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code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 124/579 This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 125/579 If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 126/579 HI 2310 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HI Occurrence Information To supply information related to the delivery of health care Usage notes Required when there is a Occurrence Code that applies to this claim. If not required by this implementation guide, do not send. Example HI*BH>XXXXX>D8>XXX*BH>XXXXXX>D8>XXXXXX*BH>XXXX>D 8>XXXXX*BH>XX>D8>XXXX*BH>XXX>D8>XXXXX*BH>XXX>D8>X XXXXX*BH>XX>D8>XXX*BH>XXXXXX>D8>XXXX*BH>X>D8>XX X*BH>XX>D8>XXXXX*BH>XX>D8>XXXXX*BH>XXXXXX>D8>XXXX XX~ Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 2 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 127/579 C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Max use 1 Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 128/579 Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 129/579 If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-06 C022 Health Care Code Information Max use 1 Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 130/579 To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating | Health Partner Plans 837 Health Care Claim_ Institutional.pdf |
dates, times or dates and times HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 129/579 If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-06 C022 Health Care Code Information Max use 1 Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 130/579 To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-07 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 131/579 Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 132/579 Expression of a date, a time, or range of dates, times or dates and times HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-10 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 133/579 BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 134/579 C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 135/579 HI 2310 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HI Occurrence Span Information To supply information related to the delivery of health care Usage notes Required when there is an Occurrence Span Code that applies to this claim. If not required by this implementation guide, do not send. Example HI*BI>XXXXXX>RD8>XX*BI>XXXXXX>RD8>XX*BI>XXXXX>RD 8>XXXX*BI>XXX>RD8>XXXXXX*BI>XXXXXX>RD8>XXXX*BI>X X>RD8>XXX*BI>XXXXX>RD8>XXXXX*BI>XXXX>RD8>XXXX*B I>XXXXX>RD8>XXXXXX*BI>XX>RD8>X*BI>XXXX>RD8>XXXX*B I>XXXXXX>RD8>XXXXX~ Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 2 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 136/579 C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or | Health Partner Plans 837 Health Care Claim_ Institutional.pdf |
or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 134/579 C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 135/579 HI 2310 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HI Occurrence Span Information To supply information related to the delivery of health care Usage notes Required when there is an Occurrence Span Code that applies to this claim. If not required by this implementation guide, do not send. Example HI*BI>XXXXXX>RD8>XX*BI>XXXXXX>RD8>XX*BI>XXXXX>RD 8>XXXX*BI>XXX>RD8>XXXXXX*BI>XXXXXX>RD8>XXXX*BI>X X>RD8>XXX*BI>XXXXX>RD8>XXXXX*BI>XXXX>RD8>XXXX*B I>XXXXX>RD8>XXXXXX*BI>XX>RD8>X*BI>XXXX>RD8>XXXX*B I>XXXXXX>RD8>XXXXX~ Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 2 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 136/579 C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Max use 1 Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 137/579 Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 138/579 If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-06 C022 Health Care Code Information Max use 1 Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 139/579 To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-07 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 140/579 Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 141/579 Expression of a date, a time, or range of dates, times or dates and times HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence | Health Partner Plans 837 Health Care Claim_ Institutional.pdf |
is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-07 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 140/579 Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 141/579 Expression of a date, a time, or range of dates, times or dates and times HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-10 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 142/579 BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 143/579 C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 144/579 HI 2310 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HI Other Diagnosis Information To supply information related to the delivery of health care Usage notes Do not transmit the decimal point for ICD codes. The decimal point is implied. Required when other condition(s) coexist or develop(s) subsequently during the patient's treatment. If not required by this implementation guide, do not send. Example HI*BF>XXXX>>>>>>>W*ABF>XXX>>>>>>>N*BF>XXXXXX>>>>> >>N*BF>XXXXXX>>>>>>>Y*BF>XXXX>>>>>>>U*BF>XXXXX>>> >>>>W*BF>XX>>>>>>>U*BF>XXXXX>>>>>>>N*ABF>XXXX>>>> >>>U*ABF>XXXXXX>>>>>>>W*BF>XX>>>>>>>W*ABF>XXX>>>> >>>N~ Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 2 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 145/579 BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 146/579 C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) | Health Partner Plans 837 Health Care Claim_ Institutional.pdf |
law, OR For claims which are not covered under HIPAA. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 145/579 BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 146/579 C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 147/579 If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 148/579 Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 149/579 an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-06 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 150/579 C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-07 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 | Health Partner Plans 837 Health Care Claim_ Institutional.pdf |
N No U Unknown W Not Applicable Y Yes HI-06 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 150/579 C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-07 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 151/579 N No U Unknown W Not Applicable Y Yes HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 152/579 Y Yes HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-10 C022 Health Care Code Information 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 153/579 To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Max use 1 Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 154/579 Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional | Health Partner Plans 837 Health Care Claim_ Institutional.pdf |
Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Max use 1 Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 154/579 Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 155/579 C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 156/579 HI 2310 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HI Other Procedure Information To supply information related to the delivery of health care Usage notes Required on inpatient claims when additional procedures must be reported. If not required by this implementation guide, do not send. Do not transmit the decimal point for ICD codes. The decimal point is implied. Example HI*BQ>XXXX>D8>XXX*BQ>XXXXXX>D8>XXXX*BBQ>XXXXX>D 8>XXXXX*BQ>XXXX>D8>XXXXXX*BQ>XX>D8>XXXX*BBQ>XXX>D 8>XXX*BQ>XX>D8>XXXXX*BQ>XX>D8>XXXX*BBQ>XXXXXX>D 8>XX*BQ>XXXXX>D8>X*BBQ>XXXXX>D8>XXXXXX*BBQ>X>D8>X XXXXX~ Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 2 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 157/579 OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 158/579 Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 159/579 Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required 1/30/25, 11:52 | Health Partner Plans 837 Health Care Claim_ Institutional.pdf |
procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 159/579 Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 160/579 Expression of a date, a time, or range of dates, times or dates and times HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-06 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Max use 1 Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 161/579 Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-07 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 162/579 Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 163/579 OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 164/579 C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-10 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This | Health Partner Plans 837 Health Care Claim_ Institutional.pdf |
use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 164/579 C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-10 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 165/579 Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 166/579 Expression of a date, a time, or range of dates, times or dates and times HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 167/579 HI 2310 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HI Patient's Reason For Visit To supply information related to the delivery of health care Usage notes Required when claim involves outpatient visits. If not required by this implementation guide, do not send. Do not transmit the decimal point for ICD codes. The decimal point is implied. Example HI*PR>XXXX*PR>XXX*APR>XXXX~ Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 1 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 168/579 APR International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. PR International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit C022-02 1271 Patient Reason For Visit Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional Patient's Reason for Visit must be sent and the preceding HI data elements have been used to report other patient's reason for visit. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. APR International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. PR International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit C022-02 1271 Patient Reason For Visit Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 169/579 HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional Patient's Reason for Visit must be sent and the preceding HI data elements have been used to report other patient's reason for visit. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. APR International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. PR International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit C022-02 1271 Patient Reason For Visit Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI | Health Partner Plans 837 Health Care Claim_ Institutional.pdf |
are not covered under HIPAA. PR International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit C022-02 1271 Patient Reason For Visit Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional Patient's Reason for Visit must be sent and the preceding HI data elements have been used to report other patient's reason for visit. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. APR International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. PR International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit C022-02 1271 Patient Reason For Visit Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 169/579 HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional Patient's Reason for Visit must be sent and the preceding HI data elements have been used to report other patient's reason for visit. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. APR International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. PR International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit C022-02 1271 Patient Reason For Visit Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 170/579 HI 2310 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HI Principal Diagnosis To supply information related to the delivery of health care Usage notes Do not transmit the decimal point for ICD codes. The decimal point is implied. Example HI*BK>XX>>>>>>>N~ Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 1 Required HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABK International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BK International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis C022-02 1271 Principal Diagnosis Code Min 1 Max 30 String (AN) Required 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 171/579 Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 172/579 HI 2310 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HI Principal Procedure Information To supply information related to the delivery of health care Usage notes Required on inpatient claims when a procedure was performed. If not required by this implementation guide, do not send. Do not transmit the decimal point for ICD codes. The decimal point is implied. Example HI*CAH>XXXXX>D8>X~ Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Treatment Code Information HI Value Information Max use 1 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 173/579 BBR International Classification of Diseases Clinical Modification (ICD-10-PCS) Principal Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BR International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Procedure Codes CAH Advanced Billing Concepts (ABC) Codes C022-02 1271 Principal Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Principal Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 174/579 HI 2310 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HI Treatment Code Information To supply information related to the delivery of health care Usage notes Required when Home Health Agencies need to report Plan of Treatment information under various payer contracts. If not required by this implementation guide, do not send. Example HI*TC>XXX*TC>XXX*TC>X*TC>XXXX*TC>XXXXXX*TC>XXX*T C>XXXXX*TC>XXXXX*TC>X*TC>XXXXXX*TC>XX*TC>XXXXXX~ Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Value Information Max use 2 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 175/579 Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 176/579 C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 | Health Partner Plans 837 Health Care Claim_ Institutional.pdf |
industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 175/579 Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 176/579 C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-06 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 177/579 TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-07 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 178/579 If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-10 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Max use 1 Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 179/579 Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 180/579 HI 2310 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HI Value Information To supply information related to the delivery of health care Usage notes Required when there is a Value Code that applies to this claim. If not required by this implementation guide, do not send. Example HI*BE>XXX>>>000000000*BE>XXX>>>0*BE>XXXXXX>>>0*B E>XXX>>>0000*BE>X>>>0000000000*BE>XX>>>000*BE>XXX X>>>00000000000000*BE>XXXXX>>>000000000000*BE>XXX XX>>>0000000*BE>XXX>>>0000000000000*BE>XXX>>>0000 0000*BE>XXXX>>>00000000~ Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information Max use 2 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 181/579 C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 182/579 If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not | Health Partner Plans 837 Health Care Claim_ Institutional.pdf |
Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information Max use 2 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 181/579 C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 182/579 If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 183/579 C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-06 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-07 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 184/579 BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 185/579 Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-10 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 186/579 C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 187/579 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 188/579 HCP 2410 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HCP Claim Pricing/Repricing Information To specify pricing or repricing information about a health care claim or line item Usage notes Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send. This information is specific to the destination payer reported in Loop ID-2010BB. For capitated encounters, pricing or repricing information usually is not applicable and is provided to qualify other information within the claim. Example HCP*04*0000000000*00000*XXXXXX*000*XXXXX*00*XXXX X***DA*000*T4*4*3~ If either Unit or Basis for Measurement Code (HCP-11) or Repriced Approved Service Unit Count (HCP-12) is present, then the other is required Max use 1 Optional HCP-01 1473 Pricing Methodology Identifier (ID) Required Code specifying pricing methodology at which the claim or line item has been priced or repriced Usage notes Specific code use is determined by Trading Partner Agreement due to the variances in contracting policies in the industry. 00 Zero Pricing (Not Covered Under Contract) 01 Priced as Billed at 100% 02 Priced at the Standard Fee Schedule 03 Priced at a Contractual Percentage 04 Bundled Pricing 05 Peer Review Pricing 06 Per Diem Pricing 07 Flat Rate Pricing 08 Combination Pricing 09 Maternity Pricing 10 Other Pricing 11 Lower of Cost 12 Ratio of Cost 13 Cost Reimbursed 14 Adjustment Pricing HCP-02 782 Repriced Allowed Amount Min 1 Max 15 Decimal number (R) Required Monetary | Health Partner Plans 837 Health Care Claim_ Institutional.pdf |
Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 186/579 C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 187/579 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 188/579 HCP 2410 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HCP Claim Pricing/Repricing Information To specify pricing or repricing information about a health care claim or line item Usage notes Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send. This information is specific to the destination payer reported in Loop ID-2010BB. For capitated encounters, pricing or repricing information usually is not applicable and is provided to qualify other information within the claim. Example HCP*04*0000000000*00000*XXXXXX*000*XXXXX*00*XXXX X***DA*000*T4*4*3~ If either Unit or Basis for Measurement Code (HCP-11) or Repriced Approved Service Unit Count (HCP-12) is present, then the other is required Max use 1 Optional HCP-01 1473 Pricing Methodology Identifier (ID) Required Code specifying pricing methodology at which the claim or line item has been priced or repriced Usage notes Specific code use is determined by Trading Partner Agreement due to the variances in contracting policies in the industry. 00 Zero Pricing (Not Covered Under Contract) 01 Priced as Billed at 100% 02 Priced at the Standard Fee Schedule 03 Priced at a Contractual Percentage 04 Bundled Pricing 05 Peer Review Pricing 06 Per Diem Pricing 07 Flat Rate Pricing 08 Combination Pricing 09 Maternity Pricing 10 Other Pricing 11 Lower of Cost 12 Ratio of Cost 13 Cost Reimbursed 14 Adjustment Pricing HCP-02 782 Repriced Allowed Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 189/579 HCP02 is the allowed amount. HCP-03 782 Repriced Saving Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount HCP03 is the savings amount. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-04 127 Repricing Organization Identifier Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier HCP04 is the repricing organization identification number. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-05 118 Repricing Per Diem or Flat Rate Amount Decimal number (R) Optional Min 1 Max 9 Rate expressed in the standard monetary denomination for the currency specified HCP05 is the pricing rate associated with per diem or flat rate repricing. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-06 127 Repriced Approved DRG Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier HCP06 is the approved DRG code. HCP06, HCP07, HCP08, HCP10, and HCP12 are fields that will contain different values from the original submitted values. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-07 782 Repriced Approved Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount HCP07 is the approved DRG amount. Usage notes 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 190/579 This information is specific to the destination payer reported in Loop ID-2010BB. HCP-08 234 Repriced Approved Revenue Code Min 1 Max 48 String (AN) Optional Identifying number for a product or service HCP08 is the approved revenue code. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-11 355 Unit or Basis for Measurement Code Identifier (ID) Optional Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken DA Days UN Unit HCP-12 380 Repriced Approved Service Unit Count Decimal number (R) Optional Min 1 Max 15 Numeric value of quantity HCP12 is the approved service units or inpatient days. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three. HCP-13 901 Reject Reason Code Identifier (ID) Optional Code assigned by issuer to identify reason for rejection HCP13 is the rejection message returned from the third party organization. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. T1 Cannot Identify Provider as TPO (Third Party Organization) Participant T2 Cannot Identify Payer as TPO (Third Party Organization) Participant T3 Cannot Identify Insured as TPO (Third Party Organization) Participant T4 Payer Name or Identifier Missing T5 Certification Information Missing T6 Claim does not contain enough information for re-pricing HCP-14 1526 Policy Compliance Code Identifier (ID) Optional Code specifying policy compliance Usage notes 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 191/579 This information is specific to the destination payer reported in Loop ID-2010BB. 1 Procedure Followed (Compliance) 2 Not Followed - Call Not Made (Non-Compliance Call Not Made) 3 Not Medically Necessary (Non-Compliance Non-Medically Necessary) 4 Not Followed Other (Non-Compliance Other) 5 Emergency Admit to Non-Network Hospital HCP-15 1527 Exception Code Identifier (ID) Optional Code specifying the exception reason for consideration of out-of-network health care services HCP15 is the exception reason generated by a third party organization. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. 1 Non-Network Professional Provider in Network Hospital 2 Emergency Care 3 Services or Specialist not in Network 4 Out-of-Service Area 5 State Mandates 6 Other 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 192/579 2310A Attending Provider Name Loop Max 1 Optional Variants (all may be used) Operating Physician Name Loop Other Operating Physician Name Loop Rendering Provider Name Loop Service Facility Location Name Loop Referring Provider Name Loop NM1 2500 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Attending Provider Name Loop > NM1 Attending Provider Name To supply the full name of an individual or organizational entity Usage notes Required when the claim contains any services other than non-scheduled transportation claims. If not required by this implementation guide, do not send. The Attending Provider is the individual who has overall responsibility for the patient's medical care and treatment reported in this claim. Example NM1*71*1*XXXX*XXX*XX**X*XX*XXXXX~ If either Identification Code Qualifier (NM1-08) or Attending Provider Primary Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 71 Attending Physician When used, the term physician is any type of provider filling this role. NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Attending Provider Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Attending Provider First Name Min 1 Max 35 String (AN) Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 193/579 Individual first name NM1-05 1037 Attending Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Attending Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Attending Provider Primary Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code Usage notes Use appropriate NPI number. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 194/579 PRV 2550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Attending Provider Name Loop > PRV Attending Provider Specialty Information To specify the identifying characteristics of a provider Usage notes Required when adjudication of the destination payer, or any subsequent payer listed on this claim, is known to be impacted by the attending provider taxonomy code. If not required by this implementation guide, do not send. Example PRV*AT*PXC*XXXXX~ Max use 1 Optional PRV-01 1221 Provider Code Identifier (ID) Required Code identifying the type of provider AT Attending PRV-02 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification PXC Health Care Provider Taxonomy Code PRV-03 127 Provider Taxonomy Code Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 195/579 2310A Attending Provider Name Loop end REF 2710 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Attending Provider Name Loop > REF Attending Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. Example REF*G2*XXXXXX~ Max use 4 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. REF-02 127 Attending Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes Health partners provider identification number (5 digits). 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 196/579 2310B Operating Physician Name Loop Max 1 Optional Variants (all may be used) Attending Provider Name Loop Other Operating Physician Name Loop Rendering Provider Name Loop Service Facility Location Name Loop Referring Provider Name Loop NM1 2500 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Operating Physician Name Loop > NM1 Operating Physician Name To supply the full name of an individual or organizational entity Usage notes Required when a surgical procedure code is listed on this claim. If not required by | Health Partner Plans 837 Health Care Claim_ Institutional.pdf |
or other code Usage notes Use appropriate NPI number. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 194/579 PRV 2550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Attending Provider Name Loop > PRV Attending Provider Specialty Information To specify the identifying characteristics of a provider Usage notes Required when adjudication of the destination payer, or any subsequent payer listed on this claim, is known to be impacted by the attending provider taxonomy code. If not required by this implementation guide, do not send. Example PRV*AT*PXC*XXXXX~ Max use 1 Optional PRV-01 1221 Provider Code Identifier (ID) Required Code identifying the type of provider AT Attending PRV-02 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification PXC Health Care Provider Taxonomy Code PRV-03 127 Provider Taxonomy Code Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 195/579 2310A Attending Provider Name Loop end REF 2710 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Attending Provider Name Loop > REF Attending Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. Example REF*G2*XXXXXX~ Max use 4 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. REF-02 127 Attending Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes Health partners provider identification number (5 digits). 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 196/579 2310B Operating Physician Name Loop Max 1 Optional Variants (all may be used) Attending Provider Name Loop Other Operating Physician Name Loop Rendering Provider Name Loop Service Facility Location Name Loop Referring Provider Name Loop NM1 2500 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Operating Physician Name Loop > NM1 Operating Physician Name To supply the full name of an individual or organizational entity Usage notes Required when a surgical procedure code is listed on this claim. If not required by this implementation guide, do not send. The Operating Physician is the individual with primary responsibility for performing the surgical procedure(s). Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Example NM1*72*1*X*X*XX**XXXXXX*XX*XXXX~ If either Identification Code Qualifier (NM1-08) or Operating Physician Primary Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 72 Operating Physician NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Operating Physician Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Operating Physician First Name Min 1 Max 35 String (AN) Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 197/579 Individual first name NM1-05 1037 Operating Physician Middle Name or Initial String (AN) Optional Min 1 Max 25 Individual middle name or initial NM1-07 1039 Operating Physician Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Operating Physician Primary Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code Usage notes Use appropriate NPI number. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 198/579 2310B Operating Physician Name Loop end REF 2710 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Operating Physician Name Loop > REF Operating Physician Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. Example REF*G2*XXX~ Max use 4 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Operating Physician Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 199/579 2310C Other Operating Physician Name Loop Max 1 Optional Variants (all may be used) Attending Provider Name Loop Operating Physician Name Loop Rendering Provider Name Loop Service Facility Location Name Loop Referring Provider Name Loop NM1 2500 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Operating Physician Name Loop > NM1 Other Operating Physician Name To supply the full name of an individual or organizational entity Usage notes Required when another Operating Physician is involved. If not required by the implementation guide, do not send. The Other Operating Physician is the individual performing a secondary surgical procedure or assisting the Operating Physician. This Other Operating Physician segment can only be used when Operating Physician information (Loop ID-2310B) is also sent on this claim. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Example NM1*ZZ*1*X*XXXXX*XXX**XXXXX*XX*XXXXXXX~ If either Identification Code Qualifier (NM1-08) or Other Operating Physician Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual ZZ Mutually Defined ZZ is used to indicate Other Operating Physician. NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Other Operating Physician Last Name Min 1 Max 60 String (AN) Required 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 200/579 Individual last name or organizational name NM1-04 1036 Other Operating Physician First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Other Operating Physician Middle Name or Initial String (AN) Optional Min 1 Max 25 Individual middle name or initial NM1-07 1039 Other Operating Physician Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Other Operating Physician Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code Usage notes Use appropriate NPI number. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 201/579 2310C Other Operating Physician Name Loop end REF 2710 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Operating Physician Name Loop > REF Other Operating Physician Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. Example REF*0B*XXX~ Max use 4 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Other Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 202/579 2310D Rendering Provider Name Loop Max 1 Optional Variants (all may be used) Attending Provider Name Loop Operating Physician Name Loop Other Operating Physician Name Loop Service Facility Location Name Loop Referring Provider Name Loop NM1 2500 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Rendering Provider Name Loop > NM1 Rendering Provider Name To supply the full name of an individual or organizational entity Usage notes Required when the Rendering Provider is different than the Attending Provider reported in Loop ID-2310A of this claim. AND When state or federal regulatory requirements call for a "combined claim", that is, a claim that includes both facility and professional components (for example, a Medicaid clinic bill or Critical Access Hospital Claim.) If not required by this implementation guide, do not send. The Rendering Provider is the health care professional who delivers or completes a particular medical service or non-surgical procedure. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Example NM1*82*1*XX*XXXX*XXXXX**XXXX*XX*XXXXXXX~ If either Identification Code Qualifier (NM1-08) or Rendering Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 82 Rendering Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Rendering Provider Last Name Min 1 Max 60 String (AN) Required 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 203/579 Individual last name or organizational name NM1-04 1036 Rendering Provider First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Rendering Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Rendering Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid | Health Partner Plans 837 Health Care Claim_ Institutional.pdf |
necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. Example REF*0B*XXX~ Max use 4 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Other Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 202/579 2310D Rendering Provider Name Loop Max 1 Optional Variants (all may be used) Attending Provider Name Loop Operating Physician Name Loop Other Operating Physician Name Loop Service Facility Location Name Loop Referring Provider Name Loop NM1 2500 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Rendering Provider Name Loop > NM1 Rendering Provider Name To supply the full name of an individual or organizational entity Usage notes Required when the Rendering Provider is different than the Attending Provider reported in Loop ID-2310A of this claim. AND When state or federal regulatory requirements call for a "combined claim", that is, a claim that includes both facility and professional components (for example, a Medicaid clinic bill or Critical Access Hospital Claim.) If not required by this implementation guide, do not send. The Rendering Provider is the health care professional who delivers or completes a particular medical service or non-surgical procedure. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Example NM1*82*1*XX*XXXX*XXXXX**XXXX*XX*XXXXXXX~ If either Identification Code Qualifier (NM1-08) or Rendering Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 82 Rendering Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Rendering Provider Last Name Min 1 Max 60 String (AN) Required 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 203/579 Individual last name or organizational name NM1-04 1036 Rendering Provider First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Rendering Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Rendering Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Rendering Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 204/579 2310D Rendering Provider Name Loop end REF 2710 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Rendering Provider Name Loop > REF Rendering Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. Example REF*LU*XXXXX~ Max use 4 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Rendering Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 205/579 2310E Service Facility Location Name Loop Max 1 Optional Variants (all may be used) Attending Provider Name Loop Operating Physician Name Loop Other Operating Physician Name Loop Rendering Provider Name Loop Referring Provider Name Loop NM1 2500 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Facility Location Name Loop > NM1 Service Facility Location Name To supply the full name of an individual or organizational entity Usage notes Required when the location of health care service is different than that carried in Loop ID-2010AA (Billing Provider). If not required by this implementation guide, do not send. When an organization health care provider's NPI is provided to identify the Service Location, the organization health care provider must be external to the entity identified as the Billing Provider (for example, reference lab). It is not permissible to report an organization health care provider NPI as the Service Location if the entity being identified is a component (for example, subpart) of the Billing Provider. In that case, the subpart must be the Billing Provider. Example NM1*77*2*XXXXXX*****XX*XXXXXXX~ If either Identification Code Qualifier (NM1-08) or Laboratory or Facility Primary Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 77 Service Location NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Laboratory or Facility Name Min 1 Max 60 String (AN) Required 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 206/579 Individual last name or organizational name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Laboratory or Facility Primary Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code Usage notes Use appropriate NPI number. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 207/579 N3 2650 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Facility Location Name Loop > N3 Service Facility Location Address To specify the location of the named party Usage notes If service facility location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".) Example N3*XXXXXX*XXXXXX~ Max use 1 Required N3-01 166 Laboratory or Facility Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Laboratory or Facility Address Line Min 1 Max 55 String (AN) Optional Address information 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 208/579 N4 2700 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Facility Location Name Loop > N4 Service Facility Location City, State, ZIP Code To specify the geographic place of the named party Usage notes Include city, 2-character state code and 9-digit ZIP code. Example N4*XXXXXXX*XX*XXXXX*XX~ Only one of Laboratory or Facility State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Laboratory or Facility City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Laboratory or Facility State or Province Code Identifier (ID) Optional Min 2 Max 2 Code (Standard State/Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Laboratory or Facility Postal Zone or ZIP Code Identifier (ID) Optional Min 3 Max 15 Code defining international postal zone code excluding punctuation and blanks (zip code for United States) Usage notes When reporting the ZIP code for U.S. addresses, the full nine digit ZIP code must be provided. N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 209/579 Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 210/579 2310E Service Facility Location Name Loop end REF 2710 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Facility Location Name Loop > REF Service Facility Location Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI implementation date when the entity is not a Health Care provider (a.k.a. an atypical provider), and an identifier is necessary for the claims processor to identify the entity. If not required by this implementation guide, do not send. Example REF*LU*XXXXX~ Max use 3 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Laboratory or Facility Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 211/579 2310F Referring Provider Name Loop Max 1 Optional Variants (all may be used) Attending Provider Name Loop Operating Physician Name Loop Other Operating Physician Name Loop Rendering Provider Name Loop Service Facility Location Name Loop NM1 2500 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Referring Provider Name Loop > NM1 Referring Provider Name To supply the full name of an individual or organizational entity Usage notes Required on an outpatient claim when the Referring Provider is different than the Attending Provider. If not required by this implementation guide, do not send. The Referring Provider is provider who sends the patient to another provider for services. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Example NM1*DN*1*XXXXXX*XXXXX*XXX**XXXXXX*XX*XXXXX~ If either Identification Code Qualifier (NM1-08) or Referring Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual DN Referring Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. | Health Partner Plans 837 Health Care Claim_ Institutional.pdf |
Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 209/579 Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 210/579 2310E Service Facility Location Name Loop end REF 2710 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Facility Location Name Loop > REF Service Facility Location Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI implementation date when the entity is not a Health Care provider (a.k.a. an atypical provider), and an identifier is necessary for the claims processor to identify the entity. If not required by this implementation guide, do not send. Example REF*LU*XXXXX~ Max use 3 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Laboratory or Facility Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 211/579 2310F Referring Provider Name Loop Max 1 Optional Variants (all may be used) Attending Provider Name Loop Operating Physician Name Loop Other Operating Physician Name Loop Rendering Provider Name Loop Service Facility Location Name Loop NM1 2500 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Referring Provider Name Loop > NM1 Referring Provider Name To supply the full name of an individual or organizational entity Usage notes Required on an outpatient claim when the Referring Provider is different than the Attending Provider. If not required by this implementation guide, do not send. The Referring Provider is provider who sends the patient to another provider for services. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Example NM1*DN*1*XXXXXX*XXXXX*XXX**XXXXXX*XX*XXXXX~ If either Identification Code Qualifier (NM1-08) or Referring Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual DN Referring Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Referring Provider Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Referring Provider First Name Min 1 Max 35 String (AN) Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 212/579 Individual first name NM1-05 1037 Referring Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Referring Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Referring Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 213/579 2310F Referring Provider Name Loop end REF 2710 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Referring Provider Name Loop > REF Referring Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. The REF segment in Loop ID-2310 applies to the entire claim unless overridden on the service line level by the presence of a REF segment with the same value in REF01. Example REF*G2*X~ Max use 3 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. REF-02 127 Referring Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 214/579 2320 Other Subscriber Information Loop Max 10 Optional SBR 2900 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > SBR Other Subscriber Information To record information specific to the primary insured and the insurance carrier for that insured Usage notes Required when other payers are known to potentially be involved in paying on this claim. If not required by this implementation guide, do not send. All information contained in Loop ID-2320 applies only to the payer identified in Loop ID-2330B of this iteration of Loop ID-2320. It is specific only to that payer. If information for an additional payer is necessary, repeat Loop ID-2320 with its respective 2330 Loops.; See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example SBR*G*20*XXX*XX*****MB~ Max use 1 Required SBR-01 1138 Payer Responsibility Sequence Number Code Identifier (ID) Required Code identifying the insurance carrier's level of responsibility for a payment of a claim Usage notes Within a given claim, the various values for the Payer Responsibility Sequence Number Code (other than value "U") may occur no more than once. A Payer Responsibility Four B Payer Responsibility Five C Payer Responsibility Six D Payer Responsibility Seven E Payer Responsibility Eight F Payer Responsibility Nine G Payer Responsibility Ten H Payer Responsibility Eleven P Primary S Secondary T Tertiary U Unknown This code may only be used in payer to payer COB claims when the original payer determined the presence of this coverage from eligibility files received from this payer or when the original claim did not provide the responsibility sequence for this payer. SBR-02 1069 Individual Relationship Code Identifier (ID) Required Code indicating the relationship between two individuals or entities SBR02 specifies the relationship to the person insured. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 215/579 01 Spouse 18 Self 19 Child 20 Employee 21 Unknown 39 Organ Donor 40 Cadaver Donor 53 Life Partner G8 Other Relationship SBR-03 127 Insured Group or Policy Number Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier SBR03 is policy or group number. Usage notes This is not the number uniquely identifying the subscriber. The unique subscriber number is submitted in Loop 2330A-NM109 for this iteration of Loop ID-2320. SBR-04 93 Other Insured Group Name Min 1 Max 60 String (AN) Optional Free-form name SBR04 is plan name. SBR-09 1032 Claim Filing Indicator Code Identifier (ID) Required Code identifying type of claim 11 Other Non-Federal Programs 12 Preferred Provider Organization (PPO) 13 Point of Service (POS) 14 Exclusive Provider Organization (EPO) 15 Indemnity Insurance 16 Health Maintenance Organization (HMO) Medicare Risk 17 Dental Maintenance Organization AM Automobile Medical BL Blue Cross/Blue Shield CH Champus CI Commercial Insurance Co. DS Disability FI Federal Employees Program HM Health Maintenance Organization LM Liability Medical MA Medicare Part A MB Medicare Part B MC Medicaid OF Other Federal Program Use code OF when submitting Medicare Part D claims. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 216/579 TV Title V VA Veterans Affairs Plan WC Workers' Compensation Health Claim ZZ Mutually Defined Use Code ZZ when Type of Insurance is not known. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 217/579 CAS 2950 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > CAS Claim Level Adjustments To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid Usage notes Required when the claim has been adjudicated by the payer identified in this loop, and the claim has claim level adjustment information. If not required by this implementation guide, do not send. Submitters must use this CAS segment to report prior payers' claim level adjustments that cause the amount paid to differ from the amount originally charged. Only one Group Code is allowed per CAS. If it is necessary to send more than one Group Code at the claim level, repeat the CAS segment. Codes and associated amounts must come from either paper remittance advice or 835s (Electronic Remittance Advice) received on the claim. When the information originates from a paper remittance advice that does not use the standard Claim Adjustment Reason Codes, the paper values must be converted to standard Claim Adjustment Reason Codes.; A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a particular Claim Adjustment Group Code (CAS01). The first non-zero adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19). Example CAS*CR*XXX*00000000*00*XX*000000000000000*000000 0*XXXX*000*00000000000*XXXXX*0*0000000000000*XX*0 0000000*00*XXXX*000000000000*000000000~ If Adjustment Reason Code (CAS-05) is present, then at least one of Adjustment Amount (CAS-06) or Adjustment Quantity (CAS-07) is required If Adjustment Amount (CAS-06) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Quantity (CAS-07) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Reason Code (CAS-08) is present, then at least one of Adjustment Amount (CAS-09) or Adjustment Quantity (CAS-10) is required If Adjustment Amount (CAS-09) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Quantity (CAS-10) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Reason Code (CAS-11) is present, then at least one of Adjustment Amount (CAS-12) or Adjustment Quantity (CAS-13) is required If Adjustment Amount (CAS-12) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Quantity (CAS-13) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS-16) is required Max use 5 Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 218/579 If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS-19) is required If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) | Health Partner Plans 837 Health Care Claim_ Institutional.pdf |
