIA17
1-18
S
MIA18
1-18
S
1-50
S
1-18
S
1-18 1-18
S S
1-18
S
1-18
S
1-18 1-18 1-18
S S S
1-18 1-15
S S
1-18
S
1-18
S
1-18
S
1-18
S
AN
1-30
S
MIA20
Claim Payment Remark Code AN
1-50
S
MIA21
Remark Code
AN
1-30
S
MIA21
Claim Payment Remark Code AN
1-50
S
MIA22
Remark Code
AN
1-30
S
MIA22
Claim Payment Remark Code AN
1-50
S
MIA23
Remark Code PPS-Capital Exception Amount
AN
1-30
S
MIA23
1-50
S
R
1-18
S
MIA24
Claim Payment Remark Code AN PPS-Capital Exception Amount R
1-18
S
MOA MOA01 MOA02 MOA03 MOA04 MOA05 MOA06 MOA07
R
1 1-10
S S
R AN AN AN AN AN
1-18 1-30 1-30 1-30 1-30 1-30
S S S S S S
Values
2320
Increase from 30 - 50 Name Change
Name Change
Remark Code
MEDICARE OUTPATIENT ADJUDICATION INFORMATION Reimbursement Rate Claim HCPCS Payable Amount Remark Code Remark Code Remark Code Remark Code Remark Code
Loop Repeat
837-I 5010
MIA20
MIA24
Loop
MOA MOA01
MEDICARE OUTPATIENT ADJUDICATION INFORMATION Reimbursement Rate
R
1 1-10
S S
MOA02 MOA03 MOA04 MOA05 MOA06 MOA07
HCPCS Payable Amount Remark Code Remark Code Remark Code Remark Code Remark Code
R AN AN AN AN AN
1-18 1-50 1-50 1-50 1-50 1-50
S S S S S S
Increase from 30 - 50 Name Change Increase from 30 - 50 Name Change Increase from 30 - 50 Name Change Increase from 30 - 50 Name Change
2320 Name Change
Page 75 of 93
Increase from 30 - 50 Increase from 30 - 50 Increase from 30 - 50 Increase from 30 - 50 Increase from 30 - 50
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1
MOA09
Claim ESRD Payment Amount Non-Payable Professional Component Amount
NM1 NM101 NM102 NM103 NM104 NM105 NM106 NM107 NM108 NM109 NM110 NM111
OTHER SUBSCRIBER NAME Entity Identifier Code Entity Type Qualifier Other Insured Last Name Other Insured First Name Other Insured Middle Name Name Prefix Other Insured Name Suffix Identification Code Qualifier Other Insured Identifier Entity Relationship Code Entity Identifier Code
MOA08
N3
OTHER SUBSCRIBER ADDRESS
N301
Other Insured Address Line
N302
Other Insured Address Line
N4 N401
OTHER SUBSCRIBER CITY/STATE/ZIP CODE Other Insured City Name
N402 N403 N404 N405 N406
REF REF01 REF02 REF03 REF04
Min. Max.
Usage Reg.
1-18
S
MOA08
R
1-18
S
MOA09
ID ID AN AN AN AN AN ID AN ID ID
1 2-3 1-1 1-35 1-25 1-25 1-10 1-10 1-2 2-80 2-2 2-3
R R R R S S N/U S R R N/U N/U
2330A
1 IL 1, 2
MI, ZZ
NM112
OTHER SUBSCRIBER NAME Entity Identifier Code Entity Type Qualifier Other Insured Last Name Other Insured First Name Other Insured Middle Name Name Prefix Other Insured Name Suffix Identification Code Qualifier Other Insured Identifier Entity Relationship Code Entity Identifier Code Name Last or Organization Name
N3
OTHER SUBSCRIBER ADDRESS
NM1 NM101 NM102 NM103 NM104 NM105 NM106 NM107 NM108 NM109 NM110 NM111
1-18
S
R
1-18
S
ID ID AN AN AN AN AN ID AN ID ID
1 2-3 1-1 1-60 1-35 1-25 1-10 1-10 1-2 2-80 2-2 2-3
R R R R S S N/U S R R N/U N/U
AN
1-60
N/U
1
S
R
N301
Other Insured Address Line
AN
1-55
R
AN
1-55
S
N302
Other Insured Address Line
AN
1-55
S
AN
1 2-30
S R
N4 N401
OTHER SUBSCRIBER CITY/STATE/ZIP CODE Other Insured City Name
AN
1 2-30
R R
2-2
R
N402
2-2
S
3-15 2-3 1-2 1-30
R S N/U N/U
N403 N404 N405 N406 N407
3-15 2-3 1-2 1-30 1-3
S S N/U N/U S
R
AN AN
1-30 1-80
R N/U N/U
2330A
2330A
REF 1W, 23, !G, SY
REF01 REF02 REF03 REF04
Other Insured State Code ID Other Insured Postal Zone or ZIP Code ID Subscriber Country Code ID Location Qualifier ID Location Identifier AN Country Subdivision Code ID OTHER SUBSCRIBER SECONDARY IDENTIFICATION Reference Identification Qualifier Other Insured Additional Identifier Description REFERENCE IDENTIFIER
Page 76 of 93
2330A
1 IL 1, 2 Increase from 35 - 60 Increase from 25 - 35
II, MI
Code Change
New Element
1-55
2-3
Values
Name Change
AN
ID
Loop Repeat
Name Change R
S
S
2330A
End Stage Renal Disease Payment Amount Non-Payable Professional Component Billed Amount
1
3
Loop
837-I 5010
R
Other Insured State Code ID Other Insured Postal Zone or ZIP Code ID Subscriber Country Code ID Location Qualifier ID Location Identifier AN
OTHER SUBSCRIBER SECONDARY IDENTIFICATION Reference Identification Qualifier Other Insured Additional Identifier Description REFERENCE IDENTIFIER
ID
2330A
2330A Usage change to Situational Usage change to Situational
New Element # of Repeat change to 2
2
S
ID
2-3
R
AN AN
1-50 1-80
R N/U N/U
2330A Code Deleted SY Increase from 30 - 50
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
2330B
1
Values
Element Identifier
PR 2
NM1 NM101 NM102
PI, XV
NM103 NM104 NM105 NM106 NM107 NM108
Description
837-I 4010A1 NM1 NM101 NM102 NM103 NM104 NM105 NM106 NM107 NM108 NM109 NM110 NM111
OTHER PAYER NAME Entity Identifier Code Entity Type Qualifier Other Payer Last or Organization Name Name First Name Middle Name Prefix Name Suffix Identification Code Qualifier
ID ID
1 2-3 1-1
R R R
AN AN AN AN AN ID
1-35 1-25 1-25 1-10 1-10 1-2
R N/U N/U N/U N/U R
Other Payer Primary Identifier AN Entity Relationship Code ID Entity Identifier Code ID
2-80 2-2 2-3
R N/U N/U
OTHER PAYER ADDRESS Other Payer Address Line Other Payer Address Line
N4 N401
OTHER PAYER CITY/STATE/ZIP CODE Other Payer City Name
N402 N403 N404 N405 N406
DTP DTP01 DTP02 DTP03
REF REF01 REF02 REF03
Other Payer State Code Other Payer Postal Zone or ZIP Code Payer Country Code Location Qualifier Location Identifier
CLAIM ADJUDICATION DATE Date Time Qualifier Date Time Period Format Qualifier
NM109 NM110 NM111
2330B
AN ID
2-2
R
N402
ID ID ID AN
3-15 2-3 1-2 1-30
R S N/U N/U
N403 N404 N405 N406 N407
2-3
Adjudication or Payment Date AN
1-35
OTHER PAYER SECONDARY IDENTIFICATION AND REFERENCE NUMBER Reference Identification Qualifier Other Payer Secondary Identifier Description
Loop Repeat
2330B
1
Values
2330B
R R R
AN AN AN AN AN ID
1-60 1-35 1-25 1-10 1-10 1-2
R N/U N/U N/U N/U R
Other Payer Primary Identifier AN Entity Relationship Code ID Entity Identifier Code ID Name Last or Organization Name AN
2-80 2-2 2-3
R N/U N/U
1-60
N/U
1 1-55 1-55
S R S
2330B
AN AN
R R
2330B
AN
1 2-30
ID
2-2
S
ID ID ID AN ID
3-15 2-3 1-2 1-30 1-3
S S N/U N/U S
ID
1 3-3
S R
ID
2-3
R
D8
Adjudication or Payment Date AN
1-35
R
CCYYMMDD
OTHER PAYER CITY/STATE/ZIP CODE Other Payer City Name
S R
ID
Loop
1 2-3 1-1
N4 N401
1 2-30
ID
Usage Reg.
ID ID
OTHER PAYER ADDRESS Other Payer Address Line Other Payer Address Line
S R S
S R
OTHER PAYER NAME Entity Identifier Code Entity Type Qualifier Other Payer Last or Organization Name Name First Name Middle Name Prefix Name Suffix Identification Code Qualifier
N3 N301 N302
1 1-55 1-55
2330B
AN AN
1 3-3
Min. Max.
837-I 5010
NM112 N3 N301 N302
ID
573
DTP DTP01
R
D8
DTP02
R
CCYYMMDD
DTP03
Other Payer State Code Other Payer Postal Zone or ZIP Code Other Payer Country Code Location Qualifier Location Identifier Country Subdivision Code DATE - CLAIM CHECK OR REMITTANCE DATE Date Time Qualifier Date Time Period Format Qualifier
PR 2 Increase from 35 - 60 Increase from 25 - 35
PI, XV
New Element
Usage change to Required
Usage change to Situational Usage change to Situational Name Change
New Element Name Change 2330B 573
Name Change
2
S
ID
2-3
R
AN AN
1-30 1-80
R N/U
2330B
REF 2U, F8, FY, NF, TJ
REF01 REF02 REF03
OTHER PAYER SECONDARY IDENTIFICATION Reference Identification Qualifier Other Payer Secondary Identifier Description
Page 77 of 93
2
S
ID
2-3
R
AN AN
1-50 1-80
R N/U
2330B Code Change 2U, EI, FY, NF Increase from 30 - 50
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
REF04
REFERENCE IDENTIFIER
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
REF04
REFERENCE IDENTIFIER
837-I 4010A1
REF REF01 REF02 REF03 REF04
OTHER PAYER PRIOR AUTHORIZATION OR REFERRAL NUMBER Reference Identification Qualifier Authorization or Referral Number Description REFERENCE IDENTIFIER
S
ID
2-3
R
AN AN
1-30 1-80
R N/U N/U
2330B
REF 9F, G1
REF01 REF02 REF03 REF04
OTHER PAYER PRIOR AUTHORIZATION NUMBER Reference Identification Qualifier Other Payer Prior Authorization Number Description REFERENCE IDENTIFIER
1
S
ID
2-3
R
Loop Repeat
Values
AN AN
1-50 1-80
R N/U N/U
1
S
New Segment
R
REF02 REF03 REF04
Other Payer Referral Number AN Description AN REFERENCE IDENTIFIER
1-50 1-80
R N/U N/U
1
S
ID
2-3
R
AN AN
1-50 1-80
R N/U N/U
1
S
ID
2-3
R
AN AN
1-50 1-80
R N/U N/U
REF02 REF03 REF04
REF REF01 REF02 REF03 REF04
OTHER PAYER CLAIM CONTROL NUMBER Reference Identification Qualifier Other Payer Claim Control Number Description REFERENCE IDENTIFIER
G1 Increase from 30 - 50
2-3
OTHER PAYER CLAIM ADJUSTMENT INDICATOR Reference Identification Qualifier Other Payer Claim Adjustment Indicator Description REFERENCE IDENTIFIER
2330B Code Change
ID
REF01
NM103 NM104 NM105 NM106 NM107
Loop
N/U
REF01
REF
OTHER PAYER PATIENT INFORMATION Entity Identifier Code Entity Type Qualifier Name Last or Organization Name Name First Name Middle Name Prefix Name Suffix
Usage Reg.
OTHER PAYER REFERRAL NUMBER Reference Identification Qualifier
REF
NM1 NM101 NM102
Min. Max.
837-I 5010
N/U
1
ID
2330B 9F
New Segment 2330B T4
New Segment 2330B F8
Segment Deleted ID ID
1 2-3 1-1
S R R
AN AN AN AN AN
1-35 1-25 1-25 1-10 1-10
N/U N/U N/U N/U N/U
2330C
1 QC 1
Page 78 of 93
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1 NM108 NM109 NM110 NM111
REF REF01 REF02 REF03 REF04
Identification Code Qualifier Other Payer Patient Primary Identifier Entity Relationship Code Entity Identifier Code OTHER PAYER PATIENT IDENTIFICATION NUMBER Reference Identification Qualifier Other Payer Patient Secondary Identifier Description REFERENCE IDENTIFIER
ID
1-2
R
AN ID ID
2-80 2-2 2-3
R N/U N/U
3
S
ID
2-3
R
AN AN
1-30 1-80
R N/U N/U
S R R
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010 EI, MI
Segment Deleted 2330C 1W, IG, SY
ID ID
1 2-3 1-1
NM103 NM104 NM105 NM106 NM107 NM108
OTHER PAYER ATTENDING PROVIDER Entity Identifier Code Entity Type Qualifier Name Last or Organization Name Name First Name Middle Name Prefix Name Suffix Identification Code Qualifier
AN AN AN AN AN ID
1-35 1-25 1-25 1-10 1-10 1-2
N/U N/U N/U N/U N/U N/U
NM103 NM104 NM105 NM106 NM107 NM108
NM109 NM110 NM111
Identification Code Entity Relationship Code Entity Identifier Code
AN ID ID
2-80 2-2 2-3
N/U N/U N/U
NM109 NM110 NM111
NM1 NM101 NM102
ID
2330D
1 71 1, 2
NM1 NM101 NM102
OTHER PAYER ATTENDING PROVIDER Entity Identifier Code Entity Type Qualifier Name Last or Organization Name Name First Name Middle Name Prefix Name Suffix Identification Code Qualifier
Loop Change ID ID
1 2-3 1-1
S R R
AN AN AN AN AN ID
1-60 1-35 1-25 1-10 1-10 1-2
N/U N/U N/U N/U N/U N/U
Other Payer Primary Identifier AN Entity Relationship Code ID Entity Identifier Code ID Name Last or Organization Name AN
2-80 2-2 2-3
N/U N/U N/U
1-60
N/U
2330C
1 71 1
Code Deleted Increase from 35 - 60 Increase from 25 - 35
Name Change
NM112
REF
REF01 REF02 REF03 REF04
NM1 NM101 NM102 NM103
OTHER PAYER ATTENDING PROVIDER SECONDARY IDENTIFICATION Reference Identification Qualifier Secondary Identifier Description REFERENCE IDENTIFIER OTHER PAYER OPERATING PROVIDER Entity Identifier Code Entity Type Qualifier Name Last or Organization Name
3
R
ID AN AN
2-3 1-30 1-80
R R N/U N/U
ID ID
1 2-3 1-1
S R R
AN
1-35
N/U
2330D 1A, 1B, 1C, 1D, 1G, 1H, EI, G2, LU, N5
2330E
1 72 1