> Claim Information Loop > Other Subscriber Information Loop > CAS Claim Level Adjustments To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid Usage notes Required when the claim has been adjudicated by the payer identified in this loop, and the claim has claim level adjustment information. If not required by this implementation guide, do not send. Submitters must use this CAS segment to report prior payers' claim level adjustments that cause the amount paid to differ from the amount originally charged. Only one Group Code is allowed per CAS. If it is necessary to send more than one Group Code at the claim level, repeat the CAS segment. Codes and associated amounts must come from either paper remittance advice or 835s (Electronic Remittance Advice) received on the claim. When the information originates from a paper remittance advice that does not use the standard Claim Adjustment Reason Codes, the paper values must be converted to standard Claim Adjustment Reason Codes.; A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a particular Claim Adjustment Group Code (CAS01). The first non-zero adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19). Example CAS*CR*XXX*00000000*00*XX*000000000000000*000000 0*XXXX*000*00000000000*XXXXX*0*0000000000000*XX*0 0000000*00*XXXX*000000000000*000000000~ If Adjustment Reason Code (CAS-05) is present, then at least one of Adjustment Amount (CAS-06) or Adjustment Quantity (CAS-07) is required If Adjustment Amount (CAS-06) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Quantity (CAS-07) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Reason Code (CAS-08) is present, then at least one of Adjustment Amount (CAS-09) or Adjustment Quantity (CAS-10) is required If Adjustment Amount (CAS-09) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Quantity (CAS-10) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Reason Code (CAS-11) is present, then at least one of Adjustment Amount (CAS-12) or Adjustment Quantity (CAS-13) is required If Adjustment Amount (CAS-12) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Quantity (CAS-13) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS-16) is required Max use 5 Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 218/579 If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS-19) is required If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required CAS-01 1033 Claim Adjustment Group Code Identifier (ID) Required Code identifying the general category of payment adjustment CO Contractual Obligations CR Correction and Reversals OA Other adjustments PI Payor Initiated Reductions PR Patient Responsibility CAS-02 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Required Code identifying the detailed reason the adjustment was made Usage notes See CODE SOURCE 139: Claim Adjustment Reason Code CAS-03 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CAS03 is the amount of adjustment. CAS-04 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS04 is the units of service being adjusted. CAS-05 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-06 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 219/579 CAS06 is the amount of the adjustment. CAS-07 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS07 is the units of service being adjusted. CAS-08 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-09 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS09 is the amount of the adjustment. CAS-10 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS10 is the units of service being adjusted. CAS-11 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-12 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS12 is the amount of the adjustment. CAS-13 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS13 is the units of service being adjusted. CAS-14 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 220/579 CAS-15 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS15 is the amount of the adjustment. CAS-16 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS16 is the units of service being adjusted. CAS-17 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-18 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS18 is the amount of the adjustment. CAS-19 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS19 is the units of service being adjusted. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 221/579 AMT 3000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > AMT Coordination of Benefits (COB) Payer Paid Amount To indicate the total monetary amount Usage notes Required when the claim has been adjudicated by the payer identified in Loop ID- 2330B of this loop. OR Required when Loop ID-2010AC is present. In this case, the claim is a post payment recovery claim submitted by a subrogated Medicaid agency. If not required by this implementation guide, do not send.; Example AMT*D*0000000000~ Variants (all may be used) AMT Coordination of Benefits (COB) Total Non-Covered Amount AMT Remaining Patient Liability Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount D Payor Amount Paid AMT-02 782 Payer Paid Amount Min 1 Max 15 Decimal number (R) Required Monetary amount Usage notes It is acceptable to show "0" as the amount paid. When Loop ID-2010AC is present, this is the amount the Medicaid agency actually paid. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 222/579 AMT 3000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > AMT Coordination of Benefits (COB) Total Non-Covered Amount To indicate the total monetary amount Usage notes Required when the destination payer's cost avoidance policy allows providers to bypass claim submission to the otherwise prior payer identified in Loop ID-2330B. If not required by this implementation guide, do not send. When this segment is used, the amount reported in AMT02 must equal the total claim charge amount reported in CLM02. Neither the prior payer paid AMT, nor any CAS segments are used as this claim has not been adjudicated by this payer. Example AMT*A8*0000~ Variants (all may be used) AMT Coordination of Benefits (COB) Payer Paid Amount AMT Remaining Patient Liability Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount A8 Noncovered Charges - Actual AMT-02 782 Non-Covered Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 223/579 AMT 3000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > AMT Remaining Patient Liability To indicate the total monetary amount Usage notes Required when the Other Payer identified in Loop ID-2330B (of this iteration of Loop ID-2320) has adjudicated this claim and provided claim level information only. OR Required when the Other Payer identified in Loop ID-2330B (of this iteration of Loop ID-2320) has adjudicated this claim and the provider received a paper remittance advice and the provider does not have the ability to report line item information. If not required by this implementation guide, do not send. In the judgment of the provider, this is the remaining amount to be paid after adjudication by the Other Payer identified in Loop ID-2330B of this iteration of Loop ID-2320. This segment is only used in provider submitted claims. It is not used in Payer-to-Payer Coordination of Benefits (COB). This segment is not used if the line level (Loop ID-2430) Remaining Patient Liability AMT segment is used for this Other Payer. Example AMT*EAF*000000000~ Variants (all may be used) AMT Coordination of Benefits (COB) Payer Paid Amount AMT Coordination of Benefits (COB) Total Non-Covered Amount Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount EAF Amount Owed AMT-02 782 Remaining Patient Liability Min 1 Max 15 Decimal number (R) Required Monetary amount 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 224/579 OI 3100 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > OI Other Insurance Coverage Information To specify information associated with other health insurance coverage Usage notes All information contained in the OI segment applies only to the payer identified in Loop ID-2330B in this iteration of Loop ID-2320. Example OI***W***I~ Max use 1 Required OI-03 1073 Benefits Assignment Certification Indicator Identifier (ID) Required Code indicating a Yes or No condition or response OI03 is the assignment of benefits indicator. A "Y" value indicates insured or authorized person authorizes benefits to be assigned to the provider; an "N" value indicates benefits have not been assigned to the provider. Usage notes This is a crosswalk from CLM08 when doing COB. This element answers the question whether or not the insured has authorized the plan to remit payment directly to the provider. N No W Not Applicable Use code `W' when the patient refuses to assign benefits. Y Yes OI-06 1363 Release of Information Code Identifier (ID) Required Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations Usage notes This is a crosswalk from CLM09 when doing COB. The Release of Information response is limited to the information carried in this claim. I Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes Required when the provider has not collected a signature AND state or federal laws do not require a signature be collected. Y Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim Required when the provider has collected a signature. OR Required when state or federal laws require a signature be collected. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 225/579 MIA 3150 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > MIA Inpatient Adjudication Information To provide claim-level data related to the adjudication of Medicare inpatient claims Usage notes Required when inpatient adjudication information is reported in the remittance advice. OR Required when it is necessary to report remark codes. If not required by this implementation guide, do not send. Example MIA*0000**0000000*0000*X*000000000000*000000*0000 00*00*000*000000000*0*0*000*0000*0*000000*0000000 000*00000000*X*XXXX*XXX*XXX*000000000~ Max use 1 Optional MIA-01 380 Covered Days or Visits | Health Partner Plans 837 Health Care Claim_ Institutional.pdf |
It is not used in Payer-to-Payer Coordination of Benefits (COB). This segment is not used if the line level (Loop ID-2430) Remaining Patient Liability AMT segment is used for this Other Payer. Example AMT*EAF*000000000~ Variants (all may be used) AMT Coordination of Benefits (COB) Payer Paid Amount AMT Coordination of Benefits (COB) Total Non-Covered Amount Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount EAF Amount Owed AMT-02 782 Remaining Patient Liability Min 1 Max 15 Decimal number (R) Required Monetary amount 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 224/579 OI 3100 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > OI Other Insurance Coverage Information To specify information associated with other health insurance coverage Usage notes All information contained in the OI segment applies only to the payer identified in Loop ID-2330B in this iteration of Loop ID-2320. Example OI***W***I~ Max use 1 Required OI-03 1073 Benefits Assignment Certification Indicator Identifier (ID) Required Code indicating a Yes or No condition or response OI03 is the assignment of benefits indicator. A "Y" value indicates insured or authorized person authorizes benefits to be assigned to the provider; an "N" value indicates benefits have not been assigned to the provider. Usage notes This is a crosswalk from CLM08 when doing COB. This element answers the question whether or not the insured has authorized the plan to remit payment directly to the provider. N No W Not Applicable Use code `W' when the patient refuses to assign benefits. Y Yes OI-06 1363 Release of Information Code Identifier (ID) Required Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations Usage notes This is a crosswalk from CLM09 when doing COB. The Release of Information response is limited to the information carried in this claim. I Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes Required when the provider has not collected a signature AND state or federal laws do not require a signature be collected. Y Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim Required when the provider has collected a signature. OR Required when state or federal laws require a signature be collected. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 225/579 MIA 3150 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > MIA Inpatient Adjudication Information To provide claim-level data related to the adjudication of Medicare inpatient claims Usage notes Required when inpatient adjudication information is reported in the remittance advice. OR Required when it is necessary to report remark codes. If not required by this implementation guide, do not send. Example MIA*0000**0000000*0000*X*000000000000*000000*0000 00*00*000*000000000*0*0*000*0000*0*000000*0000000 000*00000000*X*XXXX*XXX*XXX*000000000~ Max use 1 Optional MIA-01 380 Covered Days or Visits Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity MIA01 is the covered days. MIA-03 380 Lifetime Psychiatric Days Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity MIA03 is the lifetime psychiatric days. MIA-04 782 Claim DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA04 is the Diagnosis Related Group (DRG) amount. MIA-05 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA05 is the Claim Payment Remark Code. See Code Source 411. MIA-06 782 Claim Disproportionate Share Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 226/579 MIA06 is the disproportionate share amount. MIA-07 782 Claim MSP Pass-through Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA07 is the Medicare Secondary Payer (MSP) pass-through amount. MIA-08 782 Claim PPS Capital Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA08 is the total Prospective Payment System (PPS) capital amount. MIA-09 782 PPS-Capital FSP DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA09 is the Prospective Payment System (PPS) capital, federal specific portion, Diagnosis Related Group (DRG) amount. MIA-10 782 PPS-Capital HSP DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA10 is the Prospective Payment System (PPS) capital, hospital specific portion, Diagnosis Related Group (DRG), amount. MIA-11 782 PPS-Capital DSH DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA11 is the Prospective Payment System (PPS) capital, disproportionate share, hospital Diagnosis Related Group (DRG) amount. MIA-12 782 Old Capital Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA12 is the old capital amount. MIA-13 782 PPS-Capital IME amount Min 1 Max 15 Decimal number (R) Optional Monetary amount 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 227/579 MIA13 is the Prospective Payment System (PPS) capital indirect medical education claim amount. MIA-14 782 PPS-Operating Hospital Specific DRG Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA14 is hospital specific Diagnosis Related Group (DRG) Amount. MIA-15 380 Cost Report Day Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity MIA15 is the cost report days. MIA-16 782 PPS-Operating Federal Specific DRG Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA16 is the federal specific Diagnosis Related Group (DRG) amount. MIA-17 782 Claim PPS Capital Outlier Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA17 is the Prospective Payment System (PPS) Capital Outlier amount. MIA-18 782 Claim Indirect Teaching Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA18 is the indirect teaching amount. MIA-19 782 Non-Payable Professional Component Billed Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA19 is the professional component amount billed but not payable. MIA-20 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 228/579 MIA20 is the Claim Payment Remark Code. See Code Source 411. MIA-21 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA21 is the Claim Payment Remark Code. See Code Source 411. MIA-22 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA22 is the Claim Payment Remark Code. See Code Source 411. MIA-23 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA23 is the Claim Payment Remark Code. See Code Source 411. MIA-24 782 PPS-Capital Exception Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA24 is the capital exception amount. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 229/579 MOA 3200 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > MOA Outpatient Adjudication Information To convey claim-level data related to the adjudication of Medicare claims not related to an inpatient setting Usage notes Required when outpatient adjudication information is reported in the remittance advice OR Required when it is necessary to report remark codes. If not required by this implementation guide, do not send. Example MOA*0*000*XX*XXXXXX*XXXX*XX*XXXX*000000000*000000 000~ Max use 1 Optional MOA-01 954 Reimbursement Rate Min 1 Max 10 Decimal number (R) Optional Percentage expressed as a decimal (e.g., 0.0 through 1.0 represents 0% through 100%) MOA01 is the reimbursement rate. MOA-02 782 HCPCS Payable Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MOA02 is the claim Health Care Financing Administration Common Procedural Coding System (HCPCS) payable amount. MOA-03 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA03 is the Claim Payment Remark Code. See Code Source 411. MOA-04 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA04 is the Claim Payment Remark Code. See Code Source 411. MOA-05 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 230/579 MOA05 is the Claim Payment Remark Code. See Code Source 411. MOA-06 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA06 is the Claim Payment Remark Code. See Code Source 411. MOA-07 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA07 is the Claim Payment Remark Code. See Code Source 411. MOA-08 782 End Stage Renal Disease Payment Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MOA08 is the End Stage Renal Disease (ESRD) payment amount. MOA-09 782 Non-Payable Professional Component Billed Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MOA09 is the professional component amount billed but not payable. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 231/579 2330A Other Subscriber Name Loop Max 1 Required Variants (all may be used) Other Payer Name Loop Other Payer Attending Provider Loop Other Payer Operating Physician Loop Other Payer Other Operating Physician Loop Other Payer Service Facility Location Loop Other Payer Rendering Provider Name Loop Other Payer Referring Provider Loop Other Payer Billing Provider Loop NM1 3250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Subscriber Name Loop > NM1 Other Subscriber Name To supply the full name of an individual or organizational entity Usage notes If the patient can be uniquely identified to the Other Payer indicated in this iteration of Loop ID-2320 by a unique Member Identification Number, then the patient is the subscriber or is considered to be the subscriber and is identified in this Other Subscriber's Name Loop ID-2330A.; If the patient is a dependent of the subscriber for this other coverage and cannot be uniquely identified to the Other Payer indicated in this iteration of Loop ID-2320 by a unique Member Identification Number, then the subscriber for this other coverage is identified in this Other Subscriber's Name Loop ID-2330A. See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example NM1*IL*1*X*XXXXX*XXXXXX**XXXXX*II*XXXX~ Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual IL Insured or Subscriber NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Other Insured Last Name Min 1 Max 60 String (AN) Required 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 232/579 Individual last name or organizational name NM1-04 1036 Other Insured First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Other Insured Middle Name Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Other Insured Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) | Health Partner Plans 837 Health Care Claim_ Institutional.pdf |
Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA06 is the Claim Payment Remark Code. See Code Source 411. MOA-07 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA07 is the Claim Payment Remark Code. See Code Source 411. MOA-08 782 End Stage Renal Disease Payment Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MOA08 is the End Stage Renal Disease (ESRD) payment amount. MOA-09 782 Non-Payable Professional Component Billed Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MOA09 is the professional component amount billed but not payable. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 231/579 2330A Other Subscriber Name Loop Max 1 Required Variants (all may be used) Other Payer Name Loop Other Payer Attending Provider Loop Other Payer Operating Physician Loop Other Payer Other Operating Physician Loop Other Payer Service Facility Location Loop Other Payer Rendering Provider Name Loop Other Payer Referring Provider Loop Other Payer Billing Provider Loop NM1 3250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Subscriber Name Loop > NM1 Other Subscriber Name To supply the full name of an individual or organizational entity Usage notes If the patient can be uniquely identified to the Other Payer indicated in this iteration of Loop ID-2320 by a unique Member Identification Number, then the patient is the subscriber or is considered to be the subscriber and is identified in this Other Subscriber's Name Loop ID-2330A.; If the patient is a dependent of the subscriber for this other coverage and cannot be uniquely identified to the Other Payer indicated in this iteration of Loop ID-2320 by a unique Member Identification Number, then the subscriber for this other coverage is identified in this Other Subscriber's Name Loop ID-2330A. See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example NM1*IL*1*X*XXXXX*XXXXXX**XXXXX*II*XXXX~ Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual IL Insured or Subscriber NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Other Insured Last Name Min 1 Max 60 String (AN) Required 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 232/579 Individual last name or organizational name NM1-04 1036 Other Insured First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Other Insured Middle Name Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Other Insured Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system/method of code structure used for Identification Code (67) II Standard Unique Health Identifier for each Individual in the United States Required if the HIPAA Individual Patient Identifier is mandated use. If not required, use value `MI' instead. MI Member Identification Number The code MI is intended to be the subscriber's identification number as assigned by the payer. (For example, Insured's ID, Subscriber's ID, Health Insurance Claim Number (HIC), etc.) MI is also intended to be used in claims submitted to the Indian Health Service/Contract Health Services (IHS/CHS) Fiscal Intermediary for the purpose of reporting the Tribe Residency Code (Tribe County State). In the event that a Social Security Number (SSN) is also available on an IHS/CHS claim, put the SSN in REF02. When sending the Social Security Number as the Member ID, it must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid. NM1-09 67 Other Insured Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 233/579 N3 3320 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Subscriber Name Loop > N3 Other Subscriber Address To specify the location of the named party Usage notes Required when the information is available. If not required by this implementation guide, do not send. Example N3*XXX*XXXX~ Max use 1 Optional N3-01 166 Other Insured Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Other Insured Address Line Min 1 Max 55 String (AN) Optional Address information 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 234/579 N4 3400 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Subscriber Name Loop > N4 Other Subscriber City, State, ZIP Code To specify the geographic place of the named party Usage notes Required when the information is available. If not required by this implementation guide, do not send. Example N4*XXXXXX*XX*XXXXXXXX*XX~ Only one of Other Insured State Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Optional N4-01 19 Other Insured City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Other Insured State Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State/Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Other Insured Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 235/579 Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 236/579 2330A Other Subscriber Name Loop end REF 3550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Subscriber Name Loop > REF Other Subscriber Secondary Identification To specify identifying information Usage notes Required when an additional identification number to that provided in NM109 of this loop is necessary for the claim processor to identify the entity. If not required by this implementation guide, do not send. Example REF*SY*XXXX~ Max use 2 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification SY Social Security Number The Social Security Number must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid. REF-02 127 Other Insured Additional Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 237/579 2330B Other Payer Name Loop Max 1 Required Variants (all may be used) Other Subscriber Name Loop Other Payer Attending Provider Loop Other Payer Operating Physician Loop Other Payer Other Operating Physician Loop Other Payer Service Facility Location Loop Other Payer Rendering Provider Name Loop Other Payer Referring Provider Loop Other Payer Billing Provider Loop NM1 3250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > NM1 Other Payer Name To supply the full name of an individual or organizational entity Usage notes See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example NM1*PR*2*XXXXXX*****PI*XXXXX~ Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PR Payer NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Other Payer Last or Organization Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system/method of code structure used for Identification Code (67) Usage notes 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 238/579 Use code value "PI" when reporting Payor Identification. Use code value "XV" when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). Prior to the mandated implementation date for Health Plan Identifier, willing trading partners may agree to: Follow a dual use approach in which both the HPID or OEID and the Payor Identification are sent. Send XV qualifier in NM108 with HPID or OEID in NM109 and the Payor Identification, that would have been sent using qualifier PI, in the corresponding REF segment using qualifier 2U (Payer Identification Number). OR Follow an early implementation approach in which the HPID or OEID is sent in NM109. PI Payor Identification XV Centers for Medicare and Medicaid Services PlanID NM1-09 67 Other Payer Primary Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code Usage notes When sending Line Adjudication Information for this payer, the identifier sent in SVD01 (Payer Identifier) of Loop ID-2430 (Line Adjudication Information) must match this value.; 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 239/579 N3 3320 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > N3 Other Payer Address To specify the location of the named party Usage notes Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send. Example N3*XXXXXX*XXXX~ Max use 1 Optional N3-01 166 Other Payer Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Other Payer Address Line Min 1 Max 55 String (AN) Optional Address information 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 240/579 N4 3400 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > N4 Other Payer City, State, ZIP Code To specify the geographic place of the named party Usage notes Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send. Example N4*XX*XX*XXXX*XX~ Only one of Other Payer State Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Optional N4-01 19 Other Payer City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Other Payer State Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State/Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Other Payer Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) | Health Partner Plans 837 Health Care Claim_ Institutional.pdf |
reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). Prior to the mandated implementation date for Health Plan Identifier, willing trading partners may agree to: Follow a dual use approach in which both the HPID or OEID and the Payor Identification are sent. Send XV qualifier in NM108 with HPID or OEID in NM109 and the Payor Identification, that would have been sent using qualifier PI, in the corresponding REF segment using qualifier 2U (Payer Identification Number). OR Follow an early implementation approach in which the HPID or OEID is sent in NM109. PI Payor Identification XV Centers for Medicare and Medicaid Services PlanID NM1-09 67 Other Payer Primary Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code Usage notes When sending Line Adjudication Information for this payer, the identifier sent in SVD01 (Payer Identifier) of Loop ID-2430 (Line Adjudication Information) must match this value.; 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 239/579 N3 3320 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > N3 Other Payer Address To specify the location of the named party Usage notes Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send. Example N3*XXXXXX*XXXX~ Max use 1 Optional N3-01 166 Other Payer Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Other Payer Address Line Min 1 Max 55 String (AN) Optional Address information 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 240/579 N4 3400 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > N4 Other Payer City, State, ZIP Code To specify the geographic place of the named party Usage notes Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send. Example N4*XX*XX*XXXX*XX~ Only one of Other Payer State Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Optional N4-01 19 Other Payer City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Other Payer State Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State/Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Other Payer Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 241/579 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 242/579 DTP 3500 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > DTP Claim Check or Remittance Date To specify any or all of a date, a time, or a time period Usage notes Required when the payer identified in this loop has previously adjudicated the claim and Loop ID-2430, Line Check or Remittance Date, is not used. If not required by this implementation guide, do not send.; Example DTP*573*D8*XXXXX~ Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 573 Date Claim Paid DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Adjudication or Payment Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 243/579 REF 3550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > REF Other Payer Claim Adjustment Indicator To specify identifying information Usage notes Required when the claim is being sent in the payer-to-payer COB model, AND the destination payer is secondary to the payer identified in this Loop ID-2330B, AND the payer identified in this Loop ID-2330B has re-adjudicated the claim. If not required by this implementation guide, do not send. Example REF*T4*XXXXX~ Variants (all may be used) REF Other Payer Claim Control Number REF Other Payer Prior Authorization Number REF Other Payer Referral Number REF Other Payer Secondary Identifier Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification T4 Signal Code REF-02 127 Other Payer Claim Adjustment Indicator Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes Only allowed value is "Y". 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 244/579 REF 3550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > REF Other Payer Claim Control Number To specify identifying information Usage notes Required when it is necessary to identify the Other Payer's Claim Control Number in a payer-to-payer COB situation. OR Required when the Other Payer's Claim Control Number is available. If not required by this implementation guide, do not send. Example REF*F8*XX~ Variants (all may be used) REF Other Payer Claim Adjustment Indicator REF Other Payer Prior Authorization Number REF Other Payer Referral Number REF Other Payer Secondary Identifier Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification F8 Original Reference Number This is the payer's internal Claim Control Number for this claim for the payer identified in this iteration of Loop ID-2330. This value is typically used in payer-to-payer COB situations only. REF-02 127 Other Payer's Claim Control Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 245/579 REF 3550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > REF Other Payer Prior Authorization Number To specify identifying information Usage notes Required when the payer identified in this loop has assigned a prior authorization number to this claim. If not required by this implementation guide, do not send. Example REF*G1*X~ Variants (all may be used) REF Other Payer Claim Adjustment Indicator REF Other Payer Claim Control Number REF Other Payer Referral Number REF Other Payer Secondary Identifier Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification G1 Prior Authorization Number REF-02 127 Other Payer Prior Authorization Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 246/579 REF 3550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > REF Other Payer Referral Number To specify identifying information Usage notes Required when the payer identified in this loop has assigned a referral number to this claim. If not required by this implementation guide, do not send. Example REF*9F*XXXXXX~ Variants (all may be used) REF Other Payer Claim Adjustment Indicator REF Other Payer Claim Control Number REF Other Payer Prior Authorization Number REF Other Payer Secondary Identifier Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9F Referral Number REF-02 127 Other Payer Prior Authorization or Referral Number String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 247/579 2330B Other Payer Name Loop end REF 3550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > REF Other Payer Secondary Identifier To specify identifying information Usage notes Required when an additional identification number to that provided in the NM109 of this loop is necessary to identify the entity. If not required by this implementation guide, do not send. Example REF*2U*XX~ Variants (all may be used) REF Other Payer Claim Adjustment Indicator REF Other Payer Claim Control Number REF Other Payer Prior Authorization Number REF Other Payer Referral Number Max use 2 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number This code is only allowed when the qualifier XV is reported in NM108 of this loop. EI Employer's Identification Number The Employer's Identification Number must be a string of exactly nine numbers with no separators. For example, "001122333" would be valid, while sending "001-12-2333" or "00-1122333" would be invalid. FY Claim Office Number NF National Association of Insurance Commissioners (NAIC) Code REF-02 127 Other Payer Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 248/579 2330C Other Payer Attending Provider Loop Max 1 Optional Variants (all may be used) Other Subscriber Name Loop Other Payer Name Loop Other Payer Operating Physician Loop Other Payer Other Operating Physician Loop Other Payer Service Facility Location Loop Other Payer Rendering Provider Name Loop Other Payer Referring Provider Loop Other Payer Billing Provider Loop NM1 3250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Attending Provider Loop > NM1 Other Payer Attending Provider To supply the full name of an individual or organizational entity Usage notes Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. If not required by this implementation guide, do not send. See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example NM1*71*1~ Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual | Health Partner Plans 837 Health Care Claim_ Institutional.pdf |
Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 247/579 2330B Other Payer Name Loop end REF 3550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > REF Other Payer Secondary Identifier To specify identifying information Usage notes Required when an additional identification number to that provided in the NM109 of this loop is necessary to identify the entity. If not required by this implementation guide, do not send. Example REF*2U*XX~ Variants (all may be used) REF Other Payer Claim Adjustment Indicator REF Other Payer Claim Control Number REF Other Payer Prior Authorization Number REF Other Payer Referral Number Max use 2 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number This code is only allowed when the qualifier XV is reported in NM108 of this loop. EI Employer's Identification Number The Employer's Identification Number must be a string of exactly nine numbers with no separators. For example, "001122333" would be valid, while sending "001-12-2333" or "00-1122333" would be invalid. FY Claim Office Number NF National Association of Insurance Commissioners (NAIC) Code REF-02 127 Other Payer Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 248/579 2330C Other Payer Attending Provider Loop Max 1 Optional Variants (all may be used) Other Subscriber Name Loop Other Payer Name Loop Other Payer Operating Physician Loop Other Payer Other Operating Physician Loop Other Payer Service Facility Location Loop Other Payer Rendering Provider Name Loop Other Payer Referring Provider Loop Other Payer Billing Provider Loop NM1 3250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Attending Provider Loop > NM1 Other Payer Attending Provider To supply the full name of an individual or organizational entity Usage notes Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. If not required by this implementation guide, do not send. See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example NM1*71*1~ Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 71 Attending Physician NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 249/579 1 Person 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 250/579 2330C Other Payer Attending Provider Loop end REF 3550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Attending Provider Loop > REF Other Payer Attending Provider Secondary Identification To specify identifying information Usage notes Non-destination (COB) payer's provider identification number(s). See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example REF*G2*XXXXX~ Max use 4 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan. LU Location Number REF-02 127 Other Payer Attending Provider Secondary Identifier String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 251/579 2330D Other Payer Operating Physician Loop Max 1 Optional Variants (all may be used) Other Subscriber Name Loop Other Payer Name Loop Other Payer Attending Provider Loop Other Payer Other Operating Physician Loop Other Payer Service Facility Location Loop Other Payer Rendering Provider Name Loop Other Payer Referring Provider Loop Other Payer Billing Provider Loop NM1 3250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Operating Physician Loop > NM1 Other Payer Operating Physician To supply the full name of an individual or organizational entity Usage notes Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. If not required by this implementation guide, do not send. See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example NM1*72*1~ Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 72 Operating Physician NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 252/579 1 Person 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 253/579 2330D Other Payer Operating Physician Loop end REF 3550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Operating Physician Loop > REF Other Payer Operating Physician Secondary Identification To specify identifying information Usage notes Non-destination (COB) payer's provider identification number(s). See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example REF*0B*XXXXX~ Max use 4 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan. LU Location Number REF-02 127 Other Payer Operating Provider Secondary Identifier String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 254/579 2330E Other Payer Other Operating Physician Loop Max 1 Optional Variants (all may be used) Other Subscriber Name Loop Other Payer Name Loop Other Payer Attending Provider Loop Other Payer Operating Physician Loop Other Payer Service Facility Location Loop Other Payer Rendering Provider Name Loop Other Payer Referring Provider Loop Other Payer Billing Provider Loop NM1 3250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Other Operating Physician Loop > NM1 Other Payer Other Operating Physician To supply the full name of an individual or organizational entity Usage notes Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. If not required by this implementation guide, do not send. See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example NM1*ZZ*1~ Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual ZZ Mutually Defined ZZ is used to indicate Other Operating Physician. NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 255/579 1 Person 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 256/579 2330E Other Payer Other Operating Physician Loop end REF 3550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Other Operating Physician Loop > REF Other Payer Other Operating Physician Secondary Identification To specify identifying information Usage notes Non-destination (COB) payer's provider identification number(s). See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example REF*0B*XXX~ Max use 4 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan. LU Location Number REF-02 127 Other Payer Other Operating Physician Secondary Identifier String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 257/579 2330F Other Payer Service Facility Location Loop Max 1 Optional Variants (all may be used) Other Subscriber Name Loop Other Payer Name Loop Other Payer Attending Provider Loop Other Payer Operating Physician Loop Other Payer Other Operating Physician Loop Other Payer Rendering Provider Name Loop Other Payer Referring Provider Loop Other Payer Billing Provider Loop NM1 3250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Service Facility Location Loop > NM1 Other Payer Service Facility Location To supply the full name of an individual or organizational entity Usage notes Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. If not required by this implementation guide, do not send. See | Health Partner Plans 837 Health Care Claim_ Institutional.pdf |
Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual ZZ Mutually Defined ZZ is used to indicate Other Operating Physician. NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 255/579 1 Person 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 256/579 2330E Other Payer Other Operating Physician Loop end REF 3550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Other Operating Physician Loop > REF Other Payer Other Operating Physician Secondary Identification To specify identifying information Usage notes Non-destination (COB) payer's provider identification number(s). See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example REF*0B*XXX~ Max use 4 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan. LU Location Number REF-02 127 Other Payer Other Operating Physician Secondary Identifier String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 257/579 2330F Other Payer Service Facility Location Loop Max 1 Optional Variants (all may be used) Other Subscriber Name Loop Other Payer Name Loop Other Payer Attending Provider Loop Other Payer Operating Physician Loop Other Payer Other Operating Physician Loop Other Payer Rendering Provider Name Loop Other Payer Referring Provider Loop Other Payer Billing Provider Loop NM1 3250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Service Facility Location Loop > NM1 Other Payer Service Facility Location To supply the full name of an individual or organizational entity Usage notes Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. If not required by this implementation guide, do not send. See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example NM1*77*2~ Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 77 Service Location NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 258/579 2 Non-Person Entity 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 259/579 2330F Other Payer Service Facility Location Loop end REF 3550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Service Facility Location Loop > REF Other Payer Service Facility Location Secondary Identification To specify identifying information Usage notes Non-destination (COB) payer's provider identification number(s). See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example REF*G2*XXX~ Max use 3 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number G2 Provider Commercial Number This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan. LU Location Number REF-02 127 Other Payer Service Facility Location Identifier String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 260/579 2330G Other Payer Rendering Provider Name Loop Max 1 Optional Variants (all may be used) Other Subscriber Name Loop Other Payer Name Loop Other Payer Attending Provider Loop Other Payer Operating Physician Loop Other Payer Other Operating Physician Loop Other Payer Service Facility Location Loop Other Payer Referring Provider Loop Other Payer Billing Provider Loop NM1 3250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Rendering Provider Name Loop > NM1 Other Payer Rendering Provider Name To supply the full name of an individual or organizational entity Usage notes Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. If not required by this implementation guide, do not send. See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example NM1*82*1~ Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 82 Rendering Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 261/579 1 Person 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 262/579 2330G Other Payer Rendering Provider Name Loop end REF 3550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Rendering Provider Name Loop > REF Other Payer Rendering Provider Secondary Identification To specify identifying information Usage notes Non-destination (COB) payer's provider identification number(s). See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example REF*LU*X~ Max use 4 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan. LU Location Number REF-02 127 Other Payer Rendering Provider Secondary Identifier String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 263/579 2330H Other Payer Referring Provider Loop Max 1 Optional Variants (all may be used) Other Subscriber Name Loop Other Payer Name Loop Other Payer Attending Provider Loop Other Payer Operating Physician Loop Other Payer Other Operating Physician Loop Other Payer Service Facility Location Loop Other Payer Rendering Provider Name Loop Other Payer Billing Provider Loop NM1 3250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Referring Provider Loop > NM1 Other Payer Referring Provider To supply the full name of an individual or organizational entity Usage notes Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. If not required by this implementation guide, do not send. See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example NM1*DN*1~ Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual DN Referring Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 264/579 1 Person 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 265/579 2330H Other Payer Referring Provider Loop end REF 3550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Referring Provider Loop > REF Other Payer Referring Provider Secondary Identification To specify identifying information Usage notes Non-destination (COB) payer's provider identification number(s). See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example REF*0B*XX~ Max use 3 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan. REF-02 127 Other Payer Referring Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 266/579 2330I Other Payer Billing Provider Loop Max 1 Optional Variants (all may be used) Other Subscriber Name Loop Other Payer Name Loop Other Payer Attending Provider Loop Other Payer Operating Physician Loop Other Payer Other Operating Physician Loop Other Payer Service Facility Location Loop Other Payer Rendering Provider Name Loop Other Payer Referring Provider Loop NM1 3250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Billing Provider Loop > NM1 Other Payer Billing Provider To supply the full name of an individual or organizational entity Usage notes Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) | Health Partner Plans 837 Health Care Claim_ Institutional.pdf |
If not required by this implementation guide, do not send. See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example NM1*DN*1~ Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual DN Referring Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 264/579 1 Person 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 265/579 2330H Other Payer Referring Provider Loop end REF 3550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Referring Provider Loop > REF Other Payer Referring Provider Secondary Identification To specify identifying information Usage notes Non-destination (COB) payer's provider identification number(s). See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example REF*0B*XX~ Max use 3 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan. REF-02 127 Other Payer Referring Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 266/579 2330I Other Payer Billing Provider Loop Max 1 Optional Variants (all may be used) Other Subscriber Name Loop Other Payer Name Loop Other Payer Attending Provider Loop Other Payer Operating Physician Loop Other Payer Other Operating Physician Loop Other Payer Service Facility Location Loop Other Payer Rendering Provider Name Loop Other Payer Referring Provider Loop NM1 3250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Billing Provider Loop > NM1 Other Payer Billing Provider To supply the full name of an individual or organizational entity Usage notes Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. If not required by this implementation guide, do not send. See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example NM1*85*2~ Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 85 Billing Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 267/579 2 Non-Person Entity 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 268/579 2330I Other Payer Billing Provider Loop end 2320 Other Subscriber Information Loop end REF 3550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Billing Provider Loop > REF Other Payer Billing Provider Secondary Identification To specify identifying information Usage notes See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example REF*G2*XXXXXX~ Max use 2 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification G2 Provider Commercial Number This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan. LU Location Number REF-02 127 Other Payer Billing Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 269/579 2400 Service Line Number Loop Max 999 Required LX 3650 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > LX Service Line Number To reference a line number in a transaction set Usage notes The LX functions as a line counter. The Service Line LX segment must begin with one and is incremented by one for each additional service line of a claim. LX01 is used to indicate bundling in SVD06 in the Line Item Adjudication loop. See Section 1.4.1.2 for more information on bundling and unbundling. Example LX*000~ Max use 1 Required LX-01 554 Assigned Number Min 1 Max 6 Numeric (N0) Required Number assigned for differentiation within a transaction set 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 270/579 SV2 3750 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > SV2 Institutional Service Line To specify the service line item detail for a health care institution Example SV2*XXXXX*HP>XX>XX>XX>XX>XX>XX*000000000000*DA*0* *000000000000~ Max use 1 Required SV2-01 234 Service Line Revenue Code Min 1 Max 48 String (AN) Required Identifying number for a product or service SV201 is the revenue code. Usage notes See Code Source 132: National Uniform Billing Committee (NUBC) Codes. SV2-02 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers Usage notes Required for outpatient claims when an appropriate procedure code exists for this service line item. OR Required for inpatient claims when an appropriate HCPCS (drugs and/or biologics only) or HIPPS code exists for this service line item. If not required by this implementation guide, do not send.; Max use 1 Optional C003-01 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type/source of the descriptive number used in Product/Service ID (234) C003-01 qualifies C003-02 and C003-08. ER Jurisdiction Specific Procedure and Supply Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the Jurisdiction Specific Procedure and Supply Codes as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC. HP Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code IV Home Infusion EDI Coalition (HIEC) Product/Service Code 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 271/579 This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the Home Infusion EDI Coalition (HIEC) Product/Service Codes as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA.; WK Advanced Billing Concepts (ABC) Codes At the time of this writing, this code set has been approved by the Secretary of HHS as a pilot project allowed under HIPAA law. The qualifier may only be used in transactions covered under HIPAA; By parties registered in the pilot project and their trading partners, OR If a new rule names the Complementary, Alternative, or Holistic Procedure Codes as an allowable code set under HIPAA, OR For claims which are not covered under HIPAA. C003-02 234 Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. C003-03 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-03 modifies the value in C003-02 and C003-08. C003-04 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-04 modifies the value in C003-02 and C003-08. C003-05 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-05 modifies the value in C003-02 and C003-08. C003-06 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 272/579 This identifies special circumstances related to the performance of the service, as defined by trading partners C003-06 modifies the value in C003-02 and C003-08. C003-07 352 Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content C003-07 is the description of the procedure identified in C003-02. SV2-03 782 Line Item Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SV203 is the submitted service line item amount. Usage notes This is the total charge amount for this service line. The amount is inclusive of the provider's base charge and any applicable tax amounts reported within this line's AMT segments. Zero "0" is an acceptable value for this element. SV2-04 355 Unit or Basis for Measurement Code Identifier (ID) Required Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken DA Days UN Unit SV2-05 380 Service Unit Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity Usage notes The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three. SV2-07 782 Line Item Denied Charge or Non-Covered Charge Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount SV207 is a non-covered service amount. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 273/579 PWK 4200 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > PWK Line Supplemental Information To identify the type or transmission or both of paperwork or supporting information Usage notes Required when there is a paper attachment following this claim. OR Required when attachments are sent electronically (PWK02 = EL) but are transmitted in another functional group (for example, 275) rather than by paper. PWK06 is then used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment. OR Required when the provider deems it necessary to identify additional information that is being held at the provider's office and is available upon request by the payer (or appropriate entity), but the information is not being submitted with the claim. Use the value of "AA" in PWK02 to convey this specific use of the PWK segment. If not required by this implementation guide, do not send. Example PWK*CK*AA***AC*XXXXXXX~ If either Identification Code Qualifier (PWK-05) or Attachment Control Number (PWK-06) is present, then the other | Health Partner Plans 837 Health Care Claim_ Institutional.pdf |
as defined by trading partners C003-04 modifies the value in C003-02 and C003-08. C003-05 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-05 modifies the value in C003-02 and C003-08. C003-06 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 272/579 This identifies special circumstances related to the performance of the service, as defined by trading partners C003-06 modifies the value in C003-02 and C003-08. C003-07 352 Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content C003-07 is the description of the procedure identified in C003-02. SV2-03 782 Line Item Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SV203 is the submitted service line item amount. Usage notes This is the total charge amount for this service line. The amount is inclusive of the provider's base charge and any applicable tax amounts reported within this line's AMT segments. Zero "0" is an acceptable value for this element. SV2-04 355 Unit or Basis for Measurement Code Identifier (ID) Required Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken DA Days UN Unit SV2-05 380 Service Unit Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity Usage notes The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three. SV2-07 782 Line Item Denied Charge or Non-Covered Charge Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount SV207 is a non-covered service amount. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 273/579 PWK 4200 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > PWK Line Supplemental Information To identify the type or transmission or both of paperwork or supporting information Usage notes Required when there is a paper attachment following this claim. OR Required when attachments are sent electronically (PWK02 = EL) but are transmitted in another functional group (for example, 275) rather than by paper. PWK06 is then used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment. OR Required when the provider deems it necessary to identify additional information that is being held at the provider's office and is available upon request by the payer (or appropriate entity), but the information is not being submitted with the claim. Use the value of "AA" in PWK02 to convey this specific use of the PWK segment. If not required by this implementation guide, do not send. Example PWK*CK*AA***AC*XXXXXXX~ If either Identification Code Qualifier (PWK-05) or Attachment Control Number (PWK-06) is present, then the other is required Max use 10 Optional PWK-01 755 Attachment Report Type Code Identifier (ID) Required Code indicating the title or contents of a document, report or supporting item 03 Report Justifying Treatment Beyond Utilization Guidelines 04 Drugs Administered 05 Treatment Diagnosis 06 Initial Assessment 07 Functional Goals 08 Plan of Treatment 09 Progress Report 10 Continued Treatment 11 Chemical Analysis 13 Certified Test Report 15 Justification for Admission 21 Recovery Plan A3 Allergies/Sensitivities Document A4 Autopsy Report AM Ambulance Certification AS Admission Summary B2 Prescription B3 Physician Order B4 Referral Form BR Benchmark Testing Results BS Baseline BT Blanket Test Results CB Chiropractic Justification 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 274/579 CK Consent Form(s) CT Certification D2 Drug Profile Document DA Dental Models DB Durable Medical Equipment Prescription DG Diagnostic Report DJ Discharge Monitoring Report DS Discharge Summary EB Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payor) HC Health Certificate HR Health Clinic Records I5 Immunization Record IR State School Immunization Records LA Laboratory Results M1 Medical Record Attachment MT Models NN Nursing Notes OB Operative Note OC Oxygen Content Averaging Report OD Orders and Treatments Document OE Objective Physical Examination (including vital signs) Document OX Oxygen Therapy Certification OZ Support Data for Claim P4 Pathology Report P5 Patient Medical History Document PE Parenteral or Enteral Certification PN Physical Therapy Notes PO Prosthetics or Orthotic Certification PQ Paramedical Results PY Physician's Report PZ Physical Therapy Certification RB Radiology Films RR Radiology Reports RT Report of Tests and Analysis Report RX Renewable Oxygen Content Averaging Report SG Symptoms Document V5 Death Notification XP Photographs PWK-02 756 Attachment Transmission Code Identifier (ID) Required Code defining timing, transmission method or format by which reports are to be sent AA Available on Request at Provider Site This means that the additional information is not being sent with the claim at this time. Instead, it is available to the payer (or appropriate entity) at their request. BM By Mail EL Electronically Only Indicates that the attachment is being transmitted in a separate X12 functional group. EM E-Mail FT File Transfer 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 275/579 Required when the actual attachment is maintained by an attachment warehouse or similar vendor. FX By Fax PWK-05 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) PWK05 and PWK06 may be used to identify the addressee by a code number. AC Attachment Control Number PWK-06 67 Attachment Control Number Min 2 Max 80 String (AN) Optional Code identifying a party or other code Usage notes PWK06 is used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment. For the purpose of this implementation, the maximum field length is 50. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 276/579 DTP 4550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP Date - Service Date To specify any or all of a date, a time, or a time period Usage notes Required on outpatient service lines where a drug is not being billed and the Statement Covers Period is greater than one day. OR Required on service lines where a drug is being billed and the payer's adjudication is known to be impacted by the drug duration or the date the prescription was written. If not required by this implementation guide, do not send. In cases where a drug is being billed on a service line, date range may be used to indicate drug duration for which the drug supply will be used by the patient. The difference in dates, including both the begin and end dates, are the days supply of the drug. Example: 20000101 - 20000107 (1/1/00 to 1/7/00) is used for a 7 day supply where the first day of the drug used by the patient is 1/1/00. In the event a drug is administered on less than a daily basis (for example, every other day) the date range would include the entire period during which the drug was supplied, including the last day the drug was used. Example: 20000101 - 20000108 (1/1/00 to 1/8/00) is used for an 8 days supply where the prescription is written for Q48 (every 48 hours), four doses of the drug are dispensed and the first dose is used on 1/1/00. In cases where a drug is being billed on a service line, a single date may be used to indicate the date the prescription was written (or otherwise communicated by the prescriber if not written). Example DTP*472*RD8*XXXXX~ Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 472 Service DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. Usage notes RD8 is required only when the "To and From" dates are different. However, at the discretion of the submitter, RD8 can also be used when the "To and From" dates are the same. D8 Date Expressed in Format CCYYMMDD RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD DTP-03 1251 Service Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 277/579 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 278/579 REF 4700 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF Adjusted Repriced Line Item Reference Number To specify identifying information Usage notes Required when a repricing (pricing) organization needs to have an identifying number on an adjusted service line in their submission to their payer organization. This segment is not completed by providers. If not required by this implementation guide, do not send. Example REF*9D*XXXX~ Variants (all may be used) REF Line Item Control Number REF Repriced Line Item Reference Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9D Adjusted Repriced Line Item Reference Number REF-02 127 Adjusted Repriced Line Item Reference Number String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 279/579 REF 4700 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF Line Item Control Number To specify identifying information Usage notes Required when the submitter needs a line item control number for subsequent communications to or from the payer. If not required by this implementation guide, do not send. The line item control number must be unique within a patient control number (CLM01). Payers are required to return this number in the remittance advice transaction (835) if the provider sends it to them in the 837 and adjudication is based upon line item detail regardless of whether bundling or unbundling has occurred. Submitters are STRONGLY encouraged to routinely send a unique line item control number on all service lines, particularly if the submitter automatically posts their remittance advice. Submitting a unique line item control number allows the capability to automatically post by service line. Example REF*6R*XXXXXX~ Variants (all may be used) REF Adjusted Repriced Line Item Reference Number REF Repriced Line Item Reference Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 6R Provider Control Number REF-02 127 Line Item Control Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The maximum number of characters to be supported for this field is 30'. A submitter may submit fewer characters depending upon their needs. However, the HIPAA maximum requirement to be supported by any receiving system is 30'. Characters beyond 30 are not required to be stored nor returned by any 837-receiving system. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 280/579 REF 4700 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF Repriced Line Item Reference Number To specify identifying information Usage notes Required when a repricing (pricing) organization needs to have an identifying number on the service line in their submission to their payer organization. This segment is not completed by providers. If not required by this implementation guide, do not send. Example REF*9B*XXXXXX~ Variants (all may be used) REF Adjusted Repriced Line | Health Partner Plans 837 Health Care Claim_ Institutional.pdf |
an identifying number on an adjusted service line in their submission to their payer organization. This segment is not completed by providers. If not required by this implementation guide, do not send. Example REF*9D*XXXX~ Variants (all may be used) REF Line Item Control Number REF Repriced Line Item Reference Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9D Adjusted Repriced Line Item Reference Number REF-02 127 Adjusted Repriced Line Item Reference Number String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 279/579 REF 4700 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF Line Item Control Number To specify identifying information Usage notes Required when the submitter needs a line item control number for subsequent communications to or from the payer. If not required by this implementation guide, do not send. The line item control number must be unique within a patient control number (CLM01). Payers are required to return this number in the remittance advice transaction (835) if the provider sends it to them in the 837 and adjudication is based upon line item detail regardless of whether bundling or unbundling has occurred. Submitters are STRONGLY encouraged to routinely send a unique line item control number on all service lines, particularly if the submitter automatically posts their remittance advice. Submitting a unique line item control number allows the capability to automatically post by service line. Example REF*6R*XXXXXX~ Variants (all may be used) REF Adjusted Repriced Line Item Reference Number REF Repriced Line Item Reference Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 6R Provider Control Number REF-02 127 Line Item Control Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The maximum number of characters to be supported for this field is 30'. A submitter may submit fewer characters depending upon their needs. However, the HIPAA maximum requirement to be supported by any receiving system is 30'. Characters beyond 30 are not required to be stored nor returned by any 837-receiving system. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 280/579 REF 4700 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF Repriced Line Item Reference Number To specify identifying information Usage notes Required when a repricing (pricing) organization needs to have an identifying number on the service line in their submission to their payer organization. This segment is not completed by providers. If not required by this implementation guide, do not send. Example REF*9B*XXXXXX~ Variants (all may be used) REF Adjusted Repriced Line Item Reference Number REF Line Item Control Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9B Repriced Line Item Reference Number REF-02 127 Repriced Line Item Reference Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 281/579 AMT 4750 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > AMT Facility Tax Amount To indicate the total monetary amount Usage notes Required when a facility tax or surcharge applies to the service being reported in SV201 and the submitter is required to report that information to the receiver. If not required by this implementation guide, do not send. When reporting the Facility Tax Amount (AMT02), the amount reported in the Line Item Charge Amount (SV203) for this service line must include the amount reported in the Facility Tax Amount. Example AMT*N8*00000000~ Variants (all may be used) AMT Service Tax Amount Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount N8 Miscellaneous Taxes AMT-02 782 Facility Tax Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 282/579 AMT 4750 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > AMT Service Tax Amount To indicate the total monetary amount Usage notes Required when a service tax or surcharge applies to the service being reported in SV201 and the submitter is required to report that information to the receiver. If not required by this implementation guide, do not send. When reporting the Service Tax Amount (AMT02), the amount reported in the Line Item Charge Amount (SV203) for this service line must include the amount reported in the Service Tax Amount. Example AMT*GT*0~ Variants (all may be used) AMT Facility Tax Amount Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount GT Goods and Services Tax AMT-02 782 Service Tax Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 283/579 NTE 4850 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > NTE Third Party Organization Notes To transmit information in a free-form format, if necessary, for comment or special instruction Usage notes Required when the TPO/repricer needs to forward additional information to the payer. This segment is not completed by providers. If not required by this implementation guide, do not send. Example NTE*TPO*X~ Max use 1 Optional NTE-01 363 Note Reference Code Identifier (ID) Required Code identifying the functional area or purpose for which the note applies TPO Third Party Organization Notes NTE-02 352 Line Note Text Min 1 Max 80 String (AN) Required A free-form description to clarify the related data elements and their content 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 284/579 HCP 4920 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > HCP Line Pricing/Repricing Information To specify pricing or repricing information about a health care claim or line item Usage notes Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send. This information is specific to the destination payer reported in Loop ID-2010BB. For capitated encounters, pricing or repricing information usually is not applicable and is provided to qualify other information within the claim. Example HCP*09*00000000000*00000*XXXXX*00*XXXXXX*00000000 0000*XXXXX*IV*XXXX*UN*0*T6*3*1~ If either Product or Service ID Qualifier (HCP-09) or Repriced Approved HCPCS Code (HCP-10) is present, then the other is required If either Unit or Basis for Measurement Code (HCP-11) or Quantity (HCP-12) is present, then the other is required Max use 1 Optional HCP-01 1473 Pricing Methodology Identifier (ID) Required Code specifying pricing methodology at which the claim or line item has been priced or repriced Usage notes Specific code use is determined by Trading Partner Agreement due to the variances in contracting policies in the industry. 00 Zero Pricing (Not Covered Under Contract) 01 Priced as Billed at 100% 02 Priced at the Standard Fee Schedule 03 Priced at a Contractual Percentage 04 Bundled Pricing 05 Peer Review Pricing 06 Per Diem Pricing 07 Flat Rate Pricing 08 Combination Pricing 09 Maternity Pricing 10 Other Pricing 11 Lower of Cost 12 Ratio of Cost 13 Cost Reimbursed 14 Adjustment Pricing HCP-02 782 Monetary Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 285/579 HCP02 is the allowed amount. HCP-03 782 Monetary Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount HCP03 is the savings amount. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-04 127 Reference Identification Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier HCP04 is the repricing organization identification number. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-05 118 Rate Min 1 Max 9 Decimal number (R) Optional Rate expressed in the standard monetary denomination for the currency specified HCP05 is the pricing rate associated with per diem or flat rate repricing. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-06 127 Reference Identification Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier HCP06 is the approved DRG code. HCP06, HCP07, HCP08, HCP10, and HCP12 are fields that will contain different values from the original submitted values. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-07 782 Monetary Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount HCP07 is the approved DRG amount. Usage notes 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 286/579 This information is specific to the destination payer reported in Loop ID-2010BB. HCP-08 234 Product or Service ID Min 1 Max 48 String (AN) Optional Identifying number for a product or service HCP08 is the approved revenue code. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-09 235 Product or Service ID Qualifier Identifier (ID) Optional Code identifying the type/source of the descriptive number used in Product/Service ID (234) ER Jurisdiction Specific Procedure and Supply Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the Jurisdiction Specific Procedure and Supply Codes as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC. HP Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code IV Home Infusion EDI Coalition (HIEC) Product/Service Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the Home Infusion EDI Coalition (HIEC) Product/Service Codes as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA.; WK Advanced Billing Concepts (ABC) Codes At the time of this writing, this code set has been approved by the Secretary of HHS as a pilot project allowed under HIPAA law. The qualifier may only be used in transactions covered under HIPAA; By parties registered in the pilot project and their trading partners, OR If a new rule names the Complementary, Alternative, or Holistic Procedure Codes as an allowable code set under HIPAA, OR For claims which are not covered under HIPAA. HCP-10 234 Repriced Approved HCPCS Code Min 1 Max 48 String (AN) Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 287/579 Identifying number for a product or service HCP10 is the approved procedure code. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-11 355 Unit or Basis for Measurement Code Identifier (ID) Optional Code specifying the units in which a value is being expressed, or | Health Partner Plans 837 Health Care Claim_ Institutional.pdf |
Qualifier HCP06 is the approved DRG code. HCP06, HCP07, HCP08, HCP10, and HCP12 are fields that will contain different values from the original submitted values. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-07 782 Monetary Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount HCP07 is the approved DRG amount. Usage notes 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 286/579 This information is specific to the destination payer reported in Loop ID-2010BB. HCP-08 234 Product or Service ID Min 1 Max 48 String (AN) Optional Identifying number for a product or service HCP08 is the approved revenue code. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-09 235 Product or Service ID Qualifier Identifier (ID) Optional Code identifying the type/source of the descriptive number used in Product/Service ID (234) ER Jurisdiction Specific Procedure and Supply Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the Jurisdiction Specific Procedure and Supply Codes as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC. HP Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code IV Home Infusion EDI Coalition (HIEC) Product/Service Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the Home Infusion EDI Coalition (HIEC) Product/Service Codes as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA.; WK Advanced Billing Concepts (ABC) Codes At the time of this writing, this code set has been approved by the Secretary of HHS as a pilot project allowed under HIPAA law. The qualifier may only be used in transactions covered under HIPAA; By parties registered in the pilot project and their trading partners, OR If a new rule names the Complementary, Alternative, or Holistic Procedure Codes as an allowable code set under HIPAA, OR For claims which are not covered under HIPAA. HCP-10 234 Repriced Approved HCPCS Code Min 1 Max 48 String (AN) Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 287/579 Identifying number for a product or service HCP10 is the approved procedure code. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-11 355 Unit or Basis for Measurement Code Identifier (ID) Optional Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken DA Days UN Unit HCP-12 380 Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity HCP12 is the approved service units or inpatient days. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three. HCP-13 901 Reject Reason Code Identifier (ID) Optional Code assigned by issuer to identify reason for rejection HCP13 is the rejection message returned from the third party organization. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. T1 Cannot Identify Provider as TPO (Third Party Organization) Participant T2 Cannot Identify Payer as TPO (Third Party Organization) Participant T3 Cannot Identify Insured as TPO (Third Party Organization) Participant T4 Payer Name or Identifier Missing T5 Certification Information Missing T6 Claim does not contain enough information for re-pricing HCP-14 1526 Policy Compliance Code Identifier (ID) Optional Code specifying policy compliance Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. 1 Procedure Followed (Compliance) 2 Not Followed - Call Not Made (Non-Compliance Call Not Made) 3 Not Medically Necessary (Non-Compliance Non-Medically Necessary) 4 Not Followed Other (Non-Compliance Other) 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 288/579 5 Emergency Admit to Non-Network Hospital HCP-15 1527 Exception Code Identifier (ID) Optional Code specifying the exception reason for consideration of out-of-network health care services HCP15 is the exception reason generated by a third party organization. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. 1 Non-Network Professional Provider in Network Hospital 2 Emergency Care 3 Services or Specialist not in Network 4 Out-of-Service Area 5 State Mandates 6 Other 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 289/579 2410 Drug Identification Loop Max 1 Optional LIN 4930 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Drug Identification Loop > LIN Drug Identification To specify basic item identification data Usage notes Drugs and biologics reported in this segment are a further specification of service(s) described in the SV2 segment of this Service Line Loop ID-2400. Required when government regulation mandates that prescribed drugs and biologics are reported with NDC numbers. OR Required when the provider or submitter chooses to report NDC numbers to enhance the claim reporting or adjudication processes. If not required by this implementation guide, do not send. Example LIN**N4*XXX~ Max use 1 Required LIN-02 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type/source of the descriptive number used in Product/Service ID (234) LIN02 through LIN31 provide for fifteen different product/service IDs for each item. For example: Case, Color, Drawing No., U.P.C. No., ISBN No., Model No., or SKU. N4 National Drug Code in 5-4-2 Format LIN-03 234 National Drug Code Min 1 Max 48 String (AN) Required Identifying number for a product or service 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 290/579 CTP 4940 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Drug Identification Loop > CTP Drug Quantity To specify pricing information Example CTP****0000000*ME~ Max use 1 Required CTP-04 380 National Drug Unit Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity CTP-05 C001 Composite Unit of Measure To identify a composite unit of measure (See Figures Appendix for examples of use) Max use 1 Required C001-01 355 Code Qualifier Identifier (ID) Required Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken F2 International Unit GR Gram ME Milligram ML Milliliter UN Unit 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 291/579 2410 Drug Identification Loop end REF 4950 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Drug Identification Loop > REF Prescription or Compound Drug Association Number To specify identifying information Usage notes In cases where a compound drug is being billed, the components of the compound will all have the same prescription number. Payers receiving the claim can relate all the components by matching the prescription number. Required when dispensing of the drug has been done with an assigned prescription number. OR Required when the provided medication involves the compounding of two or more drugs being reported and there is no prescription number. If not required by this implementation guide, do not send. For cases where the drug is provided without a prescription (for example, from a physician's office), the value provided in this segment is a "link sequence number". The link sequence number is a provider assigned number that is unique to this claim. Its purpose is to enable the receiver to piece together the components of the compound. Example REF*XZ*XXXXXX~ Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification VY Link Sequence Number XZ Pharmacy Prescription Number REF-02 127 Prescription Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 292/579 2420A Operating Physician Name Loop Max 1 Optional Variants (all may be used) Other Operating Physician Name Loop Rendering Provider Name Loop Referring Provider Name Loop NM1 5000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Operating Physician Name Loop > NM1 Operating Physician Name To supply the full name of an individual or organizational entity Usage notes Required when a surgical procedure code is listed on this claim. AND The Operating Physician for this line is different than the Operating Physician reported in Loop ID-2310B (claim level). If not required by this implementation guide, do not send. The Operating Physician is the individual with primary responsibility for performing the surgical procedure(s). Example NM1*72*1*XX*XXXX*XXXX**XX*XX*XXXXXX~ If either Identification Code Qualifier (NM1-08) or Operating Physician Primary Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 72 Operating Physician NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Operating Physician Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Operating Physician First Name Min 1 Max 35 String (AN) Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 293/579 Individual first name NM1-05 1037 Operating Physician Middle Name or Initial String (AN) Optional Min 1 Max 25 Individual middle name or initial NM1-07 1039 Operating Physician Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Operating Physician Primary Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code Usage notes Use appropriate NPI number. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 294/579 REF 5250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Operating Physician Name Loop > REF Operating Physician Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier. Example REF*LU*XXXXX**2U>XXXXX~ Max use 20 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Operating Physician Secondary Identifier Min 1 Max | Health Partner Plans 837 Health Care Claim_ Institutional.pdf |
code is listed on this claim. AND The Operating Physician for this line is different than the Operating Physician reported in Loop ID-2310B (claim level). If not required by this implementation guide, do not send. The Operating Physician is the individual with primary responsibility for performing the surgical procedure(s). Example NM1*72*1*XX*XXXX*XXXX**XX*XX*XXXXXX~ If either Identification Code Qualifier (NM1-08) or Operating Physician Primary Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 72 Operating Physician NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Operating Physician Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Operating Physician First Name Min 1 Max 35 String (AN) Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 293/579 Individual first name NM1-05 1037 Operating Physician Middle Name or Initial String (AN) Optional Min 1 Max 25 Individual middle name or initial NM1-07 1039 Operating Physician Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Operating Physician Primary Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code Usage notes Use appropriate NPI number. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 294/579 REF 5250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Operating Physician Name Loop > REF Operating Physician Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier. Example REF*LU*XXXXX**2U>XXXXX~ Max use 20 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Operating Physician Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the identifier reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 295/579 2420A Operating Physician Name Loop end C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 296/579 2420B Other Operating Physician Name Loop Max 1 Optional Variants (all may be used) Operating Physician Name Loop Rendering Provider Name Loop Referring Provider Name Loop NM1 5000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Other Operating Physician Name Loop > NM1 Other Operating Physician Name To supply the full name of an individual or organizational entity Usage notes Required when another Operating Physician is involved, AND The Other Operating Physician for this line is different than the Other Operating Physician reported in Loop ID-2310C (claim level). If not required by this implementation guide, do not send.; Example NM1*ZZ*1*X*XXX*XX**XXXXXX*XX*XXXXX~ If either Identification Code Qualifier (NM1-08) or Other Operating Physician Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual ZZ Mutually Defined ZZ is used to indicate Other Operating Physician. NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Other Operating Physician Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Other Operating Physician First Name Min 1 Max 35 String (AN) Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 297/579 Individual first name NM1-05 1037 Other Operating Physician Middle Name or Initial String (AN) Optional Min 1 Max 25 Individual middle name or initial NM1-07 1039 Other Operating Physician Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Other Operating Physician Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code Usage notes Use appropriate NPI number. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 298/579 REF 5250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Other Operating Physician Name Loop > REF Other Operating Physician Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier. Example REF*LU*XXXXXX**2U>XXX~ Max use 20 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Other Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the identifier reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 299/579 2420B Other Operating Physician Name Loop end C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 300/579 2420C Rendering Provider Name Loop Max 1 Optional Variants (all may be used) Operating Physician Name Loop Other Operating Physician Name Loop Referring Provider Name Loop NM1 5000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Rendering Provider Name Loop > NM1 Rendering Provider Name To supply the full name of an individual or organizational entity Usage notes Required when Rendering Provider is different than the Attending Provider reported in the 2310A loop of this claim. AND State or federal regulatory requirements call for a "combined claim", that is, a claim that includes both facility and professional components (for example, a Medicaid clinic bill or Critical Access Hospital Claim.) AND The Rendering Provider for this line is different than the Rendering Provider reported in Loop ID 2310D (claim level). If not required by this implementation guide, do not send. The Rendering Provider is the health care professional who delivers or completes a particular medical service or non-surgical procedure. Example NM1*82*1*XXXXX*XX*XXXX**XXX*XX*XX~ If either Identification Code Qualifier (NM1-08) or Rendering Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 82 Rendering Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Rendering Provider Last Name Min 1 Max 60 String (AN) Required 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 301/579 Individual last name or organizational name NM1-04 1036 Rendering Provider First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Rendering Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Rendering Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Rendering Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 302/579 REF 5250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Rendering Provider Name Loop > REF Rendering Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier. Example REF*1G*XXXXX**2U>XXXXX~ Max use 20 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a | Health Partner Plans 837 Health Care Claim_ Institutional.pdf |