REF
OTHER PAYER ATTENDING PROVIDER SECONDARY IDENTIFICATION
REF01 REF02 REF03 REF04
Reference Identification Qualifier Secondary Identifier Description REFERENCE IDENTIFIER
New Element
Loop Change # Repeats change to 4 4
R
2330C Code Change
NM1 NM101 NM102 NM103
OTHER PAYER OPERATING PROVIDER Entity Identifier Code Entity Type Qualifier Name Last or Organization Name
Page 79 of 93
ID AN AN
2-3 1-50 1-80
R R N/U N/U
ID ID
1 2-3 1-1
S R R
AN
1-60
N/U
0B, 1G, G2, LU Increase from 30 - 50
Loop Change 2330D
1 72 1 Increase from 35 - 60
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
NM104 NM105 NM106 NM107 NM108
Name First Name Middle Name Prefix Name Suffix Identification Code Qualifier
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Description
ID
Name First Name Middle Name Prefix Name Suffix Identification Code Qualifier
AN AN AN AN ID
1-35 1-25 1-10 1-10 1-2
N/U N/U N/U N/U N/U
Other Payer Primary Identifier AN Entity Relationship Code ID Entity Identifier Code ID Name Last or Organization Name AN
2-80 2-2 2-3
N/U N/U N/U
1-60
N/U
837-I 4010A1
NM109 NM110 NM111
1-25 1-25 1-10 1-10 1-2
N/U N/U N/U N/U N/U
NM104 NM105 NM106 NM107 NM108
Other Payer Primary Identifier AN Entity Relationship Code ID Entity Identifier Code ID
2-80 2-2 2-3
N/U N/U N/U
NM109 NM110 NM111 NM112
REF
REF01 REF02 REF03 REF04
NM1 NM101 NM102 NM103 NM104 NM105 NM106 NM107 NM108 NM109 NM110 NM111
Reference Identification Qualifier Secondary Identifier Description REFERENCE IDENTIFIER
3
R
2330E 1A, 1B, 1C, 1D, 1G, 1H, EI, G2, LU, N5
REF
OTHER PAYER OPERATING PROVIDER SECONDARY IDENTIFICATION
REF01 REF02 REF03 REF04
Reference Identification Qualifier Secondary Identifier Description REFERENCE IDENTIFIER
2-3 1-30 1-80
R R N/U N/U
ID ID
1 2-3 1-1
S R R
AN AN AN AN AN ID
1-35 1-25 1-25 1-10 1-10 1-2
N/U N/U N/U N/U N/U N/U
NM103 NM104 NM105 NM106 NM107 NM108
Other Payer Primary Identifier AN Entity Relationship Code ID Entity Identifier Code ID
2-80 2-2 2-3
N/U N/U N/U
NM109 NM110 NM111
2330F
1 73 1, 2
NM1 NM101 NM102
NM112
REF
REF01 REF02
OTHER PAYER OTHER PROVIDER IDENTIFICATION Reference Identification Qualifier Secondary Identifier
3
ID AN
2-3 1-30
R
R R
Loop Repeat
Values
2330F 1A, 1B, 1C, 1D, 1G, 1H, EI, G2, LU, N5, SY
Increase from 25 - 35
Loop Change Name Change # Repeats change to 4 4
R
2330D Code Change
ID AN AN
OTHER PAYER OTHER PROVIDER Entity Identifier Code Entity Type Qualifier Name Last or Organization Name Name First Name Middle Name Prefix Name Suffix Identification Code Qualifier
Loop
837-I 5010
AN AN AN AN ID
OTHER PAYER OPERATING PROVIDER IDENTIFICATION
Min. Max.
Usage Reg.
Element Identifier
ID AN AN
2-3 1-50 1-80
R R N/U N/U
ID ID
1 2-3 1-1
S R R
AN AN AN AN AN ID
1-60 1-35 1-25 1-10 1-10 1-2
N/U N/U N/U N/U N/U N/U
Other Payer Primary Identifier AN Entity Relationship Code ID Entity Identifier Code ID Name Last or Organization Name AN
2-80 2-2 2-3
N/U N/U N/U
1-60
N/U
OTHER PAYER OTHER OPERATING PROVIDER Entity Identifier Code Entity Type Qualifier Name Last or Organization Name Name First Name Middle Name Prefix Name Suffix Identification Code Qualifier
REF
OTHER PAYER OTHER OPERATING PROVIDER SECONDARY IDENTIFICATION
REF01 REF02
Reference Identification Qualifier Secondary Identifier
0B, 1G, G2, LU Increase from 30 - 50
2330E
1 ZZ 1
Loop Change Name Change Code Change Code Deleted Increase from 35 - 60 Increase from 25 - 35
New Element
Loop Change Name Change # Repeats change to 4 4
R
2330E Code Change
Page 80 of 93
ID AN
2-3 1-50
R R
0B, 1G, G2, LU Increase from 30 - 50
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
REF03 REF04
Description REFERENCE IDENTIFIER
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Description
ID
REF03 REF04
Description REFERENCE IDENTIFIER
AN
1-80
N/U N/U
ID ID
1 2-3 1-1
S R R
AN AN AN AN AN ID
1-60 1-35 1-25 1-10 1-10 1-2
N/U N/U N/U N/U N/U N/U
Other Payer Primary Identifier AN Entity Relationship Code ID Entity Identifier Code ID Name Last or Organization Name AN
2-80 2-2 2-3
N/U N/U N/U
1-60
N/U
837-I 4010A1
NM1 NM101 NM102 NM103 NM104 NM105 NM106 NM107 NM108 NM109 NM110 NM111 NM112
REF REF01 REF02 REF03 REF04
1-80
N/U N/U
ID ID
1 2-3 1-1
S R R
AN AN AN AN AN ID
1-35 1-25 1-25 1-10 1-10 1-2
N/U N/U N/U N/U N/U N/U
NM103 NM104 NM105 NM106 NM107 NM108
Other Payer Primary Identifier AN Entity Relationship Code ID Entity Identifier Code ID Name Last or Organization Name AN
2-80 2-2 2-3
N/U N/U N/U
NM109 NM110 NM111
1-60
N/U
NM112
OTHER PAYER SERVICE FACILITY PROVIDER IDENTIFICATION Reference Identification Qualifier Other Payer Service Facility Location Secondary Identifier Description REFERENCE IDENTIFIER
3
R
ID
2-3
R
AN AN
1-30 1-80
R N/U N/U
Loop
Loop Repeat
2330F
1
Values
837-I 5010
AN
OTHER PAYER SERVICE FACILITY PROVIDER Entity Identifier Code Entity Type Qualifier Name Last or Organization Name Name First Name Middle Name Prefix Name Suffix Identification Code Qualifier
Min. Max.
Usage Reg.
Element Identifier
2330H
1 FA 2
2330H
NM1 NM101 NM102
REF 1B, 1C, 1D, EI, G2, LU, N5
REF01 REF02 REF03 REF04
NM1 NM101 NM102 NM103 NM104 NM105 NM106 NM107 NM108 NM109 NM110 NM111 NM112
OTHER PAYER SERVICE FACILITY LOCATION Entity Identifier Code Entity Type Qualifier Name Last or Organization Name Name First Name Middle Name Prefix Name Suffix Identification Code Qualifier
OTHER PAYER SERVICE FACILITY LOCATION SECONDARY IDENTIFIER Reference Identification Qualifier Other Payer Service Facility Location Secondary Identifier Description REFERENCE IDENTIFIER
Increase from 35 - 60
R
ID
2-3
R
AN AN
1-50 1-80
R N/U N/U
ID ID
1 2-3 1-1
S R R
AN AN AN AN AN ID
1-60 1-35 1-25 1-10 1-10 1-2
N/U N/U N/U N/U N/U N/U
Other Payer Primary Identifier AN Entity Relationship Code ID Entity Identifier Code ID Name Last or Organization Name AN
2-80 2-2 2-3
N/U N/U N/U
1-60
N/U
Page 81 of 93
Increase from 25 - 35
Loop Change Name Change 3
OTHER PAYER RENDERING PROVIDER Entity Identifier Code Entity Type Qualifier Name Last or Organization Name Name First Name Middle Name Prefix Name Suffix Identification Code Qualifier
77 2
Loop Change Name Change Code Change
2330F Code Change 0B, G2, LU Increase from 30 - 50
New Segment 2330G
1 82 1
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1
ID
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010 REF REF01 REF02 REF03 REF04
NM1 NM101 NM102 NM103 NM104 NM105 NM106 NM107 NM108 NM109 NM110 NM111 NM112
OTHER PAYER RENDERING PROVIDER SECONDARY IDENTIFIER Reference Identification Qualifier Other Payer Rendering Provider Secondary Identifier Description REFERENCE IDENTIFIER
New Segment 4
R
ID
2-3
R
AN AN
1-50 1-80
R N/U N/U
ID ID
1 2-3 1-1
S R R
AN AN AN AN AN ID
1-60 1-35 1-25 1-10 1-10 1-2
N/U N/U N/U N/U N/U N/U
Other Payer Primary Identifier AN Entity Relationship Code ID Entity Identifier Code ID Name Last or Organization Name AN
2-80 2-2 2-3
N/U N/U N/U
1-60
N/U
OTHER PAYER REFERRING PROVIDER Entity Identifier Code Entity Type Qualifier Name Last or Organization Name Name First Name Middle Name Prefix Name Suffix Identification Code Qualifier
REF01
REF02 REF03 REF04
Other Payer Referring Provider Secondary Identifier Description REFERENCE IDENTIFIER
NM1 NM101 NM102 NM103 NM104 NM105 NM106 NM107
OTHER PAYER BILLING PROVIDER Entity Identifier Code Entity Type Qualifier Name Last or Organization Name Name First Name Middle Name Prefix Name Suffix
Page 82 of 93
0B, 1G, G2, LU
New Segment
OTHER PAYER REFERRING PROVIDER SECONDARY IDENTIFIER Reference Identification Qualifier ID
REF
2330G
2330H
1 DN 1
New Segment 3
R
2-3
R
AN AN
1-50 1-80
R N/U N/U
ID ID
1 2-3 1-1
S R R
AN AN AN AN AN
1-60 1-35 1-25 1-10 1-10
N/U N/U N/U N/U N/U
2330H 0B, 1G, G2
New Segment 2330I
1 85 2
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Description
ID
NM108
Identification Code Qualifier
ID
1-2
N/U
Other Payer Primary Identifier AN Entity Relationship Code ID Entity Identifier Code ID Name Last or Organization Name AN
2-80 2-2 2-3
N/U N/U N/U
1-60
N/U
837-I 4010A1
NM112
REF02 REF03 REF04 LX LX01
SERVICE LINE Assigned Number
1 1-6
R R
2400
N0
SV2 SV201
INSTITUTIONAL SERVICE LINE Revenue Code
1 1-48
R R
2400
AN
REF01
SV2 SV201
INSTITUTIONAL SERVICE LINE Revenue Code
Loop Repeat
Values
1 1-6
R R
2400
N0
R R
2400
AN
1 1-48
999
New Segment
OTHER PAYER BILLING PROVIDER SECONDARY IDENTIFICATION Reference Identification Qualifier Other Payer Billing Provider Secondary Identification Description REFERENCE IDENTIFIER
REF
SERVICE LINE NUMBER Assigned Number
Loop
837-I 5010 NM109 NM110 NM111
LX LX01
Min. Max.
Usage Reg.
Element Identifier
2
R
ID
2-3
R
AN AN
1-50 1-80
R N/U N/U
2330I G2, LU
Name Change
999
Usage change to Required
SV202-1 SV202-2 SV202-3 SV202-4 SV202-5 SV202-6
COMPOSITE Product or Service ID Qualifier Procedure Code Procedure Modifier Procedure Modifier Procedure Modifier Procedure Modifier
ID AN AN AN AN AN
2-2 1-48 2-2 2-2 2-2 2-2
R R S S S S
SV202-7
Description
AN
1-80
N/U
SV203
R
1-18
R
SV204 SV205
Line Item Charge Amount Unit or Basis for Measurement Code Service Unit Count
ID R
2-2 1-15
R R
SV206 SV207 SV208 SV209 SV210
Unit Rate Monetary Amount Y/N NHRSC Level of Care Code
ID R ID ID ID
1-10 1-18 1-1 1-1 1-1
S S N/U N/U N/U
PWK
LINE SUPPLEMENTAL INFORMATION
5
S
SV202
S
SV202 HC, IV, ZZ
SV202-1 SV202-2 SV202-3 SV202-4 SV202-5 SV202-6
2400
R ID AN AN AN AN AN
2-2 1-48 2-2 2-2 2-2 2-2
R R S S S S
AN AN R
1-80 1-48 1-18
S N/U R
SV204 SV205
Description Product/Service ID Line Item Charge Amount Unit or Basis for Measurement Code Service Units/Days
ID R
2-2 1-15
R R
SV206 SV207 SV208 SV209 SV210
Unit Rate Monetary Amount Y/N NHRSC Level of Care Code
ID R ID ID ID
1-10 1-18 1-1 1-1 1-1
N/U S N/U N/U N/U
PWK
LINE SUPPLEMENTAL INFORMATION
10
S
SV202-7 SV202-8 SV203 DA, F2, UN
COMPOSITE Product or Service ID Qualifier Procedure Code Procedure Modifier Procedure Modifier Procedure Modifier Procedure Modifier
Page 83 of 93
ER, HC, HP, IV, Code Change WK
Usage change to Situational New Element Code Deleted DA, UN Name Change Usage change to Not Used
# Repeats change to 10 2400
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1
ID
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010 Code Added
PWK01
Attachment Report Type Code
PWK02 PWK03 PWK04
Attachment Transmission Code Report Copies Needed Entity Identifier Code
PWK05 PWK06 PWK07 PWK08 PWK09
Identification Code Qualifier Identification Code Description ACTIONS INDICATED Request Category Code