Usage notes Required when Rendering Provider is different than the Attending Provider reported in the 2310A loop of this claim. AND State or federal regulatory requirements call for a "combined claim", that is, a claim that includes both facility and professional components (for example, a Medicaid clinic bill or Critical Access Hospital Claim.) AND The Rendering Provider for this line is different than the Rendering Provider reported in Loop ID 2310D (claim level). If not required by this implementation guide, do not send. The Rendering Provider is the health care professional who delivers or completes a particular medical service or non-surgical procedure. Example NM1*82*1*XXXXX*XX*XXXX**XXX*XX*XX~ If either Identification Code Qualifier (NM1-08) or Rendering Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 82 Rendering Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Rendering Provider Last Name Min 1 Max 60 String (AN) Required 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 301/579 Individual last name or organizational name NM1-04 1036 Rendering Provider First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Rendering Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Rendering Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Rendering Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 302/579 REF 5250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Rendering Provider Name Loop > REF Rendering Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier. Example REF*1G*XXXXX**2U>XXXXX~ Max use 20 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Rendering Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the identifier reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 303/579 2420C Rendering Provider Name Loop end C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 304/579 2420D Referring Provider Name Loop Max 1 Optional Variants (all may be used) Operating Physician Name Loop Other Operating Physician Name Loop Rendering Provider Name Loop NM1 5000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Referring Provider Name Loop > NM1 Referring Provider Name To supply the full name of an individual or organizational entity Usage notes Required on an outpatient claim when the Referring Provider is different than the Attending Provider. AND The Referring Provider for this line is different than the Referring Provider reported in Loop ID 2310F (claim level). If not required by this implementation guide, do not send. The Referring Provider is provider who sends the patient to another provider for services. Example NM1*DN*1*XXXXXX*XXX*XXXXXX**XXXX*XX*XXXXX~ If either Identification Code Qualifier (NM1-08) or Referring Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual DN Referring Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Referring Provider Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Referring Provider First Name Min 1 Max 35 String (AN) Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 305/579 Individual first name NM1-05 1037 Referring Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Referring Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Referring Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 306/579 REF 5250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Referring Provider Name Loop > REF Referring Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier. Example REF*1G*XXXX**2U>XX~ Max use 20 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. REF-02 127 Referring Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the identifier reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 307/579 2420D Referring Provider Name Loop end C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 308/579 2430 Line Adjudication Information Loop Max 15 Optional SVD 5400 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Line Adjudication Information Loop > SVD Line Adjudication Information To convey service line adjudication information for coordination of benefits between the initial payers of a health care claim and all subsequent payers Usage notes Required when the claim has been previously adjudicated by payer identified in Loop ID-2330B and this service line has payments and/or adjustments applied to it. If not required by this implementation guide, do not send. To show unbundled lines: If, in the original claim, line 3 is unbundled into (for example) 2 additional lines, then the SVD for line 3 is used 3 times: once for the original adjustment to line 3 and then two more times for the additional unbundled lines. Example SVD*XX*0000*ER>XXXXXX>XX>XX>XX>XX>XXXXX*XXXXXX*0 0*0000~ Max use 1 Required SVD-01 67 Other Payer Primary Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code SVD01 is the payer identification code. Usage notes This identifier indicates the payer responsible for the reimbursement described in this iteration of the 2430 loop. The identifier indicates the Other Payer by matching the appropriate Other Payer Primary Identifier (Loop ID-2330B, element NM109). SVD-02 782 Service Line Paid Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SVD02 is the amount paid for this service line. Usage notes Zero "0" is an acceptable value for this element. SVD-03 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers - SVD03 represents the medical procedure code upon which adjudication of this service line was based. This may be different than the submitted medical procedure code. Usage notes Required when a line level procedure code other than a revenue code was returned on the 835 remittance advice (SVC01). Max use 1 Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 309/579 If not required by this implementation guide, do not send. C003-01 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type/source of the descriptive number used in Product/Service ID (234) C003-01 qualifies C003-02 and C003-08. ER Jurisdiction Specific Procedure and Supply Codes HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC. HP Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code IV Home Infusion EDI Coalition (HIEC) Product/Service Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the Home Infusion EDI Coalition (HIEC) Product/Service Codes as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA.; WK Advanced Billing Concepts (ABC) Codes At the time of this writing, this code set has been approved by the Secretary of HHS as a pilot project allowed under HIPAA law. The qualifier may only be used in transactions | Health Partner Plans 837 Health Care Claim_ Institutional.pdf |
Line Adjudication Information Loop > SVD Line Adjudication Information To convey service line adjudication information for coordination of benefits between the initial payers of a health care claim and all subsequent payers Usage notes Required when the claim has been previously adjudicated by payer identified in Loop ID-2330B and this service line has payments and/or adjustments applied to it. If not required by this implementation guide, do not send. To show unbundled lines: If, in the original claim, line 3 is unbundled into (for example) 2 additional lines, then the SVD for line 3 is used 3 times: once for the original adjustment to line 3 and then two more times for the additional unbundled lines. Example SVD*XX*0000*ER>XXXXXX>XX>XX>XX>XX>XXXXX*XXXXXX*0 0*0000~ Max use 1 Required SVD-01 67 Other Payer Primary Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code SVD01 is the payer identification code. Usage notes This identifier indicates the payer responsible for the reimbursement described in this iteration of the 2430 loop. The identifier indicates the Other Payer by matching the appropriate Other Payer Primary Identifier (Loop ID-2330B, element NM109). SVD-02 782 Service Line Paid Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SVD02 is the amount paid for this service line. Usage notes Zero "0" is an acceptable value for this element. SVD-03 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers - SVD03 represents the medical procedure code upon which adjudication of this service line was based. This may be different than the submitted medical procedure code. Usage notes Required when a line level procedure code other than a revenue code was returned on the 835 remittance advice (SVC01). Max use 1 Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 309/579 If not required by this implementation guide, do not send. C003-01 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type/source of the descriptive number used in Product/Service ID (234) C003-01 qualifies C003-02 and C003-08. ER Jurisdiction Specific Procedure and Supply Codes HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC. HP Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code IV Home Infusion EDI Coalition (HIEC) Product/Service Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the Home Infusion EDI Coalition (HIEC) Product/Service Codes as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA.; WK Advanced Billing Concepts (ABC) Codes At the time of this writing, this code set has been approved by the Secretary of HHS as a pilot project allowed under HIPAA law. The qualifier may only be used in transactions covered under HIPAA; By parties registered in the pilot project and their trading partners, OR If a new rule names the Complementary, Alternative, or Holistic Procedure Codes as an allowable code set under HIPAA, OR For claims which are not covered under HIPAA. C003-02 234 Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. C003-03 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-03 modifies the value in C003-02 and C003-08. C003-04 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 310/579 This identifies special circumstances related to the performance of the service, as defined by trading partners C003-04 modifies the value in C003-02 and C003-08. C003-05 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-05 modifies the value in C003-02 and C003-08. C003-06 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-06 modifies the value in C003-02 and C003-08. C003-07 352 Procedure Code Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content C003-07 is the description of the procedure identified in C003-02. SVD-04 234 Service Line Revenue Code Min 1 Max 48 String (AN) Required Identifying number for a product or service SVD04 is the revenue code. SVD-05 380 Paid Service Unit Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity SVD05 is the paid units of service. Usage notes This is the number of paid units from the remittance advice. When paid units are not present on the remittance advice, use the original billed units. The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three. SVD-06 554 Bundled Line Number Min 1 Max 6 Numeric (N0) Optional Number assigned for differentiation within a transaction set 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 311/579 SVD06 is only used for bundling of service lines. It references the LX Assigned Number of the service line into which this service line was bundled. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 312/579 CAS 5450 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Line Adjudication Information Loop > CAS Line Adjustment To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid Usage notes Required when the payer identified in Loop 2330B made line level adjustments which caused the amount paid to differ from the amount originally charged. If not required by this implementation guide, do not send. A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a particular Claim Adjustment Group Code (CAS01). The first non-zero adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19). Example CAS*CO*XX*00000000000000*00000000*XXXXX*0000000 0*00000000000000*XXXX*00000000000000*00000000*XXX X*0000000000*000000000000*XX*0000000*000000000000 000*XXXX*0000*000000000000000~ If Adjustment Reason Code (CAS-05) is present, then at least one of Adjustment Amount (CAS-06) or Adjustment Quantity (CAS-07) is required If Adjustment Amount (CAS-06) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Quantity (CAS-07) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Reason Code (CAS-08) is present, then at least one of Adjustment Amount (CAS-09) or Adjustment Quantity (CAS-10) is required If Adjustment Amount (CAS-09) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Quantity (CAS-10) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Reason Code (CAS-11) is present, then at least one of Adjustment Amount (CAS-12) or Adjustment Quantity (CAS-13) is required If Adjustment Amount (CAS-12) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Quantity (CAS-13) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS-16) is required If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS-19) is required If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required Max use 5 Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 313/579 If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required CAS-01 1033 Claim Adjustment Group Code Identifier (ID) Required Code identifying the general category of payment adjustment CO Contractual Obligations CR Correction and Reversals OA Other adjustments PI Payor Initiated Reductions PR Patient Responsibility CAS-02 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Required Code identifying the detailed reason the adjustment was made CAS-03 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CAS03 is the amount of adjustment. CAS-04 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS04 is the units of service being adjusted. CAS-05 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CODE SOURCE 139: Claim Adjustment Reason Code CAS-06 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS06 is the amount of the adjustment. CAS-07 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 314/579 CAS07 is the units of service being adjusted. CAS-08 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CODE SOURCE 139: Claim Adjustment Reason Code CAS-09 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS09 is the amount of the adjustment. CAS-10 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS10 is the units of service being adjusted. CAS-11 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CODE SOURCE 139: Claim Adjustment Reason Code CAS-12 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS12 is the amount of the adjustment. CAS-13 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS13 is the units of service being adjusted. CAS-14 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 315/579 See CODE SOURCE 139: Claim Adjustment Reason Code CAS-15 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS15 is the amount of the adjustment. CAS-16 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS16 is the units of service being adjusted. CAS-17 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CODE SOURCE 139: Claim Adjustment Reason Code CAS-18 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS18 is the amount of the adjustment. CAS-19 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS19 is the units of service being adjusted. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 316/579 DTP 5500 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Line Adjudication Information Loop > DTP Line Check or Remittance Date To specify any or all of a date, a time, or a time period Example DTP*573*D8*XX~ Max use 1 Required DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 573 Date Claim Paid DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period | Health Partner Plans 837 Health Care Claim_ Institutional.pdf |
CAS-06 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS06 is the amount of the adjustment. CAS-07 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 314/579 CAS07 is the units of service being adjusted. CAS-08 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CODE SOURCE 139: Claim Adjustment Reason Code CAS-09 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS09 is the amount of the adjustment. CAS-10 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS10 is the units of service being adjusted. CAS-11 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CODE SOURCE 139: Claim Adjustment Reason Code CAS-12 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS12 is the amount of the adjustment. CAS-13 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS13 is the units of service being adjusted. CAS-14 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 315/579 See CODE SOURCE 139: Claim Adjustment Reason Code CAS-15 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS15 is the amount of the adjustment. CAS-16 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS16 is the units of service being adjusted. CAS-17 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CODE SOURCE 139: Claim Adjustment Reason Code CAS-18 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS18 is the amount of the adjustment. CAS-19 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS19 is the units of service being adjusted. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 316/579 DTP 5500 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Line Adjudication Information Loop > DTP Line Check or Remittance Date To specify any or all of a date, a time, or a time period Example DTP*573*D8*XX~ Max use 1 Required DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 573 Date Claim Paid DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Adjudication or Payment Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 317/579 2430 Line Adjudication Information Loop end 2400 Service Line Number Loop end 2300 Claim Information Loop end AMT 5505 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Line Adjudication Information Loop > AMT Remaining Patient Liability To indicate the total monetary amount Usage notes In the judgment of the provider, this is the remaining amount to be paid after adjudication by the Other Payer referenced in SVD01 of this iteration of Loop ID-2430. This segment is only used in provider submitted claims. It is not used in Payer-to-Payer Coordination of Benefits (COB). Required when the Other Payer referenced in SVD01 of this iteration of Loop ID-2430 has adjudicated this claim, provided line level information, and the provider has the ability to report line item information. If not required by this implementation guide, do not send. This segment is not used if the claim level (Loop ID-2320) Remaining Patient Liability AMT segment is used for this Other Payer. Example AMT*EAF*00000000000~ Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount EAF Amount Owed AMT-02 782 Remaining Patient Liability Min 1 Max 15 Decimal number (R) Required Monetary amount 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 318/579 2000C Patient Hierarchical Level Loop Max >1 Optional HL 0010 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > HL Hierarchical Level To identify dependencies among and the content of hierarchically related groups of data segments Example HL*3*2*23*0~ Max use 1 Required HL-01 628 Hierarchical ID Number Min 1 Max 12 String (AN) Required A unique number assigned by the sender to identify a particular data segment in a hierarchical structure HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction. HL-02 734 Hierarchical Parent ID Number Min 1 Max 12 String (AN) Required Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate. HL-03 735 Hierarchical Level Code Identifier (ID) Required Code defining the characteristic of a level in a hierarchical structure HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information. 23 Dependent HL-04 736 Hierarchical Child Code Identifier (ID) Optional Code indicating if there are hierarchical child data segments subordinate to the level being described HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 319/579 0 No Subordinate HL Segment in This Hierarchical Structure. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 320/579 PAT 0070 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > PAT Patient Information To supply patient information Example PAT*19~ Max use 1 Required PAT-01 1069 Individual Relationship Code Identifier (ID) Required Code indicating the relationship between two individuals or entities Usage notes Specifies the patient's relationship to the person insured. 01 Spouse 19 Child 20 Employee 21 Unknown 39 Organ Donor 40 Cadaver Donor 53 Life Partner G8 Other Relationship 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 321/579 2010CA Patient Name Loop Max 1 Required NM1 0150 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Patient Name Loop > NM1 Patient Name To supply the full name of an individual or organizational entity Example NM1*QC*1*XXX*XX*XXXXX**XXXXX~ Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual QC Patient NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Patient Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Patient First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Patient Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Patient Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 322/579 N3 0250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Patient Name Loop > N3 Patient Address To specify the location of the named party Example N3*XXXXXX*XXXX~ Max use 1 Required N3-01 166 Patient Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Patient Address Line Min 1 Max 55 String (AN) Optional Address information 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 323/579 N4 0300 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Patient Name Loop > N4 Patient City, State, ZIP Code To specify the geographic place of the named party Example N4*XXXXXXX*XX*XXX*XX~ Only one of Patient State Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Patient City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Patient State Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State/Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Patient Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 324/579 DMG 0320 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Patient Name Loop > DMG Patient Demographic Information To supply demographic information Example DMG*D8*XXXX*U~ Max use 1 Required DMG-01 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format D8 Date Expressed in Format CCYYMMDD DMG-02 1251 Patient Birth Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times DMG02 is the date of birth. DMG-03 1068 Patient Gender Code Identifier (ID) Required Code indicating the sex of the individual F Female M Male U Unknown 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 325/579 REF 0350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Patient Name Loop > REF Property and Casualty Claim Number To specify identifying information Usage notes This is a property and casualty payer-assigned claim number. Providers receive this number from the property and casualty payer during eligibility determinations or some other communication with that payer. See Section 1.4.2, Property and Casualty, for additional information about property and casualty claims.; This segment is not a HIPAA requirement as of this writing. Required when the services included in this claim are to be considered as part of a property and casualty claim. If not required by this implementation guide, do not send. Example REF*Y4*XXXXXX~ Variants (all may be used) REF Property and Casualty Patient Identifier Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification Y4 | Health Partner Plans 837 Health Care Claim_ Institutional.pdf |
City, State, ZIP Code To specify the geographic place of the named party Example N4*XXXXXXX*XX*XXX*XX~ Only one of Patient State Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Patient City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Patient State Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State/Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Patient Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 324/579 DMG 0320 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Patient Name Loop > DMG Patient Demographic Information To supply demographic information Example DMG*D8*XXXX*U~ Max use 1 Required DMG-01 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format D8 Date Expressed in Format CCYYMMDD DMG-02 1251 Patient Birth Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times DMG02 is the date of birth. DMG-03 1068 Patient Gender Code Identifier (ID) Required Code indicating the sex of the individual F Female M Male U Unknown 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 325/579 REF 0350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Patient Name Loop > REF Property and Casualty Claim Number To specify identifying information Usage notes This is a property and casualty payer-assigned claim number. Providers receive this number from the property and casualty payer during eligibility determinations or some other communication with that payer. See Section 1.4.2, Property and Casualty, for additional information about property and casualty claims.; This segment is not a HIPAA requirement as of this writing. Required when the services included in this claim are to be considered as part of a property and casualty claim. If not required by this implementation guide, do not send. Example REF*Y4*XXXXXX~ Variants (all may be used) REF Property and Casualty Patient Identifier Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification Y4 Agency Claim Number REF-02 127 Property Casualty Claim Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 326/579 2010CA Patient Name Loop end REF 0350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Patient Name Loop > REF Property and Casualty Patient Identifier To specify identifying information Usage notes Required when an identification number is needed by the receiver to identify the patient for Property and Casualty claims. If not required by this implementation guide, do not send. Example REF*SY*XX~ Variants (all may be used) REF Property and Casualty Claim Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 1W Member Identification Number This code designates a patient identification number used by the destination payer identified in the Payer Name loop, Loop ID 2010BB, associated with this claim. SY Social Security Number The Social Security Number must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid. REF-02 127 Property and Casualty Patient Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 327/579 2300 Claim Information Loop Max 100 Required CLM 1300 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > CLM Claim Information To specify basic data about the claim Usage notes The developers of this implementation guide recommend that trading partners limit the size of the transaction (ST-SE envelope) to a maximum of 5000 CLM segments. There is no recommended limit to the number of ST-SE transactions within a GS-GE or ISA- IEA. Willing trading partners can agree to set limits higher. For purposes of this documentation, the claim detail information is presented only in the dependent level. Specific claim detail information can be given in either the subscriber or the dependent hierarchical level. Because of this, the claim information is said to "float." Claim information is positioned in the same hierarchical level that describes its owner-participant, either the subscriber or the dependent. In other words, the claim information, Loop ID-2300, is placed following Loop ID-2010BB in the Subscriber Hierarchical Level (HL) when patient information is sent in Loop ID-2010BA of the Subscriber HL. Claim information is placed in the Patient HL when the patient information is sent in Loop ID-2010CA of the Patient HL. When the patient is the subscriber or is considered to be the subscriber, Loop ID-2000C and Loop ID-2010CA are not sent. See Subscriber/Patient HL Segment explanation in section 1.4.3.2.2.1 for details. Example CLM*XXXX*000***XX>A>X**A*Y*Y***********7~ Max use 1 Required CLM-01 1028 Patient Control Number Min 1 Max 38 String (AN) Required Identifier used to track a claim from creation by the health care provider through payment Usage notes The number that the submitter transmits in this position is echoed back to the submitter in the 835 and other transactions. This permits the submitter to use the value in this field as a key in the submitter's system to match the claim to the payment information returned in the 835 transaction. The two recommended identifiers are either the Patient Account Number or the Claim Number in the billing submitter's patient management system. The developers of this implementation guide strongly recommend that submitters use unique numbers for this field for each individual claim. When Loop ID-2010AC is present, CLM01 represents the subrogated Medicaid agency's claim number (ICN/DCN) from their original 835 CLP07 - Payer Claim Control Number. See Section 1.4.1.4 of the front matter for a description of post payment recovery claims for subrogated Medicaid agencies. The maximum number of characters to be supported for this field is `20'. Characters beyond the maximum are not required to be stored nor returned by any 837-receiving system. CLM-02 782 Total Claim Charge Amount Min 1 Max 15 Decimal number (R) Required 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 328/579 Monetary amount CLM02 is the total amount of all submitted charges of service segments for this claim. Usage notes The Total Claim Charge Amount must be greater than or equal to zero. The total claim charge amount must balance to the sum of all service line charge amounts reported in the Institutional Service Line (SV2) segments for this claim. CLM-05 C023 Health Care Service Location Information To provide information that identifies the place of service or the type of bill related to the location at which a health care service was rendered Max use 1 Required C023-01 1331 Facility Type Code Min 1 Max 2 String (AN) Required Code identifying where services were, or may be, performed; the first and second positions of the Uniform Bill Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services. C023-02 1332 Facility Code Qualifier Identifier (ID) Required Code identifying the type of facility referenced C023-02 qualifies C023-01 and C023-03. A Uniform Billing Claim Form Bill Type C023-03 1325 Claim Frequency Code Min 1 Max 1 Identifier (ID) Required Code specifying the frequency of the claim; this is the third position of the Uniform Billing Claim Form Bill Type CLM-07 1359 Assignment or Plan Participation Code Identifier (ID) Required Code indicating whether the provider accepts assignment Usage notes Within this element the context of the word assignment is related to the relationship between the provider and the payer. This is NOT the field for reporting whether the patient has or has not assigned benefits to the provider. The benefit assignment indicator is in CLM08. A Assigned Required when the provider accepts assignment and/or has a participation agreement with the destination payer. OR Required when the provider does not accept assignment and/or have a participation agreement, but is advising the payer to adjudicate this specific claim under participating provider benefits as allowed under certain plans. B Assignment Accepted on Clinical Lab Services Only 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 329/579 Required when the provider accepts assignment for Clinical Lab Services only. C Not Assigned Required when neither codes A' nor B' apply. CLM-08 1073 Benefits Assignment Certification Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CLM08 is assignment of benefits indicator. A "Y" value indicates insured or authorized person authorizes benefits to be assigned to the provider; an "N" value indicates benefits have not been assigned to the provider. Usage notes This element answers the question whether or not the insured has authorized the plan to remit payment directly to the provider. N No W Not Applicable Use code `W' when the patient refuses to assign benefits. Y Yes CLM-09 1363 Release of Information Code Identifier (ID) Required Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations Usage notes The Release of Information response is limited to the information carried in this claim. I Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes Required when the provider has not collected a signature AND state or federal laws do not require a signature be collected. Y Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim Required when the provider has collected a signature. OR Required when state or federal laws require a signature be collected. CLM-20 1514 Delay Reason Code Identifier (ID) Optional Code indicating the reason why a request was delayed 1 Proof of Eligibility Unknown or Unavailable 2 Litigation 3 Authorization Delays 4 Delay in Certifying Provider 5 Delay in Supplying Billing Forms 6 Delay in Delivery of Custom-made Appliances 7 Third Party Processing Delay 8 Delay in Eligibility Determination 9 Original Claim Rejected or Denied Due to a Reason Unrelated to the Billing Limitation Rules 10 Administration Delay in the Prior Approval Process 11 Other 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 330/579 15 Natural Disaster 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 331/579 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > DTP Admission Date/Hour To specify any or all of a date, a time, or a time period Usage notes Required on inpatient claims. If not required by this implementation guide, do not send. Example DTP*435*DT*X~ Variants (all may be used) DTP Date - Repricer Received Date DTP Discharge Hour DTP Statement Dates Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 435 Admission DTP-02 1250 Date Time | Health Partner Plans 837 Health Care Claim_ Institutional.pdf |
have a participation agreement, but is advising the payer to adjudicate this specific claim under participating provider benefits as allowed under certain plans. B Assignment Accepted on Clinical Lab Services Only 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 329/579 Required when the provider accepts assignment for Clinical Lab Services only. C Not Assigned Required when neither codes A' nor B' apply. CLM-08 1073 Benefits Assignment Certification Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CLM08 is assignment of benefits indicator. A "Y" value indicates insured or authorized person authorizes benefits to be assigned to the provider; an "N" value indicates benefits have not been assigned to the provider. Usage notes This element answers the question whether or not the insured has authorized the plan to remit payment directly to the provider. N No W Not Applicable Use code `W' when the patient refuses to assign benefits. Y Yes CLM-09 1363 Release of Information Code Identifier (ID) Required Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations Usage notes The Release of Information response is limited to the information carried in this claim. I Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes Required when the provider has not collected a signature AND state or federal laws do not require a signature be collected. Y Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim Required when the provider has collected a signature. OR Required when state or federal laws require a signature be collected. CLM-20 1514 Delay Reason Code Identifier (ID) Optional Code indicating the reason why a request was delayed 1 Proof of Eligibility Unknown or Unavailable 2 Litigation 3 Authorization Delays 4 Delay in Certifying Provider 5 Delay in Supplying Billing Forms 6 Delay in Delivery of Custom-made Appliances 7 Third Party Processing Delay 8 Delay in Eligibility Determination 9 Original Claim Rejected or Denied Due to a Reason Unrelated to the Billing Limitation Rules 10 Administration Delay in the Prior Approval Process 11 Other 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 330/579 15 Natural Disaster 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 331/579 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > DTP Admission Date/Hour To specify any or all of a date, a time, or a time period Usage notes Required on inpatient claims. If not required by this implementation guide, do not send. Example DTP*435*DT*X~ Variants (all may be used) DTP Date - Repricer Received Date DTP Discharge Hour DTP Statement Dates Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 435 Admission DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. Usage notes Selection of the appropriate qualifier is designated by the NUBC Billing Manual. D8 Date Expressed in Format CCYYMMDD DT Date and Time Expressed in Format CCYYMMDDHHMM DTP-03 1251 Admission Date and Hour Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 332/579 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > DTP Date - Repricer Received Date To specify any or all of a date, a time, or a time period Usage notes Required when a repricer is passing the claim onto the payer. If not required by this implementation guide, do not send. Example DTP*050*D8*XXX~ Variants (all may be used) DTP Admission Date/Hour DTP Discharge Hour DTP Statement Dates Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 050 Received DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Repricer Received Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 333/579 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > DTP Discharge Hour To specify any or all of a date, a time, or a time period Usage notes Required on all final inpatient claims. If not required by this implementation guide, do not send. Example DTP*096*TM*XXXX~ Variants (all may be used) DTP Admission Date/Hour DTP Date - Repricer Received Date DTP Statement Dates Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 096 Discharge DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. TM Time Expressed in Format HHMM DTP-03 1251 Discharge Time Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 334/579 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > DTP Statement Dates To specify any or all of a date, a time, or a time period Example DTP*434*RD8*XXX~ Variants (all may be used) DTP Admission Date/Hour DTP Date - Repricer Received Date DTP Discharge Hour Max use 1 Required DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 434 Statement DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD Use RD8 to indicate the from and through date of the statement. When the statement is for a single date of service, the from and through date are the same. DTP-03 1251 Statement From and To Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 335/579 CL1 1400 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > CL1 Institutional Claim Code To supply information specific to hospital claims Example CL1*X*X*XX~ Max use 1 Required CL1-01 1315 Admission Type Code Min 1 Max 1 Identifier (ID) Required Code indicating the priority of this admission CL1-02 1314 Admission Source Code Min 1 Max 1 Identifier (ID) Optional Code indicating the source of this admission CL1-03 1352 Patient Status Code Min 1 Max 2 Identifier (ID) Required Code indicating patient status as of the "statement covers through date" 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 336/579 PWK 1550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > PWK Claim Supplemental Information To identify the type or transmission or both of paperwork or supporting information Usage notes Required when there is a paper attachment following this claim. OR Required when attachments are sent electronically (PWK02 = EL) but are transmitted in another functional group (for example, 275) rather than by paper. PWK06 is then used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment. OR Required when the provider deems it necessary to identify additional information that is being held at the provider's office and is available upon request by the payer (or appropriate entity), but the information is not being submitted with the claim. Use the value of "AA" in PWK02 to convey this specific use of the PWK segment. If not required by this implementation guide, do not send. Example PWK*RT*AA***AC*XXXXXXX~ If either Identification Code Qualifier (PWK-05) or Attachment Control Number (PWK-06) is present, then the other is required Max use 10 Optional PWK-01 755 Attachment Report Type Code Identifier (ID) Required Code indicating the title or contents of a document, report or supporting item 03 Report Justifying Treatment Beyond Utilization Guidelines 04 Drugs Administered 05 Treatment Diagnosis 06 Initial Assessment 07 Functional Goals 08 Plan of Treatment 09 Progress Report 10 Continued Treatment 11 Chemical Analysis 13 Certified Test Report 15 Justification for Admission 21 Recovery Plan A3 Allergies/Sensitivities Document A4 Autopsy Report AM Ambulance Certification AS Admission Summary B2 Prescription B3 Physician Order B4 Referral Form BR Benchmark Testing Results BS Baseline BT Blanket Test Results CB Chiropractic Justification 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 337/579 CK Consent Form(s) CT Certification D2 Drug Profile Document DA Dental Models DB Durable Medical Equipment Prescription DG Diagnostic Report DJ Discharge Monitoring Report DS Discharge Summary EB Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payor) HC Health Certificate HR Health Clinic Records I5 Immunization Record IR State School Immunization Records LA Laboratory Results M1 Medical Record Attachment MT Models NN Nursing Notes OB Operative Note OC Oxygen Content Averaging Report OD Orders and Treatments Document OE Objective Physical Examination (including vital signs) Document OX Oxygen Therapy Certification OZ Support Data for Claim P4 Pathology Report P5 Patient Medical History Document PE Parenteral or Enteral Certification PN Physical Therapy Notes PO Prosthetics or Orthotic Certification PQ Paramedical Results PY Physician's Report PZ Physical Therapy Certification RB Radiology Films RR Radiology Reports RT Report of Tests and Analysis Report RX Renewable Oxygen Content Averaging Report SG Symptoms Document V5 Death Notification XP Photographs PWK-02 756 Attachment Transmission Code Identifier (ID) Required Code defining timing, transmission method or format by which reports are to be sent AA Available on Request at Provider Site This means that the additional information is not being sent with the claim at this time. Instead, it is available to the payer (or appropriate entity) at their request. BM By Mail EL Electronically Only Indicates that the attachment is being transmitted in a separate X12 functional group. EM E-Mail FT File Transfer 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 338/579 Required when the actual attachment is maintained by an attachment warehouse or similar vendor. FX By Fax PWK-05 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) PWK05 and PWK06 may be used to identify the addressee by a code number. AC Attachment Control Number PWK-06 67 Attachment Control Number Min 2 Max 80 String (AN) Optional Code identifying a party or other code Usage notes PWK06 is used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment. For the purpose of this implementation, the maximum field length is 50. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 339/579 CN1 1600 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > CN1 Contract Information To | Health Partner Plans 837 Health Care Claim_ Institutional.pdf |
contents of a document, report or supporting item 03 Report Justifying Treatment Beyond Utilization Guidelines 04 Drugs Administered 05 Treatment Diagnosis 06 Initial Assessment 07 Functional Goals 08 Plan of Treatment 09 Progress Report 10 Continued Treatment 11 Chemical Analysis 13 Certified Test Report 15 Justification for Admission 21 Recovery Plan A3 Allergies/Sensitivities Document A4 Autopsy Report AM Ambulance Certification AS Admission Summary B2 Prescription B3 Physician Order B4 Referral Form BR Benchmark Testing Results BS Baseline BT Blanket Test Results CB Chiropractic Justification 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 337/579 CK Consent Form(s) CT Certification D2 Drug Profile Document DA Dental Models DB Durable Medical Equipment Prescription DG Diagnostic Report DJ Discharge Monitoring Report DS Discharge Summary EB Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payor) HC Health Certificate HR Health Clinic Records I5 Immunization Record IR State School Immunization Records LA Laboratory Results M1 Medical Record Attachment MT Models NN Nursing Notes OB Operative Note OC Oxygen Content Averaging Report OD Orders and Treatments Document OE Objective Physical Examination (including vital signs) Document OX Oxygen Therapy Certification OZ Support Data for Claim P4 Pathology Report P5 Patient Medical History Document PE Parenteral or Enteral Certification PN Physical Therapy Notes PO Prosthetics or Orthotic Certification PQ Paramedical Results PY Physician's Report PZ Physical Therapy Certification RB Radiology Films RR Radiology Reports RT Report of Tests and Analysis Report RX Renewable Oxygen Content Averaging Report SG Symptoms Document V5 Death Notification XP Photographs PWK-02 756 Attachment Transmission Code Identifier (ID) Required Code defining timing, transmission method or format by which reports are to be sent AA Available on Request at Provider Site This means that the additional information is not being sent with the claim at this time. Instead, it is available to the payer (or appropriate entity) at their request. BM By Mail EL Electronically Only Indicates that the attachment is being transmitted in a separate X12 functional group. EM E-Mail FT File Transfer 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 338/579 Required when the actual attachment is maintained by an attachment warehouse or similar vendor. FX By Fax PWK-05 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) PWK05 and PWK06 may be used to identify the addressee by a code number. AC Attachment Control Number PWK-06 67 Attachment Control Number Min 2 Max 80 String (AN) Optional Code identifying a party or other code Usage notes PWK06 is used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment. For the purpose of this implementation, the maximum field length is 50. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 339/579 CN1 1600 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > CN1 Contract Information To specify basic data about the contract or contract line item Usage notes Required when the submitter is contractually obligated to supply this information on post-adjudicated claims. If not required by this implementation guide, do not send. The developers of this implementation guide note that the CN1 segment is for use only for post-adjudicated claims, which do not meet the definition of a health care claim under HIPAA. Consequently, at the time of this writing, the CN1 segment is for non- HIPAA use only. Example CN1*02*0000*000000*X*0*XXXXXX~ Max use 1 Optional CN1-01 1166 Contract Type Code Identifier (ID) Required Code identifying a contract type 01 Diagnosis Related Group (DRG) 02 Per Diem 03 Variable Per Diem 04 Flat 05 Capitated 06 Percent 09 Other CN1-02 782 Contract Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CN102 is the contract amount. CN1-03 332 Contract Percentage Min 1 Max 6 Decimal number (R) Optional Percent given in decimal format (e.g., 0.0 through 100.0 represents 0% through 100%) CN103 is the allowance or charge percent. CN1-04 127 Contract Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier CN104 is the contract code. CN1-05 338 Terms Discount Percentage Min 1 Max 6 Decimal number (R) Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 340/579 Terms discount percentage, expressed as a percent, available to the purchaser if an invoice is paid on or before the Terms Discount Due Date CN1-06 799 Contract Version Identifier Min 1 Max 30 String (AN) Optional Revision level of a particular format, program, technique or algorithm CN106 is an additional identifying number for the contract. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 341/579 AMT 1750 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > AMT Patient Estimated Amount Due To indicate the total monetary amount Usage notes Required when the Patient Responsibility Amount is applicable to this claim. If not required by this implementation guide, do not send. Example AMT*F3*000000000~ Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount F3 Patient Responsibility - Estimated AMT-02 782 Patient Responsibility Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 342/579 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > REF Adjusted Repriced Claim Number To specify identifying information Usage notes Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send. This information is specific to the destination payer reported in Loop ID-2010BB. Example REF*9C*XXX~ Variants (all may be used) REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9C Adjusted Repriced Claim Reference Number REF-02 127 Adjusted Repriced Claim Reference Number String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 343/579 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > REF Auto Accident State To specify identifying information Usage notes Required when the services reported on this claim are related to an auto accident and the accident occurred in a country or location that has a state, province, or sub- country code named in code source 22. If not required by this implementation guide, do not send. Example REF*LU*X~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification LU Location Number REF-02 127 Auto Accident State or Province Code Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes Values in this field must be valid codes found in code source 22. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 344/579 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > REF Claim Identifier For Transmission Intermediaries To specify identifying information Usage notes Required when this information is deemed necessary by transmission intermediaries (Automated Clearinghouses, and others) who need to attach their own unique claim number. If not required by this implementation guide, do not send. Although this REF is supplied for transmission intermediaries to attach their own unique claim number to a claim, 837-recipients are not required under HIPAA to return this number in any HIPAA transaction. Trading partners may voluntarily agree to this interaction if they wish. Example REF*D9*XXXX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification Usage notes Number assigned by clearinghouse, van, etc. D9 Claim Number REF-02 127 Value Added Network Trace Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 345/579 The value carried in this element is limited to a maximum of 20 positions. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 346/579 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > REF Demonstration Project Identifier To specify identifying information Usage notes Required when it is necessary to identify claims which are atypical in ways such as content, purpose, and/or payment, as could be the case for a demonstration or other special project, or a clinical trial. If not required by this implementation guide, do not send. Example REF*P4*XXXX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification P4 Project Code REF-02 127 Demonstration Project Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 347/579 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > REF Investigational Device Exemption Number To specify identifying information Usage notes Required when claim involves a Food and Drug Administration (FDA) assigned investigational device exemption (IDE) number. When more than one IDE applies, they must be split into separate claims. If not required by this implementation guide, do not send. Example REF*LX*XXXXX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 5 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification LX Qualified Products List REF-02 127 Investigational Device Exemption Identifier String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - | Health Partner Plans 837 Health Care Claim_ Institutional.pdf |
Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification Usage notes Number assigned by clearinghouse, van, etc. D9 Claim Number REF-02 127 Value Added Network Trace Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 345/579 The value carried in this element is limited to a maximum of 20 positions. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 346/579 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > REF Demonstration Project Identifier To specify identifying information Usage notes Required when it is necessary to identify claims which are atypical in ways such as content, purpose, and/or payment, as could be the case for a demonstration or other special project, or a clinical trial. If not required by this implementation guide, do not send. Example REF*P4*XXXX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification P4 Project Code REF-02 127 Demonstration Project Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 347/579 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > REF Investigational Device Exemption Number To specify identifying information Usage notes Required when claim involves a Food and Drug Administration (FDA) assigned investigational device exemption (IDE) number. When more than one IDE applies, they must be split into separate claims. If not required by this implementation guide, do not send. Example REF*LX*XXXXX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 5 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification LX Qualified Products List REF-02 127 Investigational Device Exemption Identifier String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 348/579 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > REF Medical Record Number To specify identifying information Usage notes Required when the provider needs to identify for future inquiries, the actual medical record of the patient identified in either Loop ID-2010BA or Loop ID-2010CA for this episode of care. If not required by this implementation guide, do not send. Example REF*EA*XXXXX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification EA Medical Record Identification Number REF-02 127 Medical Record Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 349/579 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > REF Payer Claim Control Number To specify identifying information Usage notes Required when CLM05-3 (Claim Frequency Code) indicates this claim is a replacement or void to a previously adjudicated claim. If not required by this implementation guide, do not send. This information is specific to the destination payer reported in Loop ID-2010BB. Example REF*F8*XXX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification F8 Original Reference Number REF-02 127 Payer Claim Control Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 350/579 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > REF Peer Review Organization (PRO) Approval Number To specify identifying information Usage notes Required when an external Peer Review Organization assigns an Approval Number to services deemed medically necessary by that organization. If not required by this implementation guide, do not send. Example REF*G4*XXXXX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification G4 Peer Review Organization (PRO) Approval Number REF-02 127 Peer Review Authorization Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 351/579 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > REF Prior Authorization To specify identifying information Usage notes Generally, preauthorization numbers are assigned by the payer or UMO to authorize a service prior to its being performed. The UMO (Utilization Management Organization) is generally the entity empowered to make a decision regarding the outcome of a health services review or the owner of information. The prior authorization number carried in this REF is specific to the destination payer reported in the Loop ID-2010BB. If other payers have similar numbers for this claim, report that information in the Loop ID-2330 loop REF which holds that payer's information. Numbers at this position apply to the entire claim unless they are overridden in the REF segment in Loop ID-2400. A reference identification is considered to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line. Required when an authorization number is assigned by the payer or UMO AND the services on this claim were preauthorized. If not required by this implementation guide, do not send. Example REF*G1*XXXXX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification G1 Prior Authorization Number REF-02 127 Prior Authorization Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 352/579 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 353/579 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > REF Referral Number To specify identifying information Usage notes Required when a referral number is assigned by the payer or Utilization Management Organization (UMO) AND a referral is involved. If not required by this implementation guide, do not send. Numbers at this position apply to the entire claim unless they are overridden in the REF segment in Loop ID-2400. A reference identification is considered to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line. Example REF*9F*X~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9F Referral Number REF-02 127 Referral Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 354/579 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > REF Repriced Claim Number To specify identifying information Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send. Example REF*9A*XXXXXX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Referral Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9A Repriced Claim Reference Number REF-02 127 Repriced Claim Reference Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 355/579 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > REF Service Authorization Exception Code To specify identifying information Usage notes Required when mandated by government law or regulation to obtain authorization for specific service(s) but, for the reasons listed in REF02, the service was performed without obtaining the authorization. If not required by this implementation guide, do not send. Example REF*4N*XX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) | Health Partner Plans 837 Health Care Claim_ Institutional.pdf |
this position apply to the entire claim unless they are overridden in the REF segment in Loop ID-2400. A reference identification is considered to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line. Example REF*9F*X~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9F Referral Number REF-02 127 Referral Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 354/579 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > REF Repriced Claim Number To specify identifying information Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send. Example REF*9A*XXXXXX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Referral Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9A Repriced Claim Reference Number REF-02 127 Repriced Claim Reference Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 355/579 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > REF Service Authorization Exception Code To specify identifying information Usage notes Required when mandated by government law or regulation to obtain authorization for specific service(s) but, for the reasons listed in REF02, the service was performed without obtaining the authorization. If not required by this implementation guide, do not send. Example REF*4N*XX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Referral Number REF Repriced Claim Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 4N Special Payment Reference Number REF-02 127 Service Authorization Exception Code Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes Allowable values for this element are: 1 Immediate/Urgent Care 2 Services Rendered in a Retroactive Period 3 Emergency Care 4 Client has Temporary Medicaid 5 Request from County for Second Opinion to Determine if Recipient Can Work 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 356/579 6 Request for Override Pending 7 Special Handling 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 357/579 K3 1850 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > K3 File Information To transmit a fixed-format record or matrix contents Usage notes Required when ALL of the following conditions are met: A regulatory agency concludes it must use the K3 to meet an emergency legislative requirement; The administering regulatory agency or other state organization has completed each one of the following steps: contacted the X12N workgroup, requested a review of the K3 data requirement to ensure there is not an existing method within the implementation guide to meet this requirement X12N determines that there is no method to meet the requirement. If not required by this implementation guide, do not send. At the time of publication of this implementation, K3 segments have no specific use. The K3 segment is expected to be used only when necessary to meet the unexpected data requirement of a legislative authority. Before this segment can be used : The X12N Health Care Claim workgroup must conclude there is no other available option in the implementation guide to meet the emergency legislative requirement. The requestor must submit a proposal for approval accompanied by the relevant business documentation to the X12N Health Care Claim workgroup chairs and receive approval for the request. Upon review of the request, X12N will issue an approval or denial decision to the requesting entity. Approved usage(s) of the K3 segment will be reviewed by the X12N Health Care Claim workgroup to develop a permanent change to include the business case in future transaction implementations. Only when all of the requirements above have been met, may the regulatory agency require the temporary use of the K3 segment. X12N will submit the necessary data maintenance and refer the request to the appropriate data content committee(s). Example K3*XX~ Max use 10 Optional K3-01 449 Fixed Format Information Min 1 Max 80 String (AN) Required Data in fixed format agreed upon by sender and receiver 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 358/579 NTE 1900 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > NTE Billing Note To transmit information in a free-form format, if necessary, for comment or special instruction Usage notes Required when in the judgment of the provider, the information is needed to substantiate the medical treatment and is not supported elsewhere within the claim data set. If not required by this implementation guide, do not send. Example NTE*ADD*XXXX~ Variants (all may be used) NTE Claim Note Max use 1 Optional NTE-01 363 Note Reference Code Identifier (ID) Required Code identifying the functional area or purpose for which the note applies ADD Additional Information NTE-02 352 Billing Note Text Min 1 Max 80 String (AN) Required A free-form description to clarify the related data elements and their content 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 359/579 NTE 1900 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > NTE Claim Note To transmit information in a free-form format, if necessary, for comment or special instruction Usage notes Required when in the judgment of the provider, the information is needed to substantiate the medical treatment and is not supported elsewhere within the claim data set. OR Required when in the judgment of the provider, narrative information from the forms "Home Health Certification and Plan of Treatment" or "Medical Update and Patient Information" is needed to substantiate home health services. If not required by this implementation guide, do not send. The developers of this implementation guide discourage using narrative information within the 837. Trading partners who use narrative information with claims are strongly encouraged to codify that information within the X12 environment.; Example NTE*SPT*XXXX~ Variants (all may be used) NTE Billing Note Max use 10 Optional NTE-01 363 Note Reference Code Identifier (ID) Required Code identifying the functional area or purpose for which the note applies ALG Allergies DCP Goals, Rehabilitation Potential, or Discharge Plans DGN Diagnosis Description DME Durable Medical Equipment (DME) and Supplies MED Medications NTR Nutritional Requirements ODT Orders for Disciplines and Treatments RHB Functional Limitations, Reason Homebound, or Both RLH Reasons Patient Leaves Home RNH Times and Reasons Patient Not at Home SET Unusual Home, Social Environment, or Both SFM Safety Measures SPT Supplementary Plan of Treatment UPI Updated Information NTE-02 352 Claim Note Text Min 1 Max 80 String (AN) Required A free-form description to clarify the related data elements and their content 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 360/579 CRC 2200 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > CRC EPSDT Referral To supply information on conditions Usage notes Required on Early & Periodic Screening, Diagnosis, and Treatment (EPSDT) claims when the screening service is being billed in this claim. If not required by this implementation guide, do not send. Example CRC*ZZ*N*S2*XXX*XX~ Max use 1 Optional CRC-01 1136 Code Qualifier Identifier (ID) Required Specifies the situation or category to which the code applies CRC01 qualifies CRC03 through CRC07. ZZ Mutually Defined EPSDT Screening referral information. CRC-02 1073 Certification Condition Code Applies Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply. Usage notes The response answers the question: Was an EPSDT referral given to the patient? N No If no, then choose "NU" in CRC03 indicating no referral given. Y Yes CRC-03 1321 Condition Indicator Identifier (ID) Required Code indicating a condition Usage notes The codes for CRC03 also can be used for CRC04 through CRC05. AV Available - Not Used Patient refused referral. NU Not Used This conditioner indicator must be used when the submitter answers "N" in CRC02. S2 Under Treatment Patient is currently under treatment for referred diagnostic or corrective health problem. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 361/579 ST New Services Requested Patient is referred to another provider for diagnostic or corrective treatment for at least one health problem identified during an initial or periodic screening service (not including dental referrals). OR Patient is scheduled for another appointment with screening provider for diagnostic or corrective treatment for at least one health problem identified during an initial or periodic screening service (not including dental referrals).; CRC-04 1321 Condition Indicator Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. CRC-05 1321 Condition Indicator Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 362/579 HI 2310 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > HI Admitting Diagnosis To supply information related to the delivery of health care Usage notes Required when claim involves an inpatient admission. If not required by this implementation guide, do not send.; Do not transmit the decimal point for ICD codes. The decimal point is implied. Example HI*BJ>X~ Variants (all may be used) HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 1 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABJ International Classification of Diseases Clinical Modification (ICD-10-CM) Admitting Diagnosis This code set is not allowed for use | Health Partner Plans 837 Health Care Claim_ Institutional.pdf |
(ID) Required Specifies the situation or category to which the code applies CRC01 qualifies CRC03 through CRC07. ZZ Mutually Defined EPSDT Screening referral information. CRC-02 1073 Certification Condition Code Applies Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply. Usage notes The response answers the question: Was an EPSDT referral given to the patient? N No If no, then choose "NU" in CRC03 indicating no referral given. Y Yes CRC-03 1321 Condition Indicator Identifier (ID) Required Code indicating a condition Usage notes The codes for CRC03 also can be used for CRC04 through CRC05. AV Available - Not Used Patient refused referral. NU Not Used This conditioner indicator must be used when the submitter answers "N" in CRC02. S2 Under Treatment Patient is currently under treatment for referred diagnostic or corrective health problem. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 361/579 ST New Services Requested Patient is referred to another provider for diagnostic or corrective treatment for at least one health problem identified during an initial or periodic screening service (not including dental referrals). OR Patient is scheduled for another appointment with screening provider for diagnostic or corrective treatment for at least one health problem identified during an initial or periodic screening service (not including dental referrals).; CRC-04 1321 Condition Indicator Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. CRC-05 1321 Condition Indicator Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 362/579 HI 2310 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > HI Admitting Diagnosis To supply information related to the delivery of health care Usage notes Required when claim involves an inpatient admission. If not required by this implementation guide, do not send.; Do not transmit the decimal point for ICD codes. The decimal point is implied. Example HI*BJ>X~ Variants (all may be used) HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 1 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABJ International Classification of Diseases Clinical Modification (ICD-10-CM) Admitting Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BJ International Classification of Diseases Clinical Modification (ICD-9-CM) Admitting Diagnosis C022-02 1271 Admitting Diagnosis Code Min 1 Max 30 String (AN) Required 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 363/579 Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 364/579 HI 2310 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > HI Condition Information To supply information related to the delivery of health care Usage notes Required when there is a Condition Code that applies to this claim. If not required by this implementation guide, do not send. Example HI*BG>X*BG>XXXXXX*BG>XXXX*BG>X*BG>XXX*BG>XXXX*B G>XXXX*BG>XXX*BG>XXXX*BG>XXXX*BG>X*BG>XXXXX~ Variants (all may be used) HI Admitting Diagnosis HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 2 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Max use 1 Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 365/579 Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 366/579 Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-06 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 367/579 Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-07 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 368/579 Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-10 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition | Health Partner Plans 837 Health Care Claim_ Institutional.pdf |
Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 368/579 Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-10 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 369/579 C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 370/579 HI 2310 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > HI Diagnosis Related Group (DRG) Information To supply information related to the delivery of health care Usage notes Required when an inpatient hospital is under DRG contract with a payer and the contract requires the provider to identify the DRG to the payer. If not required by this implementation guide, do not send. Example HI*DR>X~ Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 1 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. DR Diagnosis Related Group (DRG) C022-02 1271 Diagnosis Related Group (DRG) Code String (AN) Required Min 1 Max 30 Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 371/579 HI 2310 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > HI External Cause of Injury To supply information related to the delivery of health care Usage notes Required when an external Cause of Injury is needed to describe an injury, poisoning, or adverse effect. If not required by this implementation guide, do not send. Do not transmit the decimal point for ICD codes. The decimal point is implied. In order to fully describe an injury using ICD-10-CM, it will be necessary to report a series of 3 external cause of injury codes. Example HI*ABN>X>>>>>>>N*BN>XXX>>>>>>>Y*BN>XXXX>>>>>>>N*B N>XX>>>>>>>U*ABN>XX>>>>>>>N*ABN>XXX>>>>>>>Y*ABN>X X>>>>>>>Y*ABN>X>>>>>>>Y*ABN>XXXX>>>>>>>N*BN>XX>>> >>>>Y*ABN>XXX>>>>>>>N*BN>XXX>>>>>>>U~ Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 1 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 372/579 OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 373/579 BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 374/579 ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from | Health Partner Plans 837 Health Care Claim_ Institutional.pdf |
not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 373/579 BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 374/579 ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 375/579 This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 376/579 If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-06 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 377/579 The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-07 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 378/579 OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of | Health Partner Plans 837 Health Care Claim_ Institutional.pdf |
under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-07 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 378/579 OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 379/579 BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 380/579 ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-10 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 381/579 This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 382/579 If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at | Health Partner Plans 837 Health Care Claim_ Institutional.pdf |
unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 382/579 If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 383/579 The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 384/579 HI 2310 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > HI Occurrence Information To supply information related to the delivery of health care Usage notes Required when there is a Occurrence Code that applies to this claim. If not required by this implementation guide, do not send. Example HI*BH>XXX>D8>XXXX*BH>XX>D8>X*BH>X>D8>XXX*BH>XXX X>D8>XX*BH>XXXXX>D8>XXXXXX*BH>XXXX>D8>XXX*BH>XXXX XX>D8>XX*BH>XXXX>D8>XX*BH>XX>D8>XXXX*BH>XXXXXX>D 8>XXXXX*BH>X>D8>XXXXXX*BH>XX>D8>XXXXX~ Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 2 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 385/579 Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-03 C022 Health Care Code Information Max use 1 Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 386/579 To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 387/579 Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 388/579 Expression of a date, a time, or range of dates, times or dates and times HI-06 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and | Health Partner Plans 837 Health Care Claim_ Institutional.pdf |
and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 387/579 Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 388/579 Expression of a date, a time, or range of dates, times or dates and times HI-06 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-07 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 389/579 BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 390/579 C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-10 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 391/579 C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 392/579 D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 393/579 HI 2310 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > HI Occurrence Span Information To supply information related to the delivery of health care Usage notes Required when there is an Occurrence Span Code that applies to this claim. If not required by this implementation guide, do not send. Example HI*BI>XXXX>RD8>XXXX*BI>XXXXXX>RD8>X*BI>X>RD8>XXXX X*BI>XXXXX>RD8>XXX*BI>XXX>RD8>XX*BI>XXX>RD8>XXX*B I>XXXXX>RD8>XXX*BI>XXXXXX>RD8>XXXXXX*BI>XXXX>RD 8>XX*BI>XXXXXX>RD8>X*BI>XX>RD8>XXXXX*BI>XXXXXX>RD 8>X~ Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 2 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 394/579 C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code | Health Partner Plans 837 Health Care Claim_ Institutional.pdf |
when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 393/579 HI 2310 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > HI Occurrence Span Information To supply information related to the delivery of health care Usage notes Required when there is an Occurrence Span Code that applies to this claim. If not required by this implementation guide, do not send. Example HI*BI>XXXX>RD8>XXXX*BI>XXXXXX>RD8>X*BI>X>RD8>XXXX X*BI>XXXXX>RD8>XXX*BI>XXX>RD8>XX*BI>XXX>RD8>XXX*B I>XXXXX>RD8>XXX*BI>XXXXXX>RD8>XXXXXX*BI>XXXX>RD 8>XX*BI>XXXXXX>RD8>X*BI>XX>RD8>XXXXX*BI>XXXXXX>RD 8>X~ Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 2 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 394/579 C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Max use 1 Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 395/579 Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 396/579 If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-06 C022 Health Care Code Information Max use 1 Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 397/579 To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-07 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 398/579 Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 399/579 Expression of a date, a time, or range of dates, times or dates and times HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 | Health Partner Plans 837 Health Care Claim_ Institutional.pdf |
elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 398/579 Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 399/579 Expression of a date, a time, or range of dates, times or dates and times HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-10 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 400/579 BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 401/579 C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 402/579 HI 2310 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > HI Other Diagnosis Information To supply information related to the delivery of health care Usage notes Do not transmit the decimal point for ICD codes. The decimal point is implied. Required when other condition(s) coexist or develop(s) subsequently during the patient's treatment. If not required by this implementation guide, do not send. Example HI*BF>XX>>>>>>>Y*ABF>X>>>>>>>Y*ABF>XXXXXX>>>>>> >W*ABF>XXXXXX>>>>>>>U*BF>XX>>>>>>>N*ABF>XXXXXX>>> >>>>N*ABF>XXXXX>>>>>>>W*BF>XXXXX>>>>>>>N*BF>X>>>> >>>W*ABF>XX>>>>>>>N*BF>XX>>>>>>>N*BF>XXXX>>>>>> >N~ Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 2 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 403/579 BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 404/579 C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 | Health Partner Plans 837 Health Care Claim_ Institutional.pdf |
Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 404/579 C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 405/579 If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 406/579 Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 407/579 an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-06 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 408/579 C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-07 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred | Health Partner Plans 837 Health Care Claim_ Institutional.pdf |
a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 408/579 C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-07 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 409/579 N No U Unknown W Not Applicable Y Yes HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 410/579 Y Yes HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-10 C022 Health Care Code Information 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 411/579 To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Max use 1 Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 412/579 Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 413/579 C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification | Health Partner Plans 837 Health Care Claim_ Institutional.pdf |
the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Max use 1 Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 412/579 Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 413/579 C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 414/579 HI 2310 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > HI Other Procedure Information To supply information related to the delivery of health care Usage notes Required on inpatient claims when additional procedures must be reported. If not required by this implementation guide, do not send. Do not transmit the decimal point for ICD codes. The decimal point is implied. Example HI*BBQ>XXXXXX>D8>XX*BBQ>XXX>D8>XX*BBQ>XXXXXX>D 8>X*BBQ>XXXXXX>D8>XXXXXX*BQ>XXX>D8>XXXXX*BQ>XXXX X>D8>XXXXX*BBQ>X>D8>XXXXX*BBQ>XX>D8>XXXXX*BQ>X>D 8>XX*BBQ>XX>D8>XXXXXX*BQ>XX>D8>X*BBQ>XX>D8>XX~ Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 2 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 415/579 BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 416/579 If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 417/579 D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 418/579 Expression of a date, a time, or range of dates, times or dates and times HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other | Health Partner Plans 837 Health Care Claim_ Institutional.pdf |
at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 417/579 D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 418/579 Expression of a date, a time, or range of dates, times or dates and times HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-06 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Max use 1 Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 419/579 Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-07 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 420/579 Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 421/579 OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 422/579 C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-10 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other | Health Partner Plans 837 Health Care Claim_ Institutional.pdf |
Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 422/579 C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-10 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 423/579 Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 424/579 Expression of a date, a time, or range of dates, times or dates and times HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 425/579 HI 2310 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > HI Patient's Reason For Visit To supply information related to the delivery of health care Usage notes Required when claim involves outpatient visits. If not required by this implementation guide, do not send. Do not transmit the decimal point for ICD codes. The decimal point is implied. Example HI*PR>X*PR>XXX*APR>XXX~ Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 1 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 426/579 APR International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. PR International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit C022-02 1271 Patient Reason For Visit Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional Patient's Reason for Visit must be sent and the preceding HI data elements have been used to report other patient's reason for visit. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. APR International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. PR International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit C022-02 1271 Patient Reason For Visit Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 427/579 HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional Patient's Reason for Visit must be sent and the preceding HI data elements have been used to report other patient's reason for visit. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. APR International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. PR International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit C022-02 1271 Patient Reason For Visit Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 428/579 HI 2310 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > HI Principal Diagnosis To supply information related to the delivery of health care Usage notes Do not transmit the decimal point for ICD codes. The decimal point is implied. Example HI*BK>X>>>>>>>N~ Variants (all may be used) HI Admitting Diagnosis HI Condition | Health Partner Plans 837 Health Care Claim_ Institutional.pdf |
associated dates, amounts and quantities Usage notes Required when an additional Patient's Reason for Visit must be sent and the preceding HI data elements have been used to report other patient's reason for visit. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. APR International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. PR International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit C022-02 1271 Patient Reason For Visit Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 427/579 HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional Patient's Reason for Visit must be sent and the preceding HI data elements have been used to report other patient's reason for visit. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. APR International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. PR International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit C022-02 1271 Patient Reason For Visit Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 428/579 HI 2310 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > HI Principal Diagnosis To supply information related to the delivery of health care Usage notes Do not transmit the decimal point for ICD codes. The decimal point is implied. Example HI*BK>X>>>>>>>N~ Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 1 Required HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABK International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BK International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis C022-02 1271 Principal Diagnosis Code Min 1 Max 30 String (AN) Required 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 429/579 Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 430/579 HI 2310 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > HI Principal Procedure Information To supply information related to the delivery of health care Usage notes Required on inpatient claims when a procedure was performed. If not required by this implementation guide, do not send. Do not transmit the decimal point for ICD codes. The decimal point is implied. Example HI*CAH>XXXXXX>D8>XXX~ Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Treatment Code Information HI Value Information Max use 1 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 431/579 BBR International Classification of Diseases Clinical Modification (ICD-10-PCS) Principal Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BR International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Procedure Codes CAH Advanced Billing Concepts (ABC) Codes C022-02 1271 Principal Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Principal Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 432/579 HI 2310 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > HI Treatment Code Information To supply information related to the delivery of health care Usage notes Required when Home Health Agencies need to report Plan of Treatment information under various payer contracts. If not required by this implementation guide, do not send. Example HI*TC>XXX*TC>X*TC>XXXXXX*TC>XXXXXX*TC>X*TC>XXXX*T C>X*TC>XXX*TC>XXXX*TC>XXXXX*TC>XXX*TC>XXX~ Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Value Information Max use 2 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 433/579 Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 434/579 C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-06 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it | Health Partner Plans 837 Health Care Claim_ Institutional.pdf |
Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 433/579 Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 434/579 C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-06 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 435/579 TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-07 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 436/579 If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-10 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Max use 1 Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 437/579 Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 438/579 HI 2310 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > HI Value Information To supply information related to the delivery of health care Usage notes Required when there is a Value Code that applies to this claim. If not required by this implementation guide, do not send. Example HI*BE>XXXX>>>000000000000000*BE>XXXXX>>>000000*B E>XXX>>>000*BE>XXXX>>>00000*BE>XXXXXX>>>00000*B E>XXXX>>>000000000000000*BE>XX>>>00000000000000*B E>XXXXX>>>0000000000*BE>XX>>>0*BE>XXXX>>>00000000 000000*BE>XX>>>000000000000*BE>X>>>0000000000~ Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information Max use 2 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 439/579 C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 440/579 If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a | Health Partner Plans 837 Health Care Claim_ Institutional.pdf |
use 2 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 439/579 C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 440/579 If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 441/579 C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-06 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-07 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 442/579 BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 443/579 Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-10 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 444/579 C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 445/579 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 446/579 HCP 2410 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > HCP Claim Pricing/Repricing Information To specify pricing or repricing information about a health care claim or line item Usage notes Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send. This information is specific to the destination payer reported in Loop ID-2010BB. For capitated encounters, pricing or repricing information usually is not applicable and is provided to qualify other information within the claim. Example HCP*07*000000000*000*XXX*0000*XXXXXX*000000*XXXXX X***DA*000000000000*T4*3*2~ If either Unit or Basis for Measurement Code (HCP-11) or Repriced Approved Service Unit Count (HCP-12) is present, then the other is required Max use 1 Optional HCP-01 1473 Pricing Methodology Identifier (ID) Required Code specifying pricing methodology at which the claim or line item has been priced or repriced Usage notes Specific code use is determined by Trading Partner Agreement due to the variances in contracting policies in the industry. 00 Zero Pricing (Not Covered Under Contract) 01 Priced as Billed at 100% 02 Priced at the Standard Fee Schedule 03 Priced at a Contractual Percentage 04 Bundled Pricing 05 Peer Review Pricing 06 Per Diem Pricing 07 Flat Rate Pricing 08 Combination Pricing 09 Maternity Pricing 10 Other Pricing 11 Lower of Cost 12 Ratio of Cost 13 Cost Reimbursed 14 Adjustment Pricing HCP-02 782 Repriced Allowed Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 447/579 HCP02 is the allowed amount. HCP-03 782 Repriced Saving Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount HCP03 is the savings | Health Partner Plans 837 Health Care Claim_ Institutional.pdf |
specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 445/579 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 446/579 HCP 2410 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > HCP Claim Pricing/Repricing Information To specify pricing or repricing information about a health care claim or line item Usage notes Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send. This information is specific to the destination payer reported in Loop ID-2010BB. For capitated encounters, pricing or repricing information usually is not applicable and is provided to qualify other information within the claim. Example HCP*07*000000000*000*XXX*0000*XXXXXX*000000*XXXXX X***DA*000000000000*T4*3*2~ If either Unit or Basis for Measurement Code (HCP-11) or Repriced Approved Service Unit Count (HCP-12) is present, then the other is required Max use 1 Optional HCP-01 1473 Pricing Methodology Identifier (ID) Required Code specifying pricing methodology at which the claim or line item has been priced or repriced Usage notes Specific code use is determined by Trading Partner Agreement due to the variances in contracting policies in the industry. 00 Zero Pricing (Not Covered Under Contract) 01 Priced as Billed at 100% 02 Priced at the Standard Fee Schedule 03 Priced at a Contractual Percentage 04 Bundled Pricing 05 Peer Review Pricing 06 Per Diem Pricing 07 Flat Rate Pricing 08 Combination Pricing 09 Maternity Pricing 10 Other Pricing 11 Lower of Cost 12 Ratio of Cost 13 Cost Reimbursed 14 Adjustment Pricing HCP-02 782 Repriced Allowed Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 447/579 HCP02 is the allowed amount. HCP-03 782 Repriced Saving Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount HCP03 is the savings amount. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-04 127 Repricing Organization Identifier Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier HCP04 is the repricing organization identification number. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-05 118 Repricing Per Diem or Flat Rate Amount Decimal number (R) Optional Min 1 Max 9 Rate expressed in the standard monetary denomination for the currency specified HCP05 is the pricing rate associated with per diem or flat rate repricing. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-06 127 Repriced Approved DRG Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier HCP06 is the approved DRG code. HCP06, HCP07, HCP08, HCP10, and HCP12 are fields that will contain different values from the original submitted values. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-07 782 Repriced Approved Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount HCP07 is the approved DRG amount. Usage notes 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 448/579 This information is specific to the destination payer reported in Loop ID-2010BB. HCP-08 234 Repriced Approved Revenue Code Min 1 Max 48 String (AN) Optional Identifying number for a product or service HCP08 is the approved revenue code. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-11 355 Unit or Basis for Measurement Code Identifier (ID) Optional Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken DA Days UN Unit HCP-12 380 Repriced Approved Service Unit Count Decimal number (R) Optional Min 1 Max 15 Numeric value of quantity HCP12 is the approved service units or inpatient days. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three. HCP-13 901 Reject Reason Code Identifier (ID) Optional Code assigned by issuer to identify reason for rejection HCP13 is the rejection message returned from the third party organization. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. T1 Cannot Identify Provider as TPO (Third Party Organization) Participant T2 Cannot Identify Payer as TPO (Third Party Organization) Participant T3 Cannot Identify Insured as TPO (Third Party Organization) Participant T4 Payer Name or Identifier Missing T5 Certification Information Missing T6 Claim does not contain enough information for re-pricing HCP-14 1526 Policy Compliance Code Identifier (ID) Optional Code specifying policy compliance Usage notes 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 449/579 This information is specific to the destination payer reported in Loop ID-2010BB. 1 Procedure Followed (Compliance) 2 Not Followed - Call Not Made (Non-Compliance Call Not Made) 3 Not Medically Necessary (Non-Compliance Non-Medically Necessary) 4 Not Followed Other (Non-Compliance Other) 5 Emergency Admit to Non-Network Hospital HCP-15 1527 Exception Code Identifier (ID) Optional Code specifying the exception reason for consideration of out-of-network health care services HCP15 is the exception reason generated by a third party organization. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. 1 Non-Network Professional Provider in Network Hospital 2 Emergency Care 3 Services or Specialist not in Network 4 Out-of-Service Area 5 State Mandates 6 Other 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 450/579 2310A Attending Provider Name Loop Max 1 Optional Variants (all may be used) Operating Physician Name Loop Other Operating Physician Name Loop Rendering Provider Name Loop Service Facility Location Name Loop Referring Provider Name Loop NM1 2500 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Attending Provider Name Loop > NM1 Attending Provider Name To supply the full name of an individual or organizational entity Usage notes Required when the claim contains any services other than non-scheduled transportation claims. If not required by this implementation guide, do not send. The Attending Provider is the individual who has overall responsibility for the patient's medical care and treatment reported in this claim. Example NM1*71*1*XX*X*XXX**XX*XX*XXXXXX~ If either Identification Code Qualifier (NM1-08) or Attending Provider Primary Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 71 Attending Physician When used, the term physician is any type of provider filling this role. NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Attending Provider Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Attending Provider First Name Min 1 Max 35 String (AN) Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 451/579 Individual first name NM1-05 1037 Attending Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Attending Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Attending Provider Primary Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 452/579 PRV 2550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Attending Provider Name Loop > PRV Attending Provider Specialty Information To specify the identifying characteristics of a provider Usage notes Required when adjudication of the destination payer, or any subsequent payer listed on this claim, is known to be impacted by the attending provider taxonomy code. If not required by this implementation guide, do not send. Example PRV*AT*PXC*XXXXXX~ Max use 1 Optional PRV-01 1221 Provider Code Identifier (ID) Required Code identifying the type of provider AT Attending PRV-02 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification PXC Health Care Provider Taxonomy Code PRV-03 127 Provider Taxonomy Code Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 453/579 2310A Attending Provider Name Loop end REF 2710 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Attending Provider Name Loop > REF Attending Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. Example REF*LU*X~ Max use 4 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Attending Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 454/579 2310B Operating Physician Name Loop Max 1 Optional Variants (all may be used) Attending Provider Name Loop Other Operating Physician Name Loop Rendering Provider Name Loop Service Facility Location Name Loop Referring Provider Name Loop NM1 2500 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Operating Physician Name Loop > NM1 Operating Physician Name To supply the full name of an individual or organizational entity Usage notes Required when a surgical procedure code is listed on this claim. If not required by this implementation guide, do not send. The Operating Physician is the individual with primary responsibility for performing the | Health Partner Plans 837 Health Care Claim_ Institutional.pdf |
Level Loop > Claim Information Loop > Attending Provider Name Loop > PRV Attending Provider Specialty Information To specify the identifying characteristics of a provider Usage notes Required when adjudication of the destination payer, or any subsequent payer listed on this claim, is known to be impacted by the attending provider taxonomy code. If not required by this implementation guide, do not send. Example PRV*AT*PXC*XXXXXX~ Max use 1 Optional PRV-01 1221 Provider Code Identifier (ID) Required Code identifying the type of provider AT Attending PRV-02 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification PXC Health Care Provider Taxonomy Code PRV-03 127 Provider Taxonomy Code Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 453/579 2310A Attending Provider Name Loop end REF 2710 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Attending Provider Name Loop > REF Attending Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. Example REF*LU*X~ Max use 4 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Attending Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 454/579 2310B Operating Physician Name Loop Max 1 Optional Variants (all may be used) Attending Provider Name Loop Other Operating Physician Name Loop Rendering Provider Name Loop Service Facility Location Name Loop Referring Provider Name Loop NM1 2500 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Operating Physician Name Loop > NM1 Operating Physician Name To supply the full name of an individual or organizational entity Usage notes Required when a surgical procedure code is listed on this claim. If not required by this implementation guide, do not send. The Operating Physician is the individual with primary responsibility for performing the surgical procedure(s). Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Example NM1*72*1*XX*XXXXXX*XXXX**X*XX*XXXXXX~ If either Identification Code Qualifier (NM1-08) or Operating Physician Primary Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 72 Operating Physician NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Operating Physician Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Operating Physician First Name Min 1 Max 35 String (AN) Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 455/579 Individual first name NM1-05 1037 Operating Physician Middle Name or Initial String (AN) Optional Min 1 Max 25 Individual middle name or initial NM1-07 1039 Operating Physician Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Operating Physician Primary Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 456/579 2310B Operating Physician Name Loop end REF 2710 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Operating Physician Name Loop > REF Operating Physician Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. Example REF*LU*XXXX~ Max use 4 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Operating Physician Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 457/579 2310C Other Operating Physician Name Loop Max 1 Optional Variants (all may be used) Attending Provider Name Loop Operating Physician Name Loop Rendering Provider Name Loop Service Facility Location Name Loop Referring Provider Name Loop NM1 2500 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Operating Physician Name Loop > NM1 Other Operating Physician Name To supply the full name of an individual or organizational entity Usage notes Required when another Operating Physician is involved. If not required by the implementation guide, do not send. The Other Operating Physician is the individual performing a secondary surgical procedure or assisting the Operating Physician. This Other Operating Physician segment can only be used when Operating Physician information (Loop ID-2310B) is also sent on this claim. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Example NM1*ZZ*1*XXXX*XXXX*X**XXXXXX*XX*XXX~ If either Identification Code Qualifier (NM1-08) or Other Operating Physician Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual ZZ Mutually Defined ZZ is used to indicate Other Operating Physician. NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Other Operating Physician Last Name Min 1 Max 60 String (AN) Required 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 458/579 Individual last name or organizational name NM1-04 1036 Other Operating Physician First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Other Operating Physician Middle Name or Initial String (AN) Optional Min 1 Max 25 Individual middle name or initial NM1-07 1039 Other Operating Physician Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Other Operating Physician Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 459/579 2310C Other Operating Physician Name Loop end REF 2710 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Operating Physician Name Loop > REF Other Operating Physician Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. Example REF*0B*X~ Max use 4 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Other Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 460/579 2310D Rendering Provider Name Loop Max 1 Optional Variants (all may be used) Attending Provider Name Loop Operating Physician Name Loop Other Operating Physician Name Loop Service Facility Location Name Loop Referring Provider Name Loop NM1 2500 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Rendering Provider Name Loop > NM1 Rendering Provider Name To supply the full name of an individual or organizational entity Usage notes Required when the Rendering Provider is different than the Attending Provider reported in Loop ID-2310A of this claim. AND When state or federal regulatory requirements call for a "combined claim", that is, a claim that includes both facility and professional components (for example, a Medicaid clinic bill or Critical Access Hospital Claim.) If not required by this implementation guide, do not send. The Rendering Provider is the health care professional who delivers or completes a particular medical service or non-surgical procedure. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Example NM1*82*1*XXX*XX*XXXXXX**XX*XX*XXXXXX~ If either Identification Code Qualifier (NM1-08) or Rendering Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 82 Rendering Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Rendering Provider Last Name Min 1 Max 60 String (AN) Required 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 461/579 Individual last name or organizational name NM1-04 1036 Rendering Provider First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Rendering Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Rendering Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Rendering Provider Identifier Min | Health Partner Plans 837 Health Care Claim_ Institutional.pdf |
do not send. Example REF*0B*X~ Max use 4 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Other Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 460/579 2310D Rendering Provider Name Loop Max 1 Optional Variants (all may be used) Attending Provider Name Loop Operating Physician Name Loop Other Operating Physician Name Loop Service Facility Location Name Loop Referring Provider Name Loop NM1 2500 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Rendering Provider Name Loop > NM1 Rendering Provider Name To supply the full name of an individual or organizational entity Usage notes Required when the Rendering Provider is different than the Attending Provider reported in Loop ID-2310A of this claim. AND When state or federal regulatory requirements call for a "combined claim", that is, a claim that includes both facility and professional components (for example, a Medicaid clinic bill or Critical Access Hospital Claim.) If not required by this implementation guide, do not send. The Rendering Provider is the health care professional who delivers or completes a particular medical service or non-surgical procedure. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Example NM1*82*1*XXX*XX*XXXXXX**XX*XX*XXXXXX~ If either Identification Code Qualifier (NM1-08) or Rendering Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 82 Rendering Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Rendering Provider Last Name Min 1 Max 60 String (AN) Required 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 461/579 Individual last name or organizational name NM1-04 1036 Rendering Provider First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Rendering Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Rendering Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Rendering Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 462/579 2310D Rendering Provider Name Loop end REF 2710 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Rendering Provider Name Loop > REF Rendering Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. Example REF*1G*XXXXXX~ Max use 4 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Rendering Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 463/579 2310E Service Facility Location Name Loop Max 1 Optional Variants (all may be used) Attending Provider Name Loop Operating Physician Name Loop Other Operating Physician Name Loop Rendering Provider Name Loop Referring Provider Name Loop NM1 2500 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Facility Location Name Loop > NM1 Service Facility Location Name To supply the full name of an individual or organizational entity Usage notes Required when the location of health care service is different than that carried in Loop ID-2010AA (Billing Provider). If not required by this implementation guide, do not send. When an organization health care provider's NPI is provided to identify the Service Location, the organization health care provider must be external to the entity identified as the Billing Provider (for example, reference lab). It is not permissible to report an organization health care provider NPI as the Service Location if the entity being identified is a component (for example, subpart) of the Billing Provider. In that case, the subpart must be the Billing Provider. Example NM1*77*2*XX*****XX*XXX~ If either Identification Code Qualifier (NM1-08) or Laboratory or Facility Primary Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 77 Service Location NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Laboratory or Facility Name Min 1 Max 60 String (AN) Required 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 464/579 Individual last name or organizational name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Laboratory or Facility Primary Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 465/579 N3 2650 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Facility Location Name Loop > N3 Service Facility Location Address To specify the location of the named party Usage notes If service facility location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".) Example N3*X*XXXXXX~ Max use 1 Required N3-01 166 Laboratory or Facility Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Laboratory or Facility Address Line Min 1 Max 55 String (AN) Optional Address information 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 466/579 N4 2700 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Facility Location Name Loop > N4 Service Facility Location City, State, ZIP Code To specify the geographic place of the named party Example N4*XX*XX*XXX*XX~ Only one of Laboratory or Facility State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Laboratory or Facility City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Laboratory or Facility State or Province Code Identifier (ID) Optional Min 2 Max 2 Code (Standard State/Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Laboratory or Facility Postal Zone or ZIP Code Identifier (ID) Optional Min 3 Max 15 Code defining international postal zone code excluding punctuation and blanks (zip code for United States) Usage notes When reporting the ZIP code for U.S. addresses, the full nine digit ZIP code must be provided. N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 467/579 Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 468/579 2310E Service Facility Location Name Loop end REF 2710 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Facility Location Name Loop > REF Service Facility Location Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI implementation date when the entity is not a Health Care provider (a.k.a. an atypical provider), and an identifier is necessary for the claims processor to identify the entity. If not required by this implementation guide, do not send. Example REF*LU*XX~ Max use 3 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Laboratory or Facility Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 469/579 2310F Referring Provider Name Loop Max 1 Optional Variants (all may be used) Attending Provider Name Loop Operating Physician Name Loop Other Operating Physician Name Loop Rendering Provider Name Loop Service Facility Location Name Loop NM1 2500 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Referring Provider Name Loop > NM1 Referring Provider Name To supply the full name of an individual or organizational entity Usage notes Required on an outpatient claim when the Referring Provider is different than the Attending Provider. If not required by this implementation guide, do not send. The Referring Provider is provider who sends the patient to another provider for services. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Example NM1*DN*1*XXXXXX*XXX*X**X*XX*XX~ If either Identification Code Qualifier (NM1-08) or Referring Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual DN Referring Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity | Health Partner Plans 837 Health Care Claim_ Institutional.pdf |
Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 467/579 Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 468/579 2310E Service Facility Location Name Loop end REF 2710 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Facility Location Name Loop > REF Service Facility Location Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI implementation date when the entity is not a Health Care provider (a.k.a. an atypical provider), and an identifier is necessary for the claims processor to identify the entity. If not required by this implementation guide, do not send. Example REF*LU*XX~ Max use 3 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Laboratory or Facility Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 469/579 2310F Referring Provider Name Loop Max 1 Optional Variants (all may be used) Attending Provider Name Loop Operating Physician Name Loop Other Operating Physician Name Loop Rendering Provider Name Loop Service Facility Location Name Loop NM1 2500 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Referring Provider Name Loop > NM1 Referring Provider Name To supply the full name of an individual or organizational entity Usage notes Required on an outpatient claim when the Referring Provider is different than the Attending Provider. If not required by this implementation guide, do not send. The Referring Provider is provider who sends the patient to another provider for services. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Example NM1*DN*1*XXXXXX*XXX*X**X*XX*XX~ If either Identification Code Qualifier (NM1-08) or Referring Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual DN Referring Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Referring Provider Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Referring Provider First Name Min 1 Max 35 String (AN) Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 470/579 Individual first name NM1-05 1037 Referring Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Referring Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Referring Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 471/579 2310F Referring Provider Name Loop end REF 2710 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Referring Provider Name Loop > REF Referring Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. The REF segment in Loop ID-2310 applies to the entire claim unless overridden on the service line level by the presence of a REF segment with the same value in REF01. Example REF*G2*XXXXXX~ Max use 3 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. REF-02 127 Referring Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 472/579 2320 Other Subscriber Information Loop Max 10 Optional SBR 2900 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > SBR Other Subscriber Information To record information specific to the primary insured and the insurance carrier for that insured Usage notes Required when other payers are known to potentially be involved in paying on this claim. If not required by this implementation guide, do not send. All information contained in Loop ID-2320 applies only to the payer identified in Loop ID-2330B of this iteration of Loop ID-2320. It is specific only to that payer. If information for an additional payer is necessary, repeat Loop ID-2320 with its respective 2330 Loops.; See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example SBR*A*18*XX*X*****16~ Max use 1 Required SBR-01 1138 Payer Responsibility Sequence Number Code Identifier (ID) Required Code identifying the insurance carrier's level of responsibility for a payment of a claim Usage notes Within a given claim, the various values for the Payer Responsibility Sequence Number Code (other than value "U") may occur no more than once. A Payer Responsibility Four B Payer Responsibility Five C Payer Responsibility Six D Payer Responsibility Seven E Payer Responsibility Eight F Payer Responsibility Nine G Payer Responsibility Ten H Payer Responsibility Eleven P Primary S Secondary T Tertiary U Unknown This code may only be used in payer to payer COB claims when the original payer determined the presence of this coverage from eligibility files received from this payer or when the original claim did not provide the responsibility sequence for this payer. SBR-02 1069 Individual Relationship Code Identifier (ID) Required Code indicating the relationship between two individuals or entities SBR02 specifies the relationship to the person insured. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 473/579 01 Spouse 18 Self 19 Child 20 Employee 21 Unknown 39 Organ Donor 40 Cadaver Donor 53 Life Partner G8 Other Relationship SBR-03 127 Insured Group or Policy Number Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier SBR03 is policy or group number. Usage notes This is not the number uniquely identifying the subscriber. The unique subscriber number is submitted in Loop 2330A-NM109 for this iteration of Loop ID-2320. SBR-04 93 Other Insured Group Name Min 1 Max 60 String (AN) Optional Free-form name SBR04 is plan name. SBR-09 1032 Claim Filing Indicator Code Identifier (ID) Required Code identifying type of claim 11 Other Non-Federal Programs 12 Preferred Provider Organization (PPO) 13 Point of Service (POS) 14 Exclusive Provider Organization (EPO) 15 Indemnity Insurance 16 Health Maintenance Organization (HMO) Medicare Risk 17 Dental Maintenance Organization AM Automobile Medical BL Blue Cross/Blue Shield CH Champus CI Commercial Insurance Co. DS Disability FI Federal Employees Program HM Health Maintenance Organization LM Liability Medical MA Medicare Part A MB Medicare Part B MC Medicaid OF Other Federal Program Use code OF when submitting Medicare Part D claims. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 474/579 TV Title V VA Veterans Affairs Plan WC Workers' Compensation Health Claim ZZ Mutually Defined Use Code ZZ when Type of Insurance is not known. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 475/579 CAS 2950 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > CAS Claim Level Adjustments To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid Usage notes Required when the claim has been adjudicated by the payer identified in this loop, and the claim has claim level adjustment information. If not required by this implementation guide, do not send. Submitters must use this CAS segment to report prior payers' claim level adjustments that cause the amount paid to differ from the amount originally charged. Only one Group Code is allowed per CAS. If it is necessary to send more than one Group Code at the claim level, repeat the CAS segment. Codes and associated amounts must come from either paper remittance advice or 835s (Electronic Remittance Advice) received on the claim. When the information originates from a paper remittance advice that does not use the standard Claim Adjustment Reason Codes, the paper values must be converted to standard Claim Adjustment Reason Codes.; A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a particular Claim Adjustment Group Code (CAS01). The first non-zero adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19). Example CAS*PR*X*0000000000000*00000000000000*X*0000000*0 00000000000*XXX*00000000000000*0000000*XXXXX*000 0*00000000*XXXX*0000*0000*X*00000000000000*000000 00~ If Adjustment Reason Code (CAS-05) is present, then at least one of Adjustment Amount (CAS-06) or Adjustment Quantity (CAS-07) is required If Adjustment Amount (CAS-06) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Quantity (CAS-07) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Reason Code (CAS-08) is present, then at least one of Adjustment Amount (CAS-09) or Adjustment Quantity (CAS-10) is required If Adjustment Amount (CAS-09) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Quantity (CAS-10) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Reason Code (CAS-11) is present, then at least one of Adjustment Amount (CAS-12) or Adjustment Quantity (CAS-13) is required If Adjustment Amount (CAS-12) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Quantity (CAS-13) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS-16) is required Max use 5 Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 476/579 If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS-19) is required If Adjustment Amount (CAS-18) is | Health Partner Plans 837 Health Care Claim_ Institutional.pdf |
2950 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > CAS Claim Level Adjustments To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid Usage notes Required when the claim has been adjudicated by the payer identified in this loop, and the claim has claim level adjustment information. If not required by this implementation guide, do not send. Submitters must use this CAS segment to report prior payers' claim level adjustments that cause the amount paid to differ from the amount originally charged. Only one Group Code is allowed per CAS. If it is necessary to send more than one Group Code at the claim level, repeat the CAS segment. Codes and associated amounts must come from either paper remittance advice or 835s (Electronic Remittance Advice) received on the claim. When the information originates from a paper remittance advice that does not use the standard Claim Adjustment Reason Codes, the paper values must be converted to standard Claim Adjustment Reason Codes.; A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a particular Claim Adjustment Group Code (CAS01). The first non-zero adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19). Example CAS*PR*X*0000000000000*00000000000000*X*0000000*0 00000000000*XXX*00000000000000*0000000*XXXXX*000 0*00000000*XXXX*0000*0000*X*00000000000000*000000 00~ If Adjustment Reason Code (CAS-05) is present, then at least one of Adjustment Amount (CAS-06) or Adjustment Quantity (CAS-07) is required If Adjustment Amount (CAS-06) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Quantity (CAS-07) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Reason Code (CAS-08) is present, then at least one of Adjustment Amount (CAS-09) or Adjustment Quantity (CAS-10) is required If Adjustment Amount (CAS-09) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Quantity (CAS-10) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Reason Code (CAS-11) is present, then at least one of Adjustment Amount (CAS-12) or Adjustment Quantity (CAS-13) is required If Adjustment Amount (CAS-12) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Quantity (CAS-13) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS-16) is required Max use 5 Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 476/579 If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS-19) is required If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required CAS-01 1033 Claim Adjustment Group Code Identifier (ID) Required Code identifying the general category of payment adjustment CO Contractual Obligations CR Correction and Reversals OA Other adjustments PI Payor Initiated Reductions PR Patient Responsibility CAS-02 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Required Code identifying the detailed reason the adjustment was made Usage notes See CODE SOURCE 139: Claim Adjustment Reason Code CAS-03 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CAS03 is the amount of adjustment. CAS-04 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS04 is the units of service being adjusted. CAS-05 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-06 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 477/579 CAS06 is the amount of the adjustment. CAS-07 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS07 is the units of service being adjusted. CAS-08 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-09 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS09 is the amount of the adjustment. CAS-10 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS10 is the units of service being adjusted. CAS-11 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-12 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS12 is the amount of the adjustment. CAS-13 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS13 is the units of service being adjusted. CAS-14 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 478/579 CAS-15 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS15 is the amount of the adjustment. CAS-16 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS16 is the units of service being adjusted. CAS-17 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-18 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS18 is the amount of the adjustment. CAS-19 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS19 is the units of service being adjusted. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 479/579 AMT 3000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > AMT Coordination of Benefits (COB) Payer Paid Amount To indicate the total monetary amount Usage notes Required when the claim has been adjudicated by the payer identified in Loop ID- 2330B of this loop. OR Required when Loop ID-2010AC is present. In this case, the claim is a post payment recovery claim submitted by a subrogated Medicaid agency. If not required by this implementation guide, do not send.; Example AMT*D*000~ Variants (all may be used) AMT Coordination of Benefits (COB) Total Non-Covered Amount AMT Remaining Patient Liability Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount D Payor Amount Paid AMT-02 782 Payer Paid Amount Min 1 Max 15 Decimal number (R) Required Monetary amount Usage notes It is acceptable to show "0" as the amount paid. When Loop ID-2010AC is present, this is the amount the Medicaid agency actually paid. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 480/579 AMT 3000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > AMT Coordination of Benefits (COB) Total Non-Covered Amount To indicate the total monetary amount Usage notes Required when the destination payer's cost avoidance policy allows providers to bypass claim submission to the otherwise prior payer identified in Loop ID-2330B. If not required by this implementation guide, do not send. When this segment is used, the amount reported in AMT02 must equal the total claim charge amount reported in CLM02. Neither the prior payer paid AMT, nor any CAS segments are used as this claim has not been adjudicated by this payer. Example AMT*A8*00000000~ Variants (all may be used) AMT Coordination of Benefits (COB) Payer Paid Amount AMT Remaining Patient Liability Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount A8 Noncovered Charges - Actual AMT-02 782 Non-Covered Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 481/579 AMT 3000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > AMT Remaining Patient Liability To indicate the total monetary amount Usage notes Required when the Other Payer identified in Loop ID-2330B (of this iteration of Loop ID-2320) has adjudicated this claim and provided claim level information only. OR Required when the Other Payer identified in Loop ID-2330B (of this iteration of Loop ID-2320) has adjudicated this claim and the provider received a paper remittance advice and the provider does not have the ability to report line item information. If not required by this implementation guide, do not send. In the judgment of the provider, this is the remaining amount to be paid after adjudication by the Other Payer identified in Loop ID-2330B of this iteration of Loop ID-2320. This segment is only used in provider submitted claims. It is not used in Payer-to-Payer Coordination of Benefits (COB). This segment is not used if the line level (Loop ID-2430) Remaining Patient Liability AMT segment is used for this Other Payer. Example AMT*EAF*00000000~ Variants (all may be used) AMT Coordination of Benefits (COB) Payer Paid Amount AMT Coordination of Benefits (COB) Total Non-Covered Amount Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount EAF Amount Owed AMT-02 782 Remaining Patient Liability Min 1 Max 15 Decimal number (R) Required Monetary amount 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 482/579 OI 3100 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > OI Other Insurance Coverage Information To specify information associated with other health insurance coverage Usage notes All information contained in the OI segment applies only to the payer identified in Loop ID-2330B in this iteration of Loop ID-2320. Example OI***N***Y~ Max use 1 Required OI-03 1073 Benefits Assignment Certification Indicator Identifier (ID) Required Code indicating a Yes or No condition or response OI03 is the assignment of benefits indicator. A "Y" value indicates insured or authorized person authorizes benefits to be assigned to the provider; an "N" value indicates benefits have not been assigned to the provider. Usage notes This is a crosswalk from CLM08 when doing COB. This element answers the question whether or not the insured has authorized the plan to remit payment directly to the provider. N No W Not Applicable Use code `W' when the patient refuses to assign benefits. Y Yes OI-06 1363 Release of Information Code Identifier (ID) Required Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations Usage notes This is a crosswalk from CLM09 when doing COB. The Release of Information response is limited to the information carried in this claim. I Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes Required when the provider has not collected a signature AND state or federal laws do not require a signature be collected. Y Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim Required when the provider has collected a signature. OR Required when state or federal laws require a signature be collected. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 483/579 MIA 3150 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > MIA Inpatient Adjudication Information To provide claim-level data related to the adjudication of Medicare inpatient claims Usage notes Required | Health Partner Plans 837 Health Care Claim_ Institutional.pdf |
provider, this is the remaining amount to be paid after adjudication by the Other Payer identified in Loop ID-2330B of this iteration of Loop ID-2320. This segment is only used in provider submitted claims. It is not used in Payer-to-Payer Coordination of Benefits (COB). This segment is not used if the line level (Loop ID-2430) Remaining Patient Liability AMT segment is used for this Other Payer. Example AMT*EAF*00000000~ Variants (all may be used) AMT Coordination of Benefits (COB) Payer Paid Amount AMT Coordination of Benefits (COB) Total Non-Covered Amount Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount EAF Amount Owed AMT-02 782 Remaining Patient Liability Min 1 Max 15 Decimal number (R) Required Monetary amount 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 482/579 OI 3100 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > OI Other Insurance Coverage Information To specify information associated with other health insurance coverage Usage notes All information contained in the OI segment applies only to the payer identified in Loop ID-2330B in this iteration of Loop ID-2320. Example OI***N***Y~ Max use 1 Required OI-03 1073 Benefits Assignment Certification Indicator Identifier (ID) Required Code indicating a Yes or No condition or response OI03 is the assignment of benefits indicator. A "Y" value indicates insured or authorized person authorizes benefits to be assigned to the provider; an "N" value indicates benefits have not been assigned to the provider. Usage notes This is a crosswalk from CLM08 when doing COB. This element answers the question whether or not the insured has authorized the plan to remit payment directly to the provider. N No W Not Applicable Use code `W' when the patient refuses to assign benefits. Y Yes OI-06 1363 Release of Information Code Identifier (ID) Required Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations Usage notes This is a crosswalk from CLM09 when doing COB. The Release of Information response is limited to the information carried in this claim. I Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes Required when the provider has not collected a signature AND state or federal laws do not require a signature be collected. Y Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim Required when the provider has collected a signature. OR Required when state or federal laws require a signature be collected. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 483/579 MIA 3150 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > MIA Inpatient Adjudication Information To provide claim-level data related to the adjudication of Medicare inpatient claims Usage notes Required when inpatient adjudication information is reported in the remittance advice. OR Required when it is necessary to report remark codes. If not required by this implementation guide, do not send. Example MIA*000**00000000*00*X*0000000000*0000*0000000000 0000*0*0000000000000*000000*0000000000000*00000*0 00*00000000000*000000*000000*00000*00000000000*XX XXXX*X*XX*XXXX*00000000000000~ Max use 1 Optional MIA-01 380 Covered Days or Visits Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity MIA01 is the covered days. MIA-03 380 Lifetime Psychiatric Days Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity MIA03 is the lifetime psychiatric days. MIA-04 782 Claim DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA04 is the Diagnosis Related Group (DRG) amount. MIA-05 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA05 is the Claim Payment Remark Code. See Code Source 411. MIA-06 782 Claim Disproportionate Share Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 484/579 MIA06 is the disproportionate share amount. MIA-07 782 Claim MSP Pass-through Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA07 is the Medicare Secondary Payer (MSP) pass-through amount. MIA-08 782 Claim PPS Capital Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA08 is the total Prospective Payment System (PPS) capital amount. MIA-09 782 PPS-Capital FSP DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA09 is the Prospective Payment System (PPS) capital, federal specific portion, Diagnosis Related Group (DRG) amount. MIA-10 782 PPS-Capital HSP DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA10 is the Prospective Payment System (PPS) capital, hospital specific portion, Diagnosis Related Group (DRG), amount. MIA-11 782 PPS-Capital DSH DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA11 is the Prospective Payment System (PPS) capital, disproportionate share, hospital Diagnosis Related Group (DRG) amount. MIA-12 782 Old Capital Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA12 is the old capital amount. MIA-13 782 PPS-Capital IME amount Min 1 Max 15 Decimal number (R) Optional Monetary amount 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 485/579 MIA13 is the Prospective Payment System (PPS) capital indirect medical education claim amount. MIA-14 782 PPS-Operating Hospital Specific DRG Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA14 is hospital specific Diagnosis Related Group (DRG) Amount. MIA-15 380 Cost Report Day Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity MIA15 is the cost report days. MIA-16 782 PPS-Operating Federal Specific DRG Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA16 is the federal specific Diagnosis Related Group (DRG) amount. MIA-17 782 Claim PPS Capital Outlier Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA17 is the Prospective Payment System (PPS) Capital Outlier amount. MIA-18 782 Claim Indirect Teaching Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA18 is the indirect teaching amount. MIA-19 782 Non-Payable Professional Component Billed Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA19 is the professional component amount billed but not payable. MIA-20 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 486/579 MIA20 is the Claim Payment Remark Code. See Code Source 411. MIA-21 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA21 is the Claim Payment Remark Code. See Code Source 411. MIA-22 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA22 is the Claim Payment Remark Code. See Code Source 411. MIA-23 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA23 is the Claim Payment Remark Code. See Code Source 411. MIA-24 782 PPS-Capital Exception Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA24 is the capital exception amount. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 487/579 MOA 3200 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > MOA Outpatient Adjudication Information To convey claim-level data related to the adjudication of Medicare claims not related to an inpatient setting Usage notes Required when outpatient adjudication information is reported in the remittance advice OR Required when it is necessary to report remark codes. If not required by this implementation guide, do not send. Example MOA*00*000000*XXX*XXXXXX*XXX*XXX*XXXX*00000000000 00*0000000~ Max use 1 Optional MOA-01 954 Reimbursement Rate Min 1 Max 10 Decimal number (R) Optional Percentage expressed as a decimal (e.g., 0.0 through 1.0 represents 0% through 100%) MOA01 is the reimbursement rate. MOA-02 782 HCPCS Payable Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MOA02 is the claim Health Care Financing Administration Common Procedural Coding System (HCPCS) payable amount. MOA-03 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA03 is the Claim Payment Remark Code. See Code Source 411. MOA-04 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA04 is the Claim Payment Remark Code. See Code Source 411. MOA-05 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 488/579 MOA05 is the Claim Payment Remark Code. See Code Source 411. MOA-06 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA06 is the Claim Payment Remark Code. See Code Source 411. MOA-07 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA07 is the Claim Payment Remark Code. See Code Source 411. MOA-08 782 End Stage Renal Disease Payment Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MOA08 is the End Stage Renal Disease (ESRD) payment amount. MOA-09 782 Non-Payable Professional Component Billed Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MOA09 is the professional component amount billed but not payable. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 489/579 2330A Other Subscriber Name Loop Max 1 Required Variants (all may be used) Other Payer Name Loop Other Payer Attending Provider Loop Other Payer Operating Physician Loop Other Payer Other Operating Physician Loop Other Payer Service Facility Location Loop Other Payer Rendering Provider Name Loop Other Payer Referring Provider Loop Other Payer Billing Provider Loop NM1 3250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Subscriber Name Loop > NM1 Other Subscriber Name To supply the full name of an individual or organizational entity Usage notes If the patient can be uniquely identified to the Other Payer indicated in this iteration of Loop ID-2320 by a unique Member Identification Number, then the patient is the subscriber or is considered to be the subscriber and is identified in this Other Subscriber's Name Loop ID-2330A.; If the patient is a dependent of the subscriber for this other coverage and cannot be uniquely identified to the Other Payer indicated in this iteration of Loop ID-2320 by a unique Member Identification Number, then the subscriber for this other coverage is identified in this Other Subscriber's Name Loop ID-2330A. See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example NM1*IL*1*XXXXX*X*XXXXXX**XXXX*II*XX~ Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual IL Insured or Subscriber NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 490/579 NM1-03 1035 Other Insured Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Other | Health Partner Plans 837 Health Care Claim_ Institutional.pdf |