ID
2-2
AS, B2, B3, B4, CT, D2, DA, DG, DS, EB, MT, NN, OB, OZ, PN, PO, PZ, RB, RR, RT
R
ID N0 ID
1-2 1-2 2-3
R N/U N/U
ID AN AN
1-2 2-80 1-80
ID
1-2
S S N/U N/U N/U
AA, AB, AD, AF, AG, BM, EL, EM, FX
AC
PWK01
Attachment Report Type Code
PWK02 PWK03 PWK04
Attachment Transmission Code Report Copies Needed Entity Identifier Code
PWK05 PWK06 PWK07 PWK08 PWK09
Identification Code Qualifier Identification Code Description ACTIONS INDICATED Request Category Code
ID
2-2
03, 04, 05, 06, 07, 08, 09, 10, 11, 13, 15, 21, A3, A4, AM, AS, B2, B3, B4, BR, BS, BT, CB, CK, CT, D2, DA, DB, DG, DJ, DS, EB, HC, HR, I5, IR, LA, M1, MT, NN, OB, OC, OD, OE, OX, OZ, P4, P5, PE, PN, PO, PQ, PY, PZ, RB, RR, RT, RX, SG, V5, XP
R
Code Change ID N0 ID
1-2 1-2 2-3
R N/U N/U
ID AN AN
1-2 2-80 1-80
ID
1-2
S S N/U N/U N/U
AA, BM, EL, EM, FT, FX
AC
Name Change Usage change to Required DTP DTP01 DTP02
SERVICE LINE DATE Date Time Qualifier Date Time Period Format Qualifier
DTP03
Service Date
DTP
ASSESSMENT DATE
DTP01
ID
1 3-3
R R
ID
2-3
2400 472
DTP DTP01
R
D8, RD8
DTP02
R
CYYMMDD, CCYYMMDDCCYYMMDD
AN
1-35 1
S
ID
3-3
R
DTP02
Date Time Qualifier Date Time Period Format Qualifier
ID
2-3
R
D8
DTP03
Assessment Date
AN
1-35
R
CCYYMMDD
DATE - SERVICE DATE Date Time Qualifier Date Time Period Format Qualifier
Service Date
DTP03
ID
1 3-3
R R
ID
2-3
R
D8, RD8
R
CYYMMDD, CCYYMMDDCCYYMMDD
AN
1-35
2400 472
Segment Deleted
2400 866
REF REF01 REF02
LINE ITEM CONTROL NUMBER Reference Identification Qualifier Line Item Control Number
Page 84 of 93
New Segment
ID AN
1
S
2-3 1-50
R R
2400 6R
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
ID
REF03 REF04
Description REFERENCE IDENTIFIER
AN
837-I 4010A1
REF01 REF02 REF03 REF04
AMT AMT01 AMT02 AMT03
SERVICE TAX AMOUNT Amount Qualifier Code Service Tax Amount Credit/Debit Flag Code
1 1-3 1-18 1-1
S R R N/U
2400
ID R ID
AMT AMT01 AMT02 AMT03
FACILITY TAX AMOUNT Amount Qualifier Code Facility Tax Amount Credit/Debit Flag Code
1 1-3 1-18 1-1
S R R N/U
2400
ID R ID
HCP01 HCP02 HCP03 HCP04 HCP05
Pricing Methodology Repriced Allowed Amount Repriced Saving Amount Repricing Organization Identifier Repricing Per Diem or Flat Rate Amount
S
GT
N8
2400 00, 01, 02, 03, 04, 05, 06, 07, 08, 09, 10, 11, 12, 13, 14
1-80
N/U N/U
1
S
2-3
R
1-50 1-80
R N/U N/U
1
S
ID
2-3
R
AN AN
1-50 1-80
R N/U N/U
REPRICED LINE ITEM REFERENCE NUMBER Reference Identification Qualifier ID Repriced Line Item Reference Number AN Description AN REFERENCE IDENTIFIER
Loop Repeat
Values
New Segment 2400 9B
New Segment
REF02 REF03 REF04 AMT AMT01 AMT02 AMT03
SERVICE TAX AMOUNT Amount Qualifier Code Tax Amount Credit/Debit Flag Code
1 1-3 1-18 1-1
S R R N/U
2400
ID R ID
AMT AMT01 AMT02 AMT03
FACILITY TAX AMOUNT Amount Qualifier Code Facility Tax Amount Credit/Debit Flag Code
1 1-3 1-18 1-1
S R R N/U
2400
ID R ID
NTE NTE01 NTE02
THIRD PARTY ORGANIZATION NOTES Note Reference Code Claim Note Text
S R R
2400
ID AN
1 3-3 1-80
HCP
LINE PRICING/REPRICING INFORMATION
1
S
2400
REF01
1
Loop
ITEM REFERENCE NUMBER Reference Identification Qualifier Adjusted Repriced Line Item Reference Number Description REFERENCE IDENTIFIER
REF
LINE PRICING/REPRICING INFORMATION
Usage Reg.
837-I 5010
REF
HCP
Min. Max.
ID R R
2-2 1-18 1-18
R R S
HCP01 HCP02 HCP03
AN
1-30
S
HCP04
R
1-9
S
HCP05
Pricing Methodology Repriced Allowed Amount Repriced Saving Amount Repricing Organization Identifier Repricing Per Diem or Flat Rate Amount
Page 85 of 93
2400 9D
GT Name Change
N8
Segment Added
ID R R
2-2 1-18 1-18
R R S
AN
1-50
S
R
1-9
S
TPO
00, 01, 02, 03, 04, 05, 06, 07, 08, 09, 10, 11, 12, 13, 14
Increase from 30 - 50
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1 HCP06 HCP07
Ambulatory Patient Group Code Ambulatory Patient Group Amount
ID
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010
AN
1-30
S
HCP06
R
1-18
S
HCP07
AN
1-48
S
HCP08
ID AN ID
2-2 1-48 2-2
S S S
R
1-15
S
Ambulatory Patient Group Code Ambulatory Patient Group Amount
Increase from 30 - 50 AN
1-50
S
R
1-18
S Usage change to Not Used
HCP08 HCP09 HCP10 HCP11 HCP12
Product/Service ID Product or Service ID Qualifier Procedure Code Measurement Code Repriced Approved Service Unit Count "DA" "UN"
HCP13 HCP14 HCP15
Reject Reason Code Policy Compliance Code Exception Code
LIN LIN01
DRUG IDENTIFICATION Assigned Identification Product or Service ID Qualifier National Drug Code Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier
LIN02 LIN03 LIN04 LIN05 LIN06 LIN07 LIN08 LIN09 LIN10 LIN11 LIN12 LIN13 LIN14 LIN15 LIN16 LIN17 LIN18 LIN19 LIN20 LIN21 LIN22 LIN23 LIN24 LIN25 LIN26 LIN27 LIN28 LIN29 LIN30
ID ID ID
2-2 1-2 1-2
S S S
AN
1 1-20
S N/U
ID AN ID AN ID AN ID AN ID AN ID AN ID AN ID AN ID AN ID AN ID AN ID AN ID AN ID AN ID
2-2 1-48 2-2 1-48 2-2 1-48 2-2 1-48 2-2 1-48 2-2 1-48 2-2 1-48 2-2 1-48 2-2 1-48 2-2 1-48 2-2 1-48 2-2 1-48 2-2 1-48 2-2 1-48 2-2
R R N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U
HC DA, UN
T1, T2, T3, T4, T5, T6 1, 2, 3, 4, 5 1, 2, 3, 4, 5, 6
2410
25
N4
AN
1-48
N/U
ID AN ID
2-2 1-48 2-2
S S S
HCP12
Product/Service ID Product or Service ID Qualifier Procedure Code Measurement Code Repriced Approved Service Unit Count "DA" "UN"
R
1-15
S
HCP13 HCP14 HCP15
Reject Reason Code Policy Compliance Code Exception Code
ID ID ID
2-2 1-2 1-2
S S S
LIN LIN01
DRUG IDENTIFICATION Assigned Identification Product or Service ID Qualifier National Drug Code Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier Product/Service ID Product/Service ID Qualifier
AN
1 1-20
S N/U
ID AN ID AN ID AN ID AN ID AN ID AN ID AN ID AN ID AN ID AN ID AN ID AN ID AN ID AN ID
2-2 1-48 2-2 1-48 2-2 1-48 2-2 1-48 2-2 1-48 2-2 1-48 2-2 1-48 2-2 1-48 2-2 1-48 2-2 1-48 2-2 1-48 2-2 1-48 2-2 1-48 2-2 1-48 2-2
R R N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U N/U
HCP09 HCP10 HCP11
LIN02 LIN03 LIN04 LIN05 LIN06 LIN07 LIN08 LIN09 LIN10 LIN11 LIN12 LIN13 LIN14 LIN15 LIN16 LIN17 LIN18 LIN19 LIN20 LIN21 LIN22 LIN23 LIN24 LIN25 LIN26 LIN27 LIN28 LIN29 LIN30
Page 86 of 93
ER, HC, HP, IV, Code Added WK DA, UN
T1, T2, T3, T4, T5, T6 1, 2, 3, 4, 5 1, 2, 3, 4, 5, 6
2410
# Loop Repeats change to 1
1
N4
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
LIN31
Product/Service ID
CTP CTP01 CTP02
DRUG QUANTITY Class of Trade Code Price Identifier Code
CTP03 CTP04
Unit Price National Drug Unit Count COMPOSITE UNIT OF MEASURE Unit or Basis For Measurement Code Exponent Multiplier Unit or Basis For Measurement Code Exponent Multiplier Unit or Basis For Measurement Code Exponent Multiplier Unit or Basis For Measurement Code Exponent Multiplier Unit or Basis For Measurement Code Exponent Multiplier Price Multiplier Qualifier Multiplier Monetary Amount Basis of Unit Price Code Condition Value Multiple Price Quantity
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Description
ID
LIN31
Product/Service ID
AN
1-48
N/U
CTP CTP01 CTP02
DRUG QUANTITY Class of Trade Code Price Identifier Code
ID ID
1 2-2 3-3
R N/U N/U
Unit Price National Drug Unit Count COMPOSITE UNIT OF MEASURE Unit or Basis For Measurement Code Exponent Multiplier Unit or Basis For Measurement Code Exponent Multiplier Unit or Basis For Measurement Code Exponent Multiplier Unit or Basis For Measurement Code Exponent Multiplier Unit or Basis For Measurement Code Exponent Multiplier Price Multiplier Qualifier Multiplier Monetary Amount Basis of Unit Price Code Condition Value Multiple Price Quantity
R R
1-17 1-15
N/U R
837-I 4010A1
Min. Max.
Usage Reg.
Element Identifier
Loop
Loop Repeat
Values
837-I 5010
AN
1-48
N/U
ID ID
1 2-2 3-3
S N/U N/U
R R
1-17 1-15
R R
CTP03 CTP04
R
CTP05
Usage Change to Required 2410
2410
Usage change to Not Used
CTP05 CTP05-1 CTP05-2 CTP05-3 CTP05-4 CTP05-5 CTP05-6 CTP05-7 CTP05-8 CTP05-9 CTP05-10 CTP05-11 CTP05-12 CTP05-13 CTP05-14 CTP05-15 CTP06 CTP07 CTP08 CTP09 CTP10 CTP11
REF01 REF02 REF03 REF04
PRESCRIPTION NUMBER Reference Identification Qualifier Prescription Number Desciption REFERENCE IDENTIFIER
NM1
ATTENDING PHYSICIAN NAME
REF
F2, GR, ML, UN
ID R R
2-2 1-15 1-10
R N/U N/U
ID R R
2-2 1-15 1-10
N/U N/U N/U
CTP05-4 CTP05-5 CTP05-6
ID R R
2-2 1-15 1-10
N/U N/U N/U
CTP05-7 CTP05-8 CTP05-9
ID R R
2-2 1-15 1-10
N/U N/U N/U
CTP05-10 CTP05-11 CTP05-12
ID R R ID R R ID AN N0
2-2 1-15 1-10 3-3 1-10 1-18 2-2 1-10 1-2
N/U N/U N/U N/U N/U N/U N/U N/U N/U
CTP05-13 CTP05-14 CTP05-15 CTP06 CTP07 CTP08 CTP09 CTP10 CTP11
ID AN AN
1
S
2-3 1-30 1-80
R R N/U N/U
1
S
2410
CTP05-1 CTP05-2 CTP05-3
REF XZ
REF01 REF02 REF03 REF04
PRESCRIPTION OR COMPOUND DRUG ASSOCIATION NUMBER Reference Identification Qualifier Prescription Number Desciption REFERENCE IDENTIFIER
R ID R R
2-2 1-15 1-10
R N/U N/U
ID R R
2-2 1-15 1-10
N/U N/U N/U
ID R R
2-2 1-15 1-10
N/U N/U N/U
ID R R
2-2 1-15 1-10
N/U N/U N/U
ID R R ID R R ID AN N0
2-2 1-15 1-10 3-3 1-10 1-18 2-2 1-10 1-2
N/U N/U N/U N/U N/U N/U N/U N/U N/U
F2, GR, ME, ML, Code Added UN
Name Change 1
S
2-3 1-50 1-80
R R N/U N/U
2410 Code Added
ID AN AN
VY, XZ Increase from 30 - 50
Segment Deleted 2420A
1
Page 87 of 93
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
NM101 NM102 NM103 NM104 NM105 NM106 NM107 NM108 NM109 NM110 NM111
Entity Identifier Code Entity Type Qualifier Last Name First Name Middle Name Name Prefix Name Suffix Identification Code Qualifier Identifier Entity Relationship Code Entity Identifier Code
REF
ATTENDING PHYSICIAN SECONDARY IDENTIFICATION
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1
REF01 REF02 REF03 REF04
Reference Identification Qualifier Secondary Identifier Description REFERENCE IDENTIFIER
NM1 NM101 NM102 NM103 NM104 NM105 NM106 NM107 NM108 NM109 NM110 NM111
OPERATING PHYSICIAN NAME Entity Identifier Code Entity Type Qualifier Last Name First Name Middle Name Name Prefix Name Suffix Identification Code Qualifier Identifier Entity Relationship Code Entity Identifier Code
REF
ID ID AN AN AN AN AN ID AN ID ID
Reference Identification Qualifier Secondary Identifier Description
REF04
REFERENCE IDENTIFIER
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010 71 1, 2
R R R S S N/U S S S N/U N/U
24, 34, XX
Segment Deleted 1
S
ID AN AN
2-3 1-30 1-80
R R N/U S
ID ID AN AN AN AN AN ID AN ID ID
1 2-3 1-1 1-35 1-25 1-25 1-10 1-10 1-2 2-80 2-2 2-3
S R R R S S N/U S S S N/U N/U
OPERATING PHYSICIAN SECONDARY IDENTIFICATION
REF01 REF02 REF03
2-3 1-1 1-35 1-25 1-25 1-10 1-10 1-2 2-80 2-2 2-3
ID
1
ID AN AN
2-3 1-30 1-80
S
R R N/U
2420A OB, 1A, 1B, 1C, 1D, 1G, 1H, EI, G2, LU, N5, SY, X5
2420B
1 72 1
24, 34, XX
2420B OB, 1A, 1B, 1C, 1D, 1G, 1H, EI, G2, LU, N5, SY, X5
NM112
OPERATING PHYSICIAN NAME Entity Identifier Code Entity Type Qualifier Last Name First Name Middle Name Name Prefix Name Suffix Identification Code Qualifier Identifier Entity Relationship Code Entity Identifier Code Name Last or Organization Name
REF
OPERATING PHYSICIAN SECONDARY IDENTIFICATION
NM1 NM101 NM102 NM103 NM104 NM105 NM106 NM107 NM108 NM109 NM110 NM111