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 488/579 MOA05 is the Claim Payment Remark Code. See Code Source 411. MOA-06 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA06 is the Claim Payment Remark Code. See Code Source 411. MOA-07 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA07 is the Claim Payment Remark Code. See Code Source 411. MOA-08 782 End Stage Renal Disease Payment Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MOA08 is the End Stage Renal Disease (ESRD) payment amount. MOA-09 782 Non-Payable Professional Component Billed Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MOA09 is the professional component amount billed but not payable. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 489/579 2330A Other Subscriber Name Loop Max 1 Required Variants (all may be used) Other Payer Name Loop Other Payer Attending Provider Loop Other Payer Operating Physician Loop Other Payer Other Operating Physician Loop Other Payer Service Facility Location Loop Other Payer Rendering Provider Name Loop Other Payer Referring Provider Loop Other Payer Billing Provider Loop NM1 3250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Subscriber Name Loop > NM1 Other Subscriber Name To supply the full name of an individual or organizational entity Usage notes If the patient can be uniquely identified to the Other Payer indicated in this iteration of Loop ID-2320 by a unique Member Identification Number, then the patient is the subscriber or is considered to be the subscriber and is identified in this Other Subscriber's Name Loop ID-2330A.; If the patient is a dependent of the subscriber for this other coverage and cannot be uniquely identified to the Other Payer indicated in this iteration of Loop ID-2320 by a unique Member Identification Number, then the subscriber for this other coverage is identified in this Other Subscriber's Name Loop ID-2330A. See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example NM1*IL*1*XXXXX*X*XXXXXX**XXXX*II*XX~ Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual IL Insured or Subscriber NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 490/579 NM1-03 1035 Other Insured Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Other Insured First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Other Insured Middle Name Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Other Insured Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system/method of code structure used for Identification Code (67) II Standard Unique Health Identifier for each Individual in the United States Required if the HIPAA Individual Patient Identifier is mandated use. If not required, use value `MI' instead. MI Member Identification Number The code MI is intended to be the subscriber's identification number as assigned by the payer. (For example, Insured's ID, Subscriber's ID, Health Insurance Claim Number (HIC), etc.) MI is also intended to be used in claims submitted to the Indian Health Service/Contract Health Services (IHS/CHS) Fiscal Intermediary for the purpose of reporting the Tribe Residency Code (Tribe County State). In the event that a Social Security Number (SSN) is also available on an IHS/CHS claim, put the SSN in REF02. When sending the Social Security Number as the Member ID, it must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid. NM1-09 67 Other Insured Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 491/579 N3 3320 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Subscriber Name Loop > N3 Other Subscriber Address To specify the location of the named party Usage notes Required when the information is available. If not required by this implementation guide, do not send. Example N3*X*XX~ Max use 1 Optional N3-01 166 Other Insured Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Other Insured Address Line Min 1 Max 55 String (AN) Optional Address information 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 492/579 N4 3400 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Subscriber Name Loop > N4 Other Subscriber City, State, ZIP Code To specify the geographic place of the named party Usage notes Required when the information is available. If not required by this implementation guide, do not send. Example N4*XX*XX*XXXXXX*XXX~ Only one of Other Insured State Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Optional N4-01 19 Other Insured City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Other Insured State Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State/Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Other Insured Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 493/579 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 494/579 2330A Other Subscriber Name Loop end REF 3550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Subscriber Name Loop > REF Other Subscriber Secondary Identification To specify identifying information Usage notes Required when an additional identification number to that provided in NM109 of this loop is necessary for the claim processor to identify the entity. If not required by this implementation guide, do not send. Example REF*SY*XXX~ Max use 2 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification SY Social Security Number The Social Security Number must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid. REF-02 127 Other Insured Additional Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 495/579 2330B Other Payer Name Loop Max 1 Required Variants (all may be used) Other Subscriber Name Loop Other Payer Attending Provider Loop Other Payer Operating Physician Loop Other Payer Other Operating Physician Loop Other Payer Service Facility Location Loop Other Payer Rendering Provider Name Loop Other Payer Referring Provider Loop Other Payer Billing Provider Loop NM1 3250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > NM1 Other Payer Name To supply the full name of an individual or organizational entity Usage notes See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example NM1*PR*2*X*****PI*XXX~ Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PR Payer NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Other Payer Last or Organization Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system/method of code structure used for Identification Code (67) 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 496/579 Usage notes Use code value "PI" when reporting Payor Identification. Use code value "XV" when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). Prior to the mandated implementation date for Health Plan Identifier, willing trading partners may agree to: Follow a dual use approach in which both the HPID or OEID and the Payor Identification are sent. Send XV qualifier in NM108 with HPID or OEID in NM109 and the Payor Identification, that would have been sent using qualifier PI, in the corresponding REF segment using qualifier 2U (Payer Identification Number). OR Follow an early implementation approach in which the HPID or OEID is sent in NM109. PI Payor Identification XV Centers for Medicare and Medicaid Services PlanID NM1-09 67 Other Payer Primary Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code Usage notes When sending Line Adjudication Information for this payer, the identifier sent in SVD01 (Payer Identifier) of Loop ID-2430 (Line Adjudication Information) must match this value.; 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 497/579 N3 3320 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > N3 Other Payer Address To specify the location of the named party Usage notes Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send. Example N3*XX*XXXXXX~ Max use 1 Optional N3-01 166 Other Payer Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Other Payer Address Line Min 1 Max 55 String (AN) Optional Address information 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 498/579 N4 3400 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > N4 Other Payer City, State, ZIP Code To specify the geographic place of the named party Usage notes Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send. Example N4*XX*XX*XXXX*XX~ Only one of Other Payer State Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Optional N4-01 19 | Health Partner Plans 837 Health Care Claim_ Institutional.pdf |
Entity NM1-03 1035 Other Payer Last or Organization Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system/method of code structure used for Identification Code (67) 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 496/579 Usage notes Use code value "PI" when reporting Payor Identification. Use code value "XV" when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). Prior to the mandated implementation date for Health Plan Identifier, willing trading partners may agree to: Follow a dual use approach in which both the HPID or OEID and the Payor Identification are sent. Send XV qualifier in NM108 with HPID or OEID in NM109 and the Payor Identification, that would have been sent using qualifier PI, in the corresponding REF segment using qualifier 2U (Payer Identification Number). OR Follow an early implementation approach in which the HPID or OEID is sent in NM109. PI Payor Identification XV Centers for Medicare and Medicaid Services PlanID NM1-09 67 Other Payer Primary Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code Usage notes When sending Line Adjudication Information for this payer, the identifier sent in SVD01 (Payer Identifier) of Loop ID-2430 (Line Adjudication Information) must match this value.; 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 497/579 N3 3320 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > N3 Other Payer Address To specify the location of the named party Usage notes Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send. Example N3*XX*XXXXXX~ Max use 1 Optional N3-01 166 Other Payer Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Other Payer Address Line Min 1 Max 55 String (AN) Optional Address information 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 498/579 N4 3400 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > N4 Other Payer City, State, ZIP Code To specify the geographic place of the named party Usage notes Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send. Example N4*XX*XX*XXXX*XX~ Only one of Other Payer State Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Optional N4-01 19 Other Payer City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Other Payer State Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State/Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Other Payer Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 499/579 Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 500/579 DTP 3500 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > DTP Claim Check or Remittance Date To specify any or all of a date, a time, or a time period Usage notes Required when the payer identified in this loop has previously adjudicated the claim and Loop ID-2430, Line Check or Remittance Date, is not used. If not required by this implementation guide, do not send.; Example DTP*573*D8*XXX~ Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 573 Date Claim Paid DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Adjudication or Payment Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 501/579 REF 3550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > REF Other Payer Claim Adjustment Indicator To specify identifying information Usage notes Required when the claim is being sent in the payer-to-payer COB model, AND the destination payer is secondary to the payer identified in this Loop ID-2330B, AND the payer identified in this Loop ID-2330B has re-adjudicated the claim. If not required by this implementation guide, do not send. Example REF*T4*XXXX~ Variants (all may be used) REF Other Payer Claim Control Number REF Other Payer Prior Authorization Number REF Other Payer Referral Number REF Other Payer Secondary Identifier Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification T4 Signal Code REF-02 127 Other Payer Claim Adjustment Indicator Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes Only allowed value is "Y". 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 502/579 REF 3550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > REF Other Payer Claim Control Number To specify identifying information Usage notes Required when it is necessary to identify the Other Payer's Claim Control Number in a payer-to-payer COB situation. OR Required when the Other Payer's Claim Control Number is available. If not required by this implementation guide, do not send. Example REF*F8*XXXX~ Variants (all may be used) REF Other Payer Claim Adjustment Indicator REF Other Payer Prior Authorization Number REF Other Payer Referral Number REF Other Payer Secondary Identifier Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification F8 Original Reference Number This is the payer's internal Claim Control Number for this claim for the payer identified in this iteration of Loop ID-2330. This value is typically used in payer-to-payer COB situations only. REF-02 127 Other Payer's Claim Control Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 503/579 REF 3550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > REF Other Payer Prior Authorization Number To specify identifying information Usage notes Required when the payer identified in this loop has assigned a prior authorization number to this claim. If not required by this implementation guide, do not send. Example REF*G1*XXXXX~ Variants (all may be used) REF Other Payer Claim Adjustment Indicator REF Other Payer Claim Control Number REF Other Payer Referral Number REF Other Payer Secondary Identifier Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification G1 Prior Authorization Number REF-02 127 Other Payer Prior Authorization Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 504/579 REF 3550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > REF Other Payer Referral Number To specify identifying information Usage notes Required when the payer identified in this loop has assigned a referral number to this claim. If not required by this implementation guide, do not send. Example REF*9F*X~ Variants (all may be used) REF Other Payer Claim Adjustment Indicator REF Other Payer Claim Control Number REF Other Payer Prior Authorization Number REF Other Payer Secondary Identifier Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9F Referral Number REF-02 127 Other Payer Prior Authorization or Referral Number String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 505/579 2330B Other Payer Name Loop end REF 3550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > REF Other Payer Secondary Identifier To specify identifying information Usage notes Required when an additional identification number to that provided in the NM109 of this loop is necessary to identify the entity. If not required by this implementation guide, do not send. Example REF*FY*XXX~ Variants (all may be used) REF Other Payer Claim Adjustment Indicator REF Other Payer Claim Control Number REF Other Payer Prior Authorization Number REF Other Payer Referral Number Max use 2 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number This code is only allowed when the qualifier XV is reported in NM108 of this loop. EI Employer's Identification Number The Employer's Identification Number must be a string of exactly nine numbers with no separators. For example, "001122333" would be valid, while sending "001-12-2333" or "00-1122333" would be invalid. FY Claim Office Number NF National Association of Insurance Commissioners (NAIC) Code REF-02 127 Other Payer Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 506/579 2330C Other Payer Attending Provider Loop Max 1 Optional Variants (all may be used) Other Subscriber Name Loop Other Payer Name Loop Other Payer Operating Physician Loop Other Payer Other Operating Physician Loop Other Payer Service Facility Location Loop Other Payer Rendering Provider Name Loop Other Payer Referring Provider Loop Other Payer Billing Provider Loop NM1 3250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Attending Provider Loop > NM1 Other Payer Attending Provider To supply the full name of an individual or organizational entity Usage notes Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and | Health Partner Plans 837 Health Care Claim_ Institutional.pdf |
Other Payer Referral Number To specify identifying information Usage notes Required when the payer identified in this loop has assigned a referral number to this claim. If not required by this implementation guide, do not send. Example REF*9F*X~ Variants (all may be used) REF Other Payer Claim Adjustment Indicator REF Other Payer Claim Control Number REF Other Payer Prior Authorization Number REF Other Payer Secondary Identifier Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9F Referral Number REF-02 127 Other Payer Prior Authorization or Referral Number String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 505/579 2330B Other Payer Name Loop end REF 3550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > REF Other Payer Secondary Identifier To specify identifying information Usage notes Required when an additional identification number to that provided in the NM109 of this loop is necessary to identify the entity. If not required by this implementation guide, do not send. Example REF*FY*XXX~ Variants (all may be used) REF Other Payer Claim Adjustment Indicator REF Other Payer Claim Control Number REF Other Payer Prior Authorization Number REF Other Payer Referral Number Max use 2 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number This code is only allowed when the qualifier XV is reported in NM108 of this loop. EI Employer's Identification Number The Employer's Identification Number must be a string of exactly nine numbers with no separators. For example, "001122333" would be valid, while sending "001-12-2333" or "00-1122333" would be invalid. FY Claim Office Number NF National Association of Insurance Commissioners (NAIC) Code REF-02 127 Other Payer Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 506/579 2330C Other Payer Attending Provider Loop Max 1 Optional Variants (all may be used) Other Subscriber Name Loop Other Payer Name Loop Other Payer Operating Physician Loop Other Payer Other Operating Physician Loop Other Payer Service Facility Location Loop Other Payer Rendering Provider Name Loop Other Payer Referring Provider Loop Other Payer Billing Provider Loop NM1 3250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Attending Provider Loop > NM1 Other Payer Attending Provider To supply the full name of an individual or organizational entity Usage notes Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. If not required by this implementation guide, do not send. See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example NM1*71*1~ Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 71 Attending Physician NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 507/579 1 Person 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 508/579 2330C Other Payer Attending Provider Loop end REF 3550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Attending Provider Loop > REF Other Payer Attending Provider Secondary Identification To specify identifying information Usage notes Non-destination (COB) payer's provider identification number(s). See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example REF*LU*XXX~ Max use 4 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan. LU Location Number REF-02 127 Other Payer Attending Provider Secondary Identifier String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 509/579 2330D Other Payer Operating Physician Loop Max 1 Optional Variants (all may be used) Other Subscriber Name Loop Other Payer Name Loop Other Payer Attending Provider Loop Other Payer Other Operating Physician Loop Other Payer Service Facility Location Loop Other Payer Rendering Provider Name Loop Other Payer Referring Provider Loop Other Payer Billing Provider Loop NM1 3250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Operating Physician Loop > NM1 Other Payer Operating Physician To supply the full name of an individual or organizational entity Usage notes Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. If not required by this implementation guide, do not send. See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example NM1*72*1~ Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 72 Operating Physician NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 510/579 1 Person 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 511/579 2330D Other Payer Operating Physician Loop end REF 3550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Operating Physician Loop > REF Other Payer Operating Physician Secondary Identification To specify identifying information Usage notes Non-destination (COB) payer's provider identification number(s). See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example REF*G2*XXXX~ Max use 4 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan. LU Location Number REF-02 127 Other Payer Operating Provider Secondary Identifier String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 512/579 2330E Other Payer Other Operating Physician Loop Max 1 Optional Variants (all may be used) Other Subscriber Name Loop Other Payer Name Loop Other Payer Attending Provider Loop Other Payer Operating Physician Loop Other Payer Service Facility Location Loop Other Payer Rendering Provider Name Loop Other Payer Referring Provider Loop Other Payer Billing Provider Loop NM1 3250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Other Operating Physician Loop > NM1 Other Payer Other Operating Physician To supply the full name of an individual or organizational entity Usage notes Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. If not required by this implementation guide, do not send. See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example NM1*ZZ*1~ Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual ZZ Mutually Defined ZZ is used to indicate Other Operating Physician. NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 513/579 1 Person 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 514/579 2330E Other Payer Other Operating Physician Loop end REF 3550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Other Operating Physician Loop > REF Other Payer Other Operating Physician Secondary Identification To specify identifying information Usage notes Non-destination (COB) payer's provider identification number(s). See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example REF*LU*XXXX~ Max use 4 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan. LU Location Number REF-02 127 Other Payer Other Operating Physician Secondary Identifier String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 515/579 2330F Other Payer Service Facility Location Loop Max 1 Optional Variants (all may be used) Other Subscriber Name Loop Other Payer Name Loop Other Payer Attending Provider Loop Other Payer Operating Physician Loop Other Payer Other Operating Physician Loop Other Payer Rendering Provider Name Loop Other Payer Referring Provider Loop Other Payer Billing Provider Loop NM1 3250 Detail > Billing Provider Hierarchical Level Loop > | Health Partner Plans 837 Health Care Claim_ Institutional.pdf |
To supply the full name of an individual or organizational entity Usage notes Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. If not required by this implementation guide, do not send. See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example NM1*ZZ*1~ Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual ZZ Mutually Defined ZZ is used to indicate Other Operating Physician. NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 513/579 1 Person 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 514/579 2330E Other Payer Other Operating Physician Loop end REF 3550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Other Operating Physician Loop > REF Other Payer Other Operating Physician Secondary Identification To specify identifying information Usage notes Non-destination (COB) payer's provider identification number(s). See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example REF*LU*XXXX~ Max use 4 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan. LU Location Number REF-02 127 Other Payer Other Operating Physician Secondary Identifier String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 515/579 2330F Other Payer Service Facility Location Loop Max 1 Optional Variants (all may be used) Other Subscriber Name Loop Other Payer Name Loop Other Payer Attending Provider Loop Other Payer Operating Physician Loop Other Payer Other Operating Physician Loop Other Payer Rendering Provider Name Loop Other Payer Referring Provider Loop Other Payer Billing Provider Loop NM1 3250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Service Facility Location Loop > NM1 Other Payer Service Facility Location To supply the full name of an individual or organizational entity Usage notes Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. If not required by this implementation guide, do not send. See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example NM1*77*2~ Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 77 Service Location NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 516/579 2 Non-Person Entity 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 517/579 2330F Other Payer Service Facility Location Loop end REF 3550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Service Facility Location Loop > REF Other Payer Service Facility Location Secondary Identification To specify identifying information Usage notes Non-destination (COB) payer's provider identification number(s). See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example REF*0B*XXX~ Max use 3 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number G2 Provider Commercial Number This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan. LU Location Number REF-02 127 Other Payer Service Facility Location Identifier String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 518/579 2330G Other Payer Rendering Provider Name Loop Max 1 Optional Variants (all may be used) Other Subscriber Name Loop Other Payer Name Loop Other Payer Attending Provider Loop Other Payer Operating Physician Loop Other Payer Other Operating Physician Loop Other Payer Service Facility Location Loop Other Payer Referring Provider Loop Other Payer Billing Provider Loop NM1 3250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Rendering Provider Name Loop > NM1 Other Payer Rendering Provider Name To supply the full name of an individual or organizational entity Usage notes Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. If not required by this implementation guide, do not send. See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example NM1*82*1~ Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 82 Rendering Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 519/579 1 Person 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 520/579 2330G Other Payer Rendering Provider Name Loop end REF 3550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Rendering Provider Name Loop > REF Other Payer Rendering Provider Secondary Identification To specify identifying information Usage notes Non-destination (COB) payer's provider identification number(s). See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example REF*LU*X~ Max use 4 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan. LU Location Number REF-02 127 Other Payer Rendering Provider Secondary Identifier String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 521/579 2330H Other Payer Referring Provider Loop Max 1 Optional Variants (all may be used) Other Subscriber Name Loop Other Payer Name Loop Other Payer Attending Provider Loop Other Payer Operating Physician Loop Other Payer Other Operating Physician Loop Other Payer Service Facility Location Loop Other Payer Rendering Provider Name Loop Other Payer Billing Provider Loop NM1 3250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Referring Provider Loop > NM1 Other Payer Referring Provider To supply the full name of an individual or organizational entity Usage notes Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. If not required by this implementation guide, do not send. See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example NM1*DN*1~ Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual DN Referring Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 522/579 1 Person 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 523/579 2330H Other Payer Referring Provider Loop end REF 3550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Referring Provider Loop > REF Other Payer Referring Provider Secondary Identification To specify identifying information Usage notes Non-destination (COB) payer's provider identification number(s). See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example REF*0B*XXX~ Max use 3 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan. REF-02 127 Other Payer Referring Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 524/579 2330I Other Payer Billing Provider Loop Max 1 Optional Variants (all may be used) Other Subscriber Name Loop | Health Partner Plans 837 Health Care Claim_ Institutional.pdf |
Other Payer Other Operating Physician Loop Other Payer Service Facility Location Loop Other Payer Rendering Provider Name Loop Other Payer Billing Provider Loop NM1 3250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Referring Provider Loop > NM1 Other Payer Referring Provider To supply the full name of an individual or organizational entity Usage notes Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. If not required by this implementation guide, do not send. See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example NM1*DN*1~ Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual DN Referring Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 522/579 1 Person 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 523/579 2330H Other Payer Referring Provider Loop end REF 3550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Referring Provider Loop > REF Other Payer Referring Provider Secondary Identification To specify identifying information Usage notes Non-destination (COB) payer's provider identification number(s). See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example REF*0B*XXX~ Max use 3 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan. REF-02 127 Other Payer Referring Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 524/579 2330I Other Payer Billing Provider Loop Max 1 Optional Variants (all may be used) Other Subscriber Name Loop Other Payer Name Loop Other Payer Attending Provider Loop Other Payer Operating Physician Loop Other Payer Other Operating Physician Loop Other Payer Service Facility Location Loop Other Payer Rendering Provider Name Loop Other Payer Referring Provider Loop NM1 3250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Billing Provider Loop > NM1 Other Payer Billing Provider To supply the full name of an individual or organizational entity Usage notes Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. If not required by this implementation guide, do not send. See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example NM1*85*2~ Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 85 Billing Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 525/579 2 Non-Person Entity 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 526/579 2330I Other Payer Billing Provider Loop end 2320 Other Subscriber Information Loop end REF 3550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Billing Provider Loop > REF Other Payer Billing Provider Secondary Identification To specify identifying information Usage notes See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example REF*G2*XXXXXX~ Max use 2 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification G2 Provider Commercial Number This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan. LU Location Number REF-02 127 Other Payer Billing Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 527/579 2400 Service Line Number Loop Max 999 Required LX 3650 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > LX Service Line Number To reference a line number in a transaction set Usage notes The LX functions as a line counter. The Service Line LX segment must begin with one and is incremented by one for each additional service line of a claim. LX01 is used to indicate bundling in SVD06 in the Line Item Adjudication loop. See Section 1.4.1.2 for more information on bundling and unbundling. Example LX*0~ Max use 1 Required LX-01 554 Assigned Number Min 1 Max 6 Numeric (N0) Required Number assigned for differentiation within a transaction set 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 528/579 SV2 3750 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > SV2 Institutional Service Line To specify the service line item detail for a health care institution Example SV2*XX*WK>X>XX>XX>XX>XX>XXXXX*000000*DA*00**00000 00000000~ Max use 1 Required SV2-01 234 Service Line Revenue Code Min 1 Max 48 String (AN) Required Identifying number for a product or service SV201 is the revenue code. Usage notes See Code Source 132: National Uniform Billing Committee (NUBC) Codes. SV2-02 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers Usage notes Required for outpatient claims when an appropriate procedure code exists for this service line item. OR Required for inpatient claims when an appropriate HCPCS (drugs and/or biologics only) or HIPPS code exists for this service line item. If not required by this implementation guide, do not send.; Max use 1 Optional C003-01 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type/source of the descriptive number used in Product/Service ID (234) C003-01 qualifies C003-02 and C003-08. ER Jurisdiction Specific Procedure and Supply Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the Jurisdiction Specific Procedure and Supply Codes as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC. HP Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code IV Home Infusion EDI Coalition (HIEC) Product/Service Code 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 529/579 This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the Home Infusion EDI Coalition (HIEC) Product/Service Codes as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA.; WK Advanced Billing Concepts (ABC) Codes At the time of this writing, this code set has been approved by the Secretary of HHS as a pilot project allowed under HIPAA law. The qualifier may only be used in transactions covered under HIPAA; By parties registered in the pilot project and their trading partners, OR If a new rule names the Complementary, Alternative, or Holistic Procedure Codes as an allowable code set under HIPAA, OR For claims which are not covered under HIPAA. C003-02 234 Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. C003-03 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-03 modifies the value in C003-02 and C003-08. C003-04 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-04 modifies the value in C003-02 and C003-08. C003-05 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-05 modifies the value in C003-02 and C003-08. C003-06 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 530/579 This identifies special circumstances related to the performance of the service, as defined by trading partners C003-06 modifies the value in C003-02 and C003-08. C003-07 352 Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content C003-07 is the description of the procedure identified in C003-02. SV2-03 782 Line Item Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SV203 is the submitted service line item amount. Usage notes This is the total charge amount for this service line. The amount is inclusive of the provider's base charge and any applicable tax amounts reported within this line's AMT segments. Zero "0" is an acceptable value for this element. SV2-04 355 Unit or Basis for Measurement Code Identifier (ID) Required Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken DA Days UN Unit SV2-05 380 Service Unit Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity Usage notes The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three. SV2-07 782 Line Item Denied Charge or Non-Covered Charge Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount SV207 is a non-covered service amount. 1/30/25, 11:52 AM Health Partner Plans 837 Health | Health Partner Plans 837 Health Care Claim_ Institutional.pdf |
code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA.; WK Advanced Billing Concepts (ABC) Codes At the time of this writing, this code set has been approved by the Secretary of HHS as a pilot project allowed under HIPAA law. The qualifier may only be used in transactions covered under HIPAA; By parties registered in the pilot project and their trading partners, OR If a new rule names the Complementary, Alternative, or Holistic Procedure Codes as an allowable code set under HIPAA, OR For claims which are not covered under HIPAA. C003-02 234 Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. C003-03 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-03 modifies the value in C003-02 and C003-08. C003-04 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-04 modifies the value in C003-02 and C003-08. C003-05 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-05 modifies the value in C003-02 and C003-08. C003-06 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 530/579 This identifies special circumstances related to the performance of the service, as defined by trading partners C003-06 modifies the value in C003-02 and C003-08. C003-07 352 Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content C003-07 is the description of the procedure identified in C003-02. SV2-03 782 Line Item Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SV203 is the submitted service line item amount. Usage notes This is the total charge amount for this service line. The amount is inclusive of the provider's base charge and any applicable tax amounts reported within this line's AMT segments. Zero "0" is an acceptable value for this element. SV2-04 355 Unit or Basis for Measurement Code Identifier (ID) Required Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken DA Days UN Unit SV2-05 380 Service Unit Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity Usage notes The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three. SV2-07 782 Line Item Denied Charge or Non-Covered Charge Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount SV207 is a non-covered service amount. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 531/579 PWK 4200 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > PWK Line Supplemental Information To identify the type or transmission or both of paperwork or supporting information Usage notes Required when there is a paper attachment following this claim. OR Required when attachments are sent electronically (PWK02 = EL) but are transmitted in another functional group (for example, 275) rather than by paper. PWK06 is then used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment. OR Required when the provider deems it necessary to identify additional information that is being held at the provider's office and is available upon request by the payer (or appropriate entity), but the information is not being submitted with the claim. Use the value of "AA" in PWK02 to convey this specific use of the PWK segment. If not required by this implementation guide, do not send. Example PWK*B4*FT***AC*XX~ If either Identification Code Qualifier (PWK-05) or Attachment Control Number (PWK-06) is present, then the other is required Max use 10 Optional PWK-01 755 Attachment Report Type Code Identifier (ID) Required Code indicating the title or contents of a document, report or supporting item 03 Report Justifying Treatment Beyond Utilization Guidelines 04 Drugs Administered 05 Treatment Diagnosis 06 Initial Assessment 07 Functional Goals 08 Plan of Treatment 09 Progress Report 10 Continued Treatment 11 Chemical Analysis 13 Certified Test Report 15 Justification for Admission 21 Recovery Plan A3 Allergies/Sensitivities Document A4 Autopsy Report AM Ambulance Certification AS Admission Summary B2 Prescription B3 Physician Order B4 Referral Form BR Benchmark Testing Results BS Baseline BT Blanket Test Results CB Chiropractic Justification 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 532/579 CK Consent Form(s) CT Certification D2 Drug Profile Document DA Dental Models DB Durable Medical Equipment Prescription DG Diagnostic Report DJ Discharge Monitoring Report DS Discharge Summary EB Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payor) HC Health Certificate HR Health Clinic Records I5 Immunization Record IR State School Immunization Records LA Laboratory Results M1 Medical Record Attachment MT Models NN Nursing Notes OB Operative Note OC Oxygen Content Averaging Report OD Orders and Treatments Document OE Objective Physical Examination (including vital signs) Document OX Oxygen Therapy Certification OZ Support Data for Claim P4 Pathology Report P5 Patient Medical History Document PE Parenteral or Enteral Certification PN Physical Therapy Notes PO Prosthetics or Orthotic Certification PQ Paramedical Results PY Physician's Report PZ Physical Therapy Certification RB Radiology Films RR Radiology Reports RT Report of Tests and Analysis Report RX Renewable Oxygen Content Averaging Report SG Symptoms Document V5 Death Notification XP Photographs PWK-02 756 Attachment Transmission Code Identifier (ID) Required Code defining timing, transmission method or format by which reports are to be sent AA Available on Request at Provider Site This means that the additional information is not being sent with the claim at this time. Instead, it is available to the payer (or appropriate entity) at their request. BM By Mail EL Electronically Only Indicates that the attachment is being transmitted in a separate X12 functional group. EM E-Mail FT File Transfer 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 533/579 Required when the actual attachment is maintained by an attachment warehouse or similar vendor. FX By Fax PWK-05 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) PWK05 and PWK06 may be used to identify the addressee by a code number. AC Attachment Control Number PWK-06 67 Attachment Control Number Min 2 Max 80 String (AN) Optional Code identifying a party or other code Usage notes PWK06 is used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment. For the purpose of this implementation, the maximum field length is 50. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 534/579 DTP 4550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP Date - Service Date To specify any or all of a date, a time, or a time period Usage notes Required on outpatient service lines where a drug is not being billed and the Statement Covers Period is greater than one day. OR Required on service lines where a drug is being billed and the payer's adjudication is known to be impacted by the drug duration or the date the prescription was written. If not required by this implementation guide, do not send. In cases where a drug is being billed on a service line, date range may be used to indicate drug duration for which the drug supply will be used by the patient. The difference in dates, including both the begin and end dates, are the days supply of the drug. Example: 20000101 - 20000107 (1/1/00 to 1/7/00) is used for a 7 day supply where the first day of the drug used by the patient is 1/1/00. In the event a drug is administered on less than a daily basis (for example, every other day) the date range would include the entire period during which the drug was supplied, including the last day the drug was used. Example: 20000101 - 20000108 (1/1/00 to 1/8/00) is used for an 8 days supply where the prescription is written for Q48 (every 48 hours), four doses of the drug are dispensed and the first dose is used on 1/1/00. In cases where a drug is being billed on a service line, a single date may be used to indicate the date the prescription was written (or otherwise communicated by the prescriber if not written). Example DTP*472*D8*XXX~ Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 472 Service DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. Usage notes RD8 is required only when the "To and From" dates are different. However, at the discretion of the submitter, RD8 can also be used when the "To and From" dates are the same. D8 Date Expressed in Format CCYYMMDD RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD DTP-03 1251 Service Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 535/579 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 536/579 REF 4700 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF Adjusted Repriced Line Item Reference Number To specify identifying information Usage notes Required when a repricing (pricing) organization needs to have an identifying number on an adjusted service line in their submission to their payer organization. This segment is not completed by providers. If not required by this implementation guide, do not send. Example REF*9D*XX~ Variants (all may be used) REF Line Item Control Number REF Repriced Line Item Reference Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9D Adjusted Repriced Line Item Reference Number REF-02 127 Adjusted Repriced Line Item Reference Number String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 537/579 REF 4700 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF Line Item Control Number To specify identifying information Usage notes Required when the submitter needs a line item control number for subsequent communications to or from the payer. If not required by this implementation guide, do not send. The line item control number must be unique within a patient control number (CLM01). Payers are required to return this number in the remittance advice transaction (835) if the provider sends it to them in the 837 and adjudication is based upon line item detail regardless of whether bundling or unbundling has occurred. Submitters are STRONGLY encouraged to routinely send a unique line item control number on all service lines, particularly if the submitter automatically posts their remittance advice. Submitting a unique line item control number allows the capability to automatically post by service line. Example REF*6R*XXXXXX~ Variants (all may be used) REF Adjusted Repriced Line Item Reference Number REF | Health Partner Plans 837 Health Care Claim_ Institutional.pdf |