ID ID AN AN AN AN AN ID AN ID ID
1 2-3 1-1 1-60 1-35 1-25 1-10 1-10 1-2 2-80 2-2 2-3
S R R R S S N/U S S S N/U N/U
AN
1-60
N/U
2420A
1 72 1 Increase from 35 - 60 Increase from 25 - 35
XX
Code Deleted
New Element
# Reeats change to 20 20
S
2420A Code Change
REF01 REF02 REF03
Reference Identification Qualifier Secondary Identifier Description
REF04
REFERENCE IDENTIFIER
ID AN AN
2-3 1-50 1-80
R R N/U
OB, 1G, G2, LU Increase from 30 - 50 Usage change to Siuational
N/U
Page 88 of 93
S
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1
ID
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010 New Element REF04-1 REF04-2 REF04-3 REF04-4 REF04-5 REF04-6
NM1 NM101 NM102 NM103 NM104 NM105 NM106 NM107 NM108 NM109 NM110 NM111 NM112
REF REF01 REF02 REF03 REF04 REF04-1 REF04-2 REF04-3 REF04-4 REF04-5 REF04-6 NM1 NM101 NM102
OTHER PROVIDER NAME Entity Identifier Code Entity Type Qualifier
ID ID
1 2-3 1-1
S R R
NM103
Other Physician Last Name
AN
1-35
R
NM104
Other Physician First Name
AN
1-25
S
2420C
Reference Identifier Qualifier Idenitifer Reference Identification Qualifier Reference Identification Reference Identification Qualifier Reference Identification OTHER OPERATING PHYSICIAN NAME Entity Identifier Code Entity Type Qualifier Last Name First Name Middle Name Name Prefix Name Suffix Identification Code Qualifier Identifier Entity Relationship Code Entity Identifier Code Name Last or Organization Name OTHER OPERATING PHYSICIAN SECONDARY IDENTIFICATION Reference Identification Qualifier Secondary Identifier Description REFERENCE IDENTIFIER Reference Identifier Qualifier Idenitifer Reference Identification Qualifier Reference Identification Reference Identification Qualifier Reference Identification
ID AN
2-3 1-50
R R
ID AN
2-3 1-50
N/U N/U
ID AN
2-3 1-50
N/U N/U
ID ID AN AN AN AN AN ID AN ID ID
1 2-3 1-1 1-60 1-35 1-25 1-10 1-10 1-2 2-80 2-2 2-3
S R R R S S N/U S S S N/U N/U
AN
1-60
N/U
2U New Element New Element New Element New Element New Element New Segment 2420B
1 ZZ 1
XX
New Segment 20
S
2420B
ID AN AN
2-3 1-50 1-80
R R N/U S
OB, 1G, G2, LU
ID AN
2-3 1-50
R R
2U
ID AN
2-3 1-50
N/U N/U
ID AN
2-3 1-50
N/U N/U Segment Deleted
1 73 1, 2
Page 89 of 93
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
NM105 NM106 NM107 NM108 NM109 NM110 NM111
Middle Name Name Prefix Name Suffix Identification Code Qualifier Identifier Entity Relationship Code Entity Identifier Code
REF
OTHER PROVIDER SECONDARY IDENTIFICATION
REF01 REF02 REF03 REF04
Reference Identification Qualifier Secondary Identifier Description REFERENCE IDENTIFIER
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1 AN AN AN ID AN ID ID
1-25 1-10 1-10 1-2 2-80 2-2 2-3
ID
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010
S N/U S R R N/U N/U
24, 34, XX
Segment Deleted 1
ID AN AN
2-3 1-30 1-80
S
R R N/U S
2420B OB, 1A, 1B, 1C, 1D, 1G, 1H, EI, G2, LU, N5, SY, X5
NM1 NM101 NM102 NM103 NM104 NM105 NM106 NM107 NM108 NM109 NM110 NM111 NM112
REF REF01 REF02 REF03 REF04
RENDERING PROVIDER NAME Entity Identifier Code Entity Type Qualifier Rendering Provider Last or Organization Name Rendering Provider First Name Rendering Provider Middle Name Name Prefix Rendering Provider Name Suffix Identification Code Qualifier Rendering Provider Identifier Entity Relationship Code Entity Identifier Code Name Last or Organization Name RENDERING PROVIDER SECONDARY IDENTIFICATION Reference Identification Qualifier Rendering Provider Secondary Identifier Description REFERENCE IDENTIFIER
Page 90 of 93
New Segment ID ID
1 2-3 1-1
S R R
AN
1-60
R
AN
1-35
S
AN AN
1-25 1-10
S N/U
AN ID
1-10 1-2
S S
AN ID ID
2-80 2-2 2-3
S N/U N/U
AN
1-60
N/U
2420C
1 82 1
XX
New Segment 20
S
ID
2-3
R
AN AN
1-50 1-80
R N/U S
2420C OB, 1G, G2, LU
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
837-I 4010A1
ID
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
837-I 5010 REF04-1
Reference Identifier Qualifier
ID
2-3
R
REF04-2
Other Payer Primary Idenitifer AN Reference Identification Qualifier ID Reference Identification AN Reference Identification Qualifier ID Reference Identification AN
1-50
R
2-3 1-50
N/U N/U
2-3 1-50
N/U N/U
ID ID
1 2-3 1-1
S R R
NM103
Referring Provider Last Name AN
1-60
R
NM104
Referring Provider First Name Referring Provider Middle Name or Initial Name Prefix Referring Provider Name Suffix Identification Code Qualifier
AN
1-35
S
AN AN
1-25 1-10
S N/U
AN ID
1-10 1-2
S S
Other Payer Primary Identifier AN Entity Relationship Code ID Entity Identifier Code ID Name Last or Organization Name AN
2-80 2-2 2-3
S N/U N/U
1-60
N/U
REF04-3 REF04-4 REF04-5 REF04-6
NM1 NM101 NM102
NM105 NM106 NM107 NM108 NM109 NM110 NM111 NM112
REF REF01 REF02 REF03 REF04
REFERRING PROVIDER NAME Entity Identifier Code Entity Type Qualifier
New Segment
REFERRING PROVIDER SECONDARY IDENTIFICATION Reference Identification Qualifier ID Referring Provider Secondary Identifier AN Description AN REFERENCE IDENTIFIER
20
S
2-3
R
1-50 1-80
R N/U S
Reference Identifier Qualifier
ID
2-3
R
REF04-2
Other Payer Primary Idenitifer AN Reference Identification Qualifier ID Reference Identification AN Reference Identification Qualifier ID
1-50
R
2-3 1-50
N/U N/U
2-3
N/U
REF04-5
Page 91 of 93
2420D
1 DN 1
XX
New Segment
REF04-1
REF04-3 REF04-4
2U
2420D OB, 1G, G2
2U
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
ID
REF04-6
Reference Identification
AN
SVD
LINE ADJUDICATION INFORMATION
837-I 4010A1
SVD
LINE ADJUDICATION INFORMATION
Min. Max.
Usage Reg.
Loop
Loop Repeat
2430
15
Values
837-I 5010
1
S
2430
25
2-80 1-18
R R
SVD01 SVD02
R
SVD03
1-50
N/U
1
S
2-80 1-18
R R
Name Change
SVD03-1 SVD03-2 SVD03-3 SVD03-4 SVD03-5 SVD03-6
Payer Identifier Service Line Paid Amount COMPOSITE MEDICAL PROCEDURE IDENTIFIER Product or Service ID Qualifier Procedure Code Procedure Modifier Procedure Modifier Procedure Modifier Procedure Modifier
ID AN AN AN AN AN
2-2 1-48 2-2 2-2 2-2 2-2
R R S S S S
SVD03-7
Procedure Code Description
AN
1-80
S
SVD01 SVD02 SVD03
SVD04 SVD05 SVD06
Product or Service ID Paid Service Unit Count Bundled or Unbundled Line Number
CAS01 CAS02 CAS03 CAS04 CAS05 CAS06 CAS07 CAS08 CAS09 CAS10 CAS11 CAS12 CAS13 CAS14 CAS15 CAS16 CAS17 CAS18 CAS19
LINE ADJUSTMENT Claim Adjustment Group Code Adjustment Reason Code Adjustment Amount Adjustment Quantity Adjustment Reason Code Adjustment Amount Adjustment Quantity Adjustment Reason Code Adjustment Amount Adjustment Quantity Adjustment Reason Code Adjustment Amount Adjustment Quantity Adjustment Reason Code Adjustment Amount Adjustment Quantity Adjustment Reason Code Adjustment Amount Adjustment Quantity
DTP
SERVICE ADJUDICATION DATE
CAS
AN R
HC, IV, ZZ
SVD03-1 SVD03-2 SVD03-3 SVD03-4 SVD03-5 SVD03-6
Other Payer Primary Identifier Service Line Paid Amount COMPOSITE MEDICAL PROCEDURE IDENTIFIER Product or Service ID Qualifier Procedure Code Procedure Modifier Procedure Modifier Procedure Modifier Procedure Modifier
ID AN AN AN AN AN
2-2 1-48 2-2 2-2 2-2 2-2
R R S S S S
SVD03-7 SVD03-8
Procedure Code Description Product/Service ID
AN AN
1-80 1-48
S N/U
Product or Service ID Paid Service Unit Count Bundled or Unbundled Line Number
AN R
1-48 1-15
N/U R
N0
1-6
S
5
S
1-2 1-5 1-18 1-15 1-5 1-18 1-15 1-5 1-18 1-15 1-5 1-18 1-15 1-5 1-18 1-15 1-5 1-18 1-15
R R R S S S S S S S S S S S S S S S S
AN R
1-48 1-15
R R
SVD04 SVD05
N0
1-6
S
SVD06
99
S
ID ID R R ID R R ID R R ID R R ID R R ID R R
1-2 1-5 1-18 1-15 1-5 1-18 1-15 1-5 1-18 1-15 1-5 1-18 1-15 1-5 1-18 1-15 1-5 1-18 1-15
1
2430
R R R S S S S S S S S S S S S S S S S
S
2430
CAS01 CAS02 CAS03 CAS04 CAS05 CAS06 CAS07 CAS08 CAS09 CAS10 CAS11 CAS12 CAS13 CAS14 CAS15 CAS16 CAS17 CAS18 CAS19
LINE ADJUSTMENT Claim Adjustment Group Code Adjustment Reason Code Adjustment Amount Adjustment Quantity Adjustment Reason Code Adjustment Amount Adjustment Quantity Adjustment Reason Code Adjustment Amount Adjustment Quantity Adjustment Reason Code Adjustment Amount Adjustment Quantity Adjustment Reason Code Adjustment Amount Adjustment Quantity Adjustment Reason Code Adjustment Amount Adjustment Quantity
DTP
LINE CHECK OR REMITTANCE DATE
CAS CO, CR, OA, PI, PR
Page 92 of 93
AN R
R
ID ID R R ID R R ID R R ID R R ID R R ID R R
ER, HC, HP, IV, Code Change WK
New Element Usage change to Not Used
2430 CO, CR, OA, PI, PR
Name Change Usage change to Required 1
R
2430
INSTITUTIONAL CLAIM
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
DTP02 DTP03
Date Time Qualifier Date Time Period Format Qualifier
3-3
R
573
DTP01
ID
2-3
R
D8
DTP02
Adjudication or Payment Date AN
1-35
R
CCYYMMDD
DTP03
AMT02 AMT03
SE02
GE GE01 GE02
TRANSACTION SET TRAILER Transaction Segment Count Transaction Set Control Number FUNCTION GROUP TRAILER Number of Transaction Sets Included Group Control Number
N0
1 1-10
R R
AN
4-9
R
1
R
1-6 1-9
R R
1
R
N0 N0
IEA01
INTERCHANGE CONTROL TRAILER Number of Included Functional Groups
N0
1-5
R
IEA02
Interchange Control Number
N0
9-9
R
IEA
Loop Repeat
Date Time Qualifier Date Time Period Format Qualifier
ID
3-3
R
573
ID
2-3
R
D8
Adjudication or Payment Date AN
1-35
R
CCYYMMDD
ID
1 1-3
S R
R ID
1-18 1-1
R N/U
N0
1 1-10
R R
AN
4-9
R
1
R
1-6 1-9
R R
1
R
Loop
Values
837-I 5010
ID
AMT AMT01
SE SE01
Usage Reg.
ID
837-I 4010A1 DTP01
Min. Max.
Description
___
>1
SE SE01 SE02
___
1
GE GE01 GE02
___
1
REMAINING PATIENT LIABILITY Amount Qualifier Code Remaining Patient Liability Amount Credit/Debit Flag Code TRANSACTION SET TRAILER Transaction Segment Count Transaction Set Control Number FUNCTION GROUP TRAILER Number of Transaction Sets Included Group Control Number
New Segment
N0 N0
IEA01
INTERCHANGE CONTROL TRAILER Number of Included Functional Groups
N0
1-5
R
IEA02
Interchange Control Number
N0
9-9
R
IEA
Page 93 of 93
2430 EAF
___
>1
___
1
___
1
Related Documents
Institutional Claim A 1 To 5010
April 2020 2
Claim Status A To 5010
April 2020 3
Eligibility A 1 To 5010
April 2020 2
5010
June 2020 13
5010
December 2019 14