type of date or time, or both date and time 472 Service DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. Usage notes RD8 is required only when the "To and From" dates are different. However, at the discretion of the submitter, RD8 can also be used when the "To and From" dates are the same. D8 Date Expressed in Format CCYYMMDD RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD DTP-03 1251 Service Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 535/579 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 536/579 REF 4700 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF Adjusted Repriced Line Item Reference Number To specify identifying information Usage notes Required when a repricing (pricing) organization needs to have an identifying number on an adjusted service line in their submission to their payer organization. This segment is not completed by providers. If not required by this implementation guide, do not send. Example REF*9D*XX~ Variants (all may be used) REF Line Item Control Number REF Repriced Line Item Reference Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9D Adjusted Repriced Line Item Reference Number REF-02 127 Adjusted Repriced Line Item Reference Number String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 537/579 REF 4700 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF Line Item Control Number To specify identifying information Usage notes Required when the submitter needs a line item control number for subsequent communications to or from the payer. If not required by this implementation guide, do not send. The line item control number must be unique within a patient control number (CLM01). Payers are required to return this number in the remittance advice transaction (835) if the provider sends it to them in the 837 and adjudication is based upon line item detail regardless of whether bundling or unbundling has occurred. Submitters are STRONGLY encouraged to routinely send a unique line item control number on all service lines, particularly if the submitter automatically posts their remittance advice. Submitting a unique line item control number allows the capability to automatically post by service line. Example REF*6R*XXXXXX~ Variants (all may be used) REF Adjusted Repriced Line Item Reference Number REF Repriced Line Item Reference Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 6R Provider Control Number REF-02 127 Line Item Control Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The maximum number of characters to be supported for this field is 30'. A submitter may submit fewer characters depending upon their needs. However, the HIPAA maximum requirement to be supported by any receiving system is 30'. Characters beyond 30 are not required to be stored nor returned by any 837-receiving system. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 538/579 REF 4700 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF Repriced Line Item Reference Number To specify identifying information Usage notes Required when a repricing (pricing) organization needs to have an identifying number on the service line in their submission to their payer organization. This segment is not completed by providers. If not required by this implementation guide, do not send. Example REF*9B*XXXX~ Variants (all may be used) REF Adjusted Repriced Line Item Reference Number REF Line Item Control Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9B Repriced Line Item Reference Number REF-02 127 Repriced Line Item Reference Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 539/579 AMT 4750 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > AMT Facility Tax Amount To indicate the total monetary amount Usage notes Required when a facility tax or surcharge applies to the service being reported in SV201 and the submitter is required to report that information to the receiver. If not required by this implementation guide, do not send. When reporting the Facility Tax Amount (AMT02), the amount reported in the Line Item Charge Amount (SV203) for this service line must include the amount reported in the Facility Tax Amount. Example AMT*N8*000000000000~ Variants (all may be used) AMT Service Tax Amount Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount N8 Miscellaneous Taxes AMT-02 782 Facility Tax Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 540/579 AMT 4750 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > AMT Service Tax Amount To indicate the total monetary amount Usage notes Required when a service tax or surcharge applies to the service being reported in SV201 and the submitter is required to report that information to the receiver. If not required by this implementation guide, do not send. When reporting the Service Tax Amount (AMT02), the amount reported in the Line Item Charge Amount (SV203) for this service line must include the amount reported in the Service Tax Amount. Example AMT*GT*00000000~ Variants (all may be used) AMT Facility Tax Amount Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount GT Goods and Services Tax AMT-02 782 Service Tax Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 541/579 NTE 4850 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > NTE Third Party Organization Notes To transmit information in a free-form format, if necessary, for comment or special instruction Usage notes Required when the TPO/repricer needs to forward additional information to the payer. This segment is not completed by providers. If not required by this implementation guide, do not send. Example NTE*TPO*XX~ Max use 1 Optional NTE-01 363 Note Reference Code Identifier (ID) Required Code identifying the functional area or purpose for which the note applies TPO Third Party Organization Notes NTE-02 352 Line Note Text Min 1 Max 80 String (AN) Required A free-form description to clarify the related data elements and their content 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 542/579 HCP 4920 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > HCP Line Pricing/Repricing Information To specify pricing or repricing information about a health care claim or line item Usage notes Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send. This information is specific to the destination payer reported in Loop ID-2010BB. For capitated encounters, pricing or repricing information usually is not applicable and is provided to qualify other information within the claim. Example HCP*01*0000*00*XXXXX*000000*XXXX*00*XX*ER*XXXX*D A*00000*T1*4*1~ If either Product or Service ID Qualifier (HCP-09) or Repriced Approved HCPCS Code (HCP-10) is present, then the other is required If either Unit or Basis for Measurement Code (HCP-11) or Quantity (HCP-12) is present, then the other is required Max use 1 Optional HCP-01 1473 Pricing Methodology Identifier (ID) Required Code specifying pricing methodology at which the claim or line item has been priced or repriced Usage notes Specific code use is determined by Trading Partner Agreement due to the variances in contracting policies in the industry. 00 Zero Pricing (Not Covered Under Contract) 01 Priced as Billed at 100% 02 Priced at the Standard Fee Schedule 03 Priced at a Contractual Percentage 04 Bundled Pricing 05 Peer Review Pricing 06 Per Diem Pricing 07 Flat Rate Pricing 08 Combination Pricing 09 Maternity Pricing 10 Other Pricing 11 Lower of Cost 12 Ratio of Cost 13 Cost Reimbursed 14 Adjustment Pricing HCP-02 782 Monetary Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 543/579 HCP02 is the allowed amount. HCP-03 782 Monetary Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount HCP03 is the savings amount. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-04 127 Reference Identification Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier HCP04 is the repricing organization identification number. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-05 118 Rate Min 1 Max 9 Decimal number (R) Optional Rate expressed in the standard monetary denomination for the currency specified HCP05 is the pricing rate associated with per diem or flat rate repricing. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-06 127 Reference Identification Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier HCP06 is the approved DRG code. HCP06, HCP07, HCP08, HCP10, and HCP12 are fields that will contain different values from the original submitted values. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-07 782 Monetary Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount HCP07 is the approved DRG amount. Usage notes 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 544/579 This information is specific to the destination payer reported in Loop ID-2010BB. HCP-08 234 Product or Service ID Min 1 Max 48 String (AN) Optional Identifying number for a product or service HCP08 is the approved revenue code. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-09 235 Product or Service ID Qualifier Identifier (ID) Optional Code identifying the type/source of the descriptive number used in Product/Service ID (234) ER Jurisdiction Specific Procedure and Supply Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the Jurisdiction Specific Procedure and Supply Codes as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC. HP Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code IV Home | Health Partner Plans 837 Health Care Claim_ Institutional.pdf |
Schedule 03 Priced at a Contractual Percentage 04 Bundled Pricing 05 Peer Review Pricing 06 Per Diem Pricing 07 Flat Rate Pricing 08 Combination Pricing 09 Maternity Pricing 10 Other Pricing 11 Lower of Cost 12 Ratio of Cost 13 Cost Reimbursed 14 Adjustment Pricing HCP-02 782 Monetary Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 543/579 HCP02 is the allowed amount. HCP-03 782 Monetary Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount HCP03 is the savings amount. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-04 127 Reference Identification Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier HCP04 is the repricing organization identification number. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-05 118 Rate Min 1 Max 9 Decimal number (R) Optional Rate expressed in the standard monetary denomination for the currency specified HCP05 is the pricing rate associated with per diem or flat rate repricing. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-06 127 Reference Identification Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier HCP06 is the approved DRG code. HCP06, HCP07, HCP08, HCP10, and HCP12 are fields that will contain different values from the original submitted values. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-07 782 Monetary Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount HCP07 is the approved DRG amount. Usage notes 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 544/579 This information is specific to the destination payer reported in Loop ID-2010BB. HCP-08 234 Product or Service ID Min 1 Max 48 String (AN) Optional Identifying number for a product or service HCP08 is the approved revenue code. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-09 235 Product or Service ID Qualifier Identifier (ID) Optional Code identifying the type/source of the descriptive number used in Product/Service ID (234) ER Jurisdiction Specific Procedure and Supply Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the Jurisdiction Specific Procedure and Supply Codes as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC. HP Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code IV Home Infusion EDI Coalition (HIEC) Product/Service Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the Home Infusion EDI Coalition (HIEC) Product/Service Codes as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA.; WK Advanced Billing Concepts (ABC) Codes At the time of this writing, this code set has been approved by the Secretary of HHS as a pilot project allowed under HIPAA law. The qualifier may only be used in transactions covered under HIPAA; By parties registered in the pilot project and their trading partners, OR If a new rule names the Complementary, Alternative, or Holistic Procedure Codes as an allowable code set under HIPAA, OR For claims which are not covered under HIPAA. HCP-10 234 Repriced Approved HCPCS Code Min 1 Max 48 String (AN) Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 545/579 Identifying number for a product or service HCP10 is the approved procedure code. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-11 355 Unit or Basis for Measurement Code Identifier (ID) Optional Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken DA Days UN Unit HCP-12 380 Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity HCP12 is the approved service units or inpatient days. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three. HCP-13 901 Reject Reason Code Identifier (ID) Optional Code assigned by issuer to identify reason for rejection HCP13 is the rejection message returned from the third party organization. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. T1 Cannot Identify Provider as TPO (Third Party Organization) Participant T2 Cannot Identify Payer as TPO (Third Party Organization) Participant T3 Cannot Identify Insured as TPO (Third Party Organization) Participant T4 Payer Name or Identifier Missing T5 Certification Information Missing T6 Claim does not contain enough information for re-pricing HCP-14 1526 Policy Compliance Code Identifier (ID) Optional Code specifying policy compliance Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. 1 Procedure Followed (Compliance) 2 Not Followed - Call Not Made (Non-Compliance Call Not Made) 3 Not Medically Necessary (Non-Compliance Non-Medically Necessary) 4 Not Followed Other (Non-Compliance Other) 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 546/579 5 Emergency Admit to Non-Network Hospital HCP-15 1527 Exception Code Identifier (ID) Optional Code specifying the exception reason for consideration of out-of-network health care services HCP15 is the exception reason generated by a third party organization. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. 1 Non-Network Professional Provider in Network Hospital 2 Emergency Care 3 Services or Specialist not in Network 4 Out-of-Service Area 5 State Mandates 6 Other 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 547/579 2410 Drug Identification Loop Max 1 Optional LIN 4930 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Drug Identification Loop > LIN Drug Identification To specify basic item identification data Usage notes Drugs and biologics reported in this segment are a further specification of service(s) described in the SV2 segment of this Service Line Loop ID-2400. Required when government regulation mandates that prescribed drugs and biologics are reported with NDC numbers. OR Required when the provider or submitter chooses to report NDC numbers to enhance the claim reporting or adjudication processes. If not required by this implementation guide, do not send. Example LIN**N4*XX~ Max use 1 Required LIN-02 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type/source of the descriptive number used in Product/Service ID (234) LIN02 through LIN31 provide for fifteen different product/service IDs for each item. For example: Case, Color, Drawing No., U.P.C. No., ISBN No., Model No., or SKU. N4 National Drug Code in 5-4-2 Format LIN-03 234 National Drug Code Min 1 Max 48 String (AN) Required Identifying number for a product or service 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 548/579 CTP 4940 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Drug Identification Loop > CTP Drug Quantity To specify pricing information Example CTP****000000000000000*GR~ Max use 1 Required CTP-04 380 National Drug Unit Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity CTP-05 C001 Composite Unit of Measure To identify a composite unit of measure (See Figures Appendix for examples of use) Max use 1 Required C001-01 355 Code Qualifier Identifier (ID) Required Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken F2 International Unit GR Gram ME Milligram ML Milliliter UN Unit 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 549/579 2410 Drug Identification Loop end REF 4950 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Drug Identification Loop > REF Prescription or Compound Drug Association Number To specify identifying information Usage notes In cases where a compound drug is being billed, the components of the compound will all have the same prescription number. Payers receiving the claim can relate all the components by matching the prescription number. Required when dispensing of the drug has been done with an assigned prescription number. OR Required when the provided medication involves the compounding of two or more drugs being reported and there is no prescription number. If not required by this implementation guide, do not send. For cases where the drug is provided without a prescription (for example, from a physician's office), the value provided in this segment is a "link sequence number". The link sequence number is a provider assigned number that is unique to this claim. Its purpose is to enable the receiver to piece together the components of the compound. Example REF*XZ*XXXXXX~ Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification VY Link Sequence Number XZ Pharmacy Prescription Number REF-02 127 Prescription Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 550/579 2420A Operating Physician Name Loop Max 1 Optional Variants (all may be used) Other Operating Physician Name Loop Rendering Provider Name Loop Referring Provider Name Loop NM1 5000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Operating Physician Name Loop > NM1 Operating Physician Name To supply the full name of an individual or organizational entity Usage notes Required when a surgical procedure code is listed on this claim. AND The Operating Physician for this line is different than the Operating Physician reported in Loop ID-2310B (claim level). If not required by this implementation guide, do not send. The Operating Physician is the individual with primary responsibility for performing the surgical procedure(s). Example NM1*72*1*XX*XXXXX*XXXX**XXXX*XX*XXXX~ If either Identification Code Qualifier (NM1-08) or Operating Physician Primary Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 72 Operating Physician NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Operating Physician Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Operating Physician First Name Min 1 Max 35 String (AN) Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 551/579 Individual first name NM1-05 1037 Operating Physician Middle Name or Initial String (AN) Optional Min 1 Max 25 Individual middle name or initial NM1-07 1039 Operating Physician Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Operating Physician Primary Identifier Min 2 Max 80 String (AN) Optional Code identifying a | Health Partner Plans 837 Health Care Claim_ Institutional.pdf |
prescription number. Required when dispensing of the drug has been done with an assigned prescription number. OR Required when the provided medication involves the compounding of two or more drugs being reported and there is no prescription number. If not required by this implementation guide, do not send. For cases where the drug is provided without a prescription (for example, from a physician's office), the value provided in this segment is a "link sequence number". The link sequence number is a provider assigned number that is unique to this claim. Its purpose is to enable the receiver to piece together the components of the compound. Example REF*XZ*XXXXXX~ Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification VY Link Sequence Number XZ Pharmacy Prescription Number REF-02 127 Prescription Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 550/579 2420A Operating Physician Name Loop Max 1 Optional Variants (all may be used) Other Operating Physician Name Loop Rendering Provider Name Loop Referring Provider Name Loop NM1 5000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Operating Physician Name Loop > NM1 Operating Physician Name To supply the full name of an individual or organizational entity Usage notes Required when a surgical procedure code is listed on this claim. AND The Operating Physician for this line is different than the Operating Physician reported in Loop ID-2310B (claim level). If not required by this implementation guide, do not send. The Operating Physician is the individual with primary responsibility for performing the surgical procedure(s). Example NM1*72*1*XX*XXXXX*XXXX**XXXX*XX*XXXX~ If either Identification Code Qualifier (NM1-08) or Operating Physician Primary Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 72 Operating Physician NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Operating Physician Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Operating Physician First Name Min 1 Max 35 String (AN) Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 551/579 Individual first name NM1-05 1037 Operating Physician Middle Name or Initial String (AN) Optional Min 1 Max 25 Individual middle name or initial NM1-07 1039 Operating Physician Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Operating Physician Primary Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 552/579 REF 5250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Operating Physician Name Loop > REF Operating Physician Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier. Example REF*G2*XXXX**2U>XXXXXX~ Max use 20 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Operating Physician Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the identifier reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 553/579 2420A Operating Physician Name Loop end C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 554/579 2420B Other Operating Physician Name Loop Max 1 Optional Variants (all may be used) Operating Physician Name Loop Rendering Provider Name Loop Referring Provider Name Loop NM1 5000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Other Operating Physician Name Loop > NM1 Other Operating Physician Name To supply the full name of an individual or organizational entity Usage notes Required when another Operating Physician is involved, AND The Other Operating Physician for this line is different than the Other Operating Physician reported in Loop ID-2310C (claim level). If not required by this implementation guide, do not send.; Example NM1*ZZ*1*XXX*XXXXXX*X**XX*XX*XXXXXXX~ If either Identification Code Qualifier (NM1-08) or Other Operating Physician Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual ZZ Mutually Defined ZZ is used to indicate Other Operating Physician. NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Other Operating Physician Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Other Operating Physician First Name Min 1 Max 35 String (AN) Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 555/579 Individual first name NM1-05 1037 Other Operating Physician Middle Name or Initial String (AN) Optional Min 1 Max 25 Individual middle name or initial NM1-07 1039 Other Operating Physician Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Other Operating Physician Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 556/579 REF 5250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Other Operating Physician Name Loop > REF Other Operating Physician Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier. Example REF*0B*XX**2U>XXXX~ Max use 20 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Other Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the identifier reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 557/579 2420B Other Operating Physician Name Loop end C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 558/579 2420C Rendering Provider Name Loop Max 1 Optional Variants (all may be used) Operating Physician Name Loop Other Operating Physician Name Loop Referring Provider Name Loop NM1 5000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Rendering Provider Name Loop > NM1 Rendering Provider Name To supply the full name of an individual or organizational entity Usage notes Required when Rendering Provider is different than the Attending Provider reported in the 2310A loop of this claim. AND State or federal regulatory requirements call for a "combined claim", that is, a claim that includes both facility and professional components (for example, a Medicaid clinic bill or Critical Access Hospital Claim.) AND The Rendering Provider for this line is different than the Rendering Provider reported in Loop ID 2310D (claim level). If not required by this implementation guide, do not send. The Rendering Provider is the health care professional who delivers or completes a particular medical service or non-surgical procedure. Example NM1*82*1*XXX*X*XXXXXX**XXXXX*XX*XX~ If either Identification Code Qualifier (NM1-08) or Rendering Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 82 Rendering Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Rendering Provider Last Name Min 1 Max 60 String (AN) Required 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 559/579 Individual last name or organizational name NM1-04 1036 Rendering Provider First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Rendering Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Rendering | Health Partner Plans 837 Health Care Claim_ Institutional.pdf |
Number REF-02 127 Other Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the identifier reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 557/579 2420B Other Operating Physician Name Loop end C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 558/579 2420C Rendering Provider Name Loop Max 1 Optional Variants (all may be used) Operating Physician Name Loop Other Operating Physician Name Loop Referring Provider Name Loop NM1 5000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Rendering Provider Name Loop > NM1 Rendering Provider Name To supply the full name of an individual or organizational entity Usage notes Required when Rendering Provider is different than the Attending Provider reported in the 2310A loop of this claim. AND State or federal regulatory requirements call for a "combined claim", that is, a claim that includes both facility and professional components (for example, a Medicaid clinic bill or Critical Access Hospital Claim.) AND The Rendering Provider for this line is different than the Rendering Provider reported in Loop ID 2310D (claim level). If not required by this implementation guide, do not send. The Rendering Provider is the health care professional who delivers or completes a particular medical service or non-surgical procedure. Example NM1*82*1*XXX*X*XXXXXX**XXXXX*XX*XX~ If either Identification Code Qualifier (NM1-08) or Rendering Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 82 Rendering Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Rendering Provider Last Name Min 1 Max 60 String (AN) Required 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 559/579 Individual last name or organizational name NM1-04 1036 Rendering Provider First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Rendering Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Rendering Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Rendering Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 560/579 REF 5250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Rendering Provider Name Loop > REF Rendering Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier. Example REF*G2*XXXXXX**2U>X~ Max use 20 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Rendering Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the identifier reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 561/579 2420C Rendering Provider Name Loop end C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 562/579 2420D Referring Provider Name Loop Max 1 Optional Variants (all may be used) Operating Physician Name Loop Other Operating Physician Name Loop Rendering Provider Name Loop NM1 5000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Referring Provider Name Loop > NM1 Referring Provider Name To supply the full name of an individual or organizational entity Usage notes Required on an outpatient claim when the Referring Provider is different than the Attending Provider. AND The Referring Provider for this line is different than the Referring Provider reported in Loop ID 2310F (claim level). If not required by this implementation guide, do not send. The Referring Provider is provider who sends the patient to another provider for services. Example NM1*DN*1*XXXX*XX*X**XXXXXX*XX*XX~ If either Identification Code Qualifier (NM1-08) or Referring Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual DN Referring Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Referring Provider Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Referring Provider First Name Min 1 Max 35 String (AN) Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 563/579 Individual first name NM1-05 1037 Referring Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Referring Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Referring Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 564/579 REF 5250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Referring Provider Name Loop > REF Referring Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier. Example REF*G2*X**2U>XXX~ Max use 20 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. REF-02 127 Referring Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the identifier reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 565/579 2420D Referring Provider Name Loop end C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 566/579 2430 Line Adjudication Information Loop Max 15 Optional SVD 5400 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Line Adjudication Information Loop > SVD Line Adjudication Information To convey service line adjudication information for coordination of benefits between the initial payers of a health care claim and all subsequent payers Usage notes Required when the claim has been previously adjudicated by payer identified in Loop ID-2330B and this service line has payments and/or adjustments applied to it. If not required by this implementation guide, do not send. To show unbundled lines: If, in the original claim, line 3 is unbundled into (for example) 2 additional lines, then the SVD for line 3 is used 3 times: once for the original adjustment to line 3 and then two more times for the additional unbundled lines. Example SVD*XXXX*000000000000000*IV>X>XX>XX>XX>XX>XXXX*XX XXX*00000000000*000000~ Max use 1 Required SVD-01 67 Other Payer Primary Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code SVD01 is the payer identification code. Usage notes This identifier indicates the payer responsible for the reimbursement described in this iteration of the 2430 loop. The identifier indicates the Other Payer by matching the appropriate Other Payer Primary Identifier (Loop ID-2330B, element NM109). SVD-02 782 Service Line Paid Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SVD02 is the amount paid for this service line. Usage notes Zero "0" is an acceptable value for this element. SVD-03 C003 | Health Partner Plans 837 Health Care Claim_ Institutional.pdf |
Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. REF-02 127 Referring Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the identifier reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 565/579 2420D Referring Provider Name Loop end C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 566/579 2430 Line Adjudication Information Loop Max 15 Optional SVD 5400 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Line Adjudication Information Loop > SVD Line Adjudication Information To convey service line adjudication information for coordination of benefits between the initial payers of a health care claim and all subsequent payers Usage notes Required when the claim has been previously adjudicated by payer identified in Loop ID-2330B and this service line has payments and/or adjustments applied to it. If not required by this implementation guide, do not send. To show unbundled lines: If, in the original claim, line 3 is unbundled into (for example) 2 additional lines, then the SVD for line 3 is used 3 times: once for the original adjustment to line 3 and then two more times for the additional unbundled lines. Example SVD*XXXX*000000000000000*IV>X>XX>XX>XX>XX>XXXX*XX XXX*00000000000*000000~ Max use 1 Required SVD-01 67 Other Payer Primary Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code SVD01 is the payer identification code. Usage notes This identifier indicates the payer responsible for the reimbursement described in this iteration of the 2430 loop. The identifier indicates the Other Payer by matching the appropriate Other Payer Primary Identifier (Loop ID-2330B, element NM109). SVD-02 782 Service Line Paid Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SVD02 is the amount paid for this service line. Usage notes Zero "0" is an acceptable value for this element. SVD-03 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers - SVD03 represents the medical procedure code upon which adjudication of this service line was based. This may be different than the submitted medical procedure code. Usage notes Required when a line level procedure code other than a revenue code was returned on the 835 remittance advice (SVC01). Max use 1 Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 567/579 If not required by this implementation guide, do not send. C003-01 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type/source of the descriptive number used in Product/Service ID (234) C003-01 qualifies C003-02 and C003-08. ER Jurisdiction Specific Procedure and Supply Codes HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC. HP Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code IV Home Infusion EDI Coalition (HIEC) Product/Service Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the Home Infusion EDI Coalition (HIEC) Product/Service Codes as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA.; WK Advanced Billing Concepts (ABC) Codes At the time of this writing, this code set has been approved by the Secretary of HHS as a pilot project allowed under HIPAA law. The qualifier may only be used in transactions covered under HIPAA; By parties registered in the pilot project and their trading partners, OR If a new rule names the Complementary, Alternative, or Holistic Procedure Codes as an allowable code set under HIPAA, OR For claims which are not covered under HIPAA. C003-02 234 Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. C003-03 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-03 modifies the value in C003-02 and C003-08. C003-04 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 568/579 This identifies special circumstances related to the performance of the service, as defined by trading partners C003-04 modifies the value in C003-02 and C003-08. C003-05 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-05 modifies the value in C003-02 and C003-08. C003-06 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-06 modifies the value in C003-02 and C003-08. C003-07 352 Procedure Code Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content C003-07 is the description of the procedure identified in C003-02. SVD-04 234 Service Line Revenue Code Min 1 Max 48 String (AN) Required Identifying number for a product or service SVD04 is the revenue code. SVD-05 380 Paid Service Unit Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity SVD05 is the paid units of service. Usage notes This is the number of paid units from the remittance advice. When paid units are not present on the remittance advice, use the original billed units. The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three. SVD-06 554 Bundled Line Number Min 1 Max 6 Numeric (N0) Optional Number assigned for differentiation within a transaction set 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 569/579 SVD06 is only used for bundling of service lines. It references the LX Assigned Number of the service line into which this service line was bundled. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 570/579 CAS 5450 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Line Adjudication Information Loop > CAS Line Adjustment To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid Usage notes Required when the payer identified in Loop 2330B made line level adjustments which caused the amount paid to differ from the amount originally charged. If not required by this implementation guide, do not send. A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a particular Claim Adjustment Group Code (CAS01). The first non-zero adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19). Example CAS*CR*XXX*00000000000000*000000000000000*X*00000 0*000000000000000*XXX*00000000000*0000000000000 0*X*000*0000000000000*XXXXX*00000000000000*000000 000000*X*00000*00000000~ If Adjustment Reason Code (CAS-05) is present, then at least one of Adjustment Amount (CAS-06) or Adjustment Quantity (CAS-07) is required If Adjustment Amount (CAS-06) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Quantity (CAS-07) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Reason Code (CAS-08) is present, then at least one of Adjustment Amount (CAS-09) or Adjustment Quantity (CAS-10) is required If Adjustment Amount (CAS-09) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Quantity (CAS-10) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Reason Code (CAS-11) is present, then at least one of Adjustment Amount (CAS-12) or Adjustment Quantity (CAS-13) is required If Adjustment Amount (CAS-12) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Quantity (CAS-13) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS-16) is required If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS-19) is required If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required Max use 5 Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 571/579 If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required CAS-01 1033 Claim Adjustment Group Code Identifier (ID) Required Code identifying the general category of payment adjustment CO Contractual Obligations CR Correction and Reversals OA Other adjustments PI Payor Initiated Reductions PR Patient Responsibility CAS-02 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Required Code identifying the detailed reason the adjustment was made CAS-03 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CAS03 is the amount of adjustment. CAS-04 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS04 is the units of service being adjusted. CAS-05 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CODE SOURCE 139: Claim Adjustment Reason Code CAS-06 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS06 is the amount of the adjustment. CAS-07 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 572/579 CAS07 is the units of service being adjusted. CAS-08 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CODE SOURCE 139: Claim Adjustment Reason Code CAS-09 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS09 is the amount of the adjustment. CAS-10 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS10 is the units of service being adjusted. CAS-11 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CODE SOURCE 139: Claim Adjustment Reason Code CAS-12 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS12 is the amount of the adjustment. CAS-13 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS13 is the units of service being adjusted. CAS-14 1034 Adjustment Reason | Health Partner Plans 837 Health Care Claim_ Institutional.pdf |
If Adjustment Reason Code (CAS-11) is present, then at least one of Adjustment Amount (CAS-12) or Adjustment Quantity (CAS-13) is required If Adjustment Amount (CAS-12) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Quantity (CAS-13) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS-16) is required If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS-19) is required If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required Max use 5 Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 571/579 If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required CAS-01 1033 Claim Adjustment Group Code Identifier (ID) Required Code identifying the general category of payment adjustment CO Contractual Obligations CR Correction and Reversals OA Other adjustments PI Payor Initiated Reductions PR Patient Responsibility CAS-02 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Required Code identifying the detailed reason the adjustment was made CAS-03 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CAS03 is the amount of adjustment. CAS-04 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS04 is the units of service being adjusted. CAS-05 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CODE SOURCE 139: Claim Adjustment Reason Code CAS-06 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS06 is the amount of the adjustment. CAS-07 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 572/579 CAS07 is the units of service being adjusted. CAS-08 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CODE SOURCE 139: Claim Adjustment Reason Code CAS-09 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS09 is the amount of the adjustment. CAS-10 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS10 is the units of service being adjusted. CAS-11 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CODE SOURCE 139: Claim Adjustment Reason Code CAS-12 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS12 is the amount of the adjustment. CAS-13 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS13 is the units of service being adjusted. CAS-14 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 573/579 See CODE SOURCE 139: Claim Adjustment Reason Code CAS-15 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS15 is the amount of the adjustment. CAS-16 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS16 is the units of service being adjusted. CAS-17 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CODE SOURCE 139: Claim Adjustment Reason Code CAS-18 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS18 is the amount of the adjustment. CAS-19 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS19 is the units of service being adjusted. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 574/579 DTP 5500 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Line Adjudication Information Loop > DTP Line Check or Remittance Date To specify any or all of a date, a time, or a time period Example DTP*573*D8*XXXXXX~ Max use 1 Required DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 573 Date Claim Paid DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Adjudication or Payment Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 575/579 2430 Line Adjudication Information Loop end 2400 Service Line Number Loop end 2300 Claim Information Loop end 2000C Patient Hierarchical Level Loop end 2000B Subscriber Hierarchical Level Loop end AMT 5505 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Line Adjudication Information Loop > AMT Remaining Patient Liability To indicate the total monetary amount Usage notes In the judgment of the provider, this is the remaining amount to be paid after adjudication by the Other Payer referenced in SVD01 of this iteration of Loop ID-2430. This segment is only used in provider submitted claims. It is not used in Payer-to-Payer Coordination of Benefits (COB). Required when the Other Payer referenced in SVD01 of this iteration of Loop ID-2430 has adjudicated this claim, provided line level information, and the provider has the ability to report line item information. If not required by this implementation guide, do not send. This segment is not used if the claim level (Loop ID-2320) Remaining Patient Liability AMT segment is used for this Other Payer. Example AMT*EAF*000000000000~ Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount EAF Amount Owed AMT-02 782 Remaining Patient Liability Min 1 Max 15 Decimal number (R) Required Monetary amount 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 576/579 2000A Billing Provider Hierarchical Level Loop end Detail end SE 5550 Detail > SE Transaction Set Trailer To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments) Example SE*00*0001~ Max use 1 Required SE-01 96 Transaction Segment Count Min 1 Max 10 Numeric (N0) Required Total number of segments included in a transaction set including ST and SE segments SE-02 329 Transaction Set Control Number Min 4 Max 9 Numeric (N) Required Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set Usage notes The Transaction Set Control Number in ST02 and SE02 must be identical. The number must be unique within a specific interchange (ISA-IEA), but can repeat in other interchanges. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 577/579 GE Functional Group Trailer To indicate the end of a functional group and to provide control information Example GE*000000*00000~ Max use 1 Required GE-01 97 Number of Transaction Sets Included Min 1 Max 6 Numeric (N0) Required Total number of transaction sets included in the functional group or interchange (transmission) group terminated by the trailer containing this data element GE-02 28 Group Control Number Min 1 Max 9 Numeric (N0) Required Assigned number originated and maintained by the sender 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 578/579 Stedi is a registered trademark of Stedi, Inc. All names, logos, and brands of third parties listed on this page are trademarks of their respective owners (including “X12”, which is a trademark of X12 Incorporated). Stedi, Inc. and its products and services are not endorsed by, sponsored by, or affiliated with these third parties. Use of these names, logos, and brands is for identification purposes only, and does not imply any such endorsement, sponsorship, or affiliation. IEA Interchange Control Trailer To define the end of an interchange of zero or more functional groups and interchange- related control segments Example IEA*000*000000000~ Max use 1 Required IEA-01 I16 Number of Included Functional Groups Min 1 Max 5 Numeric (N0) Required A count of the number of functional groups included in an interchange IEA-02 I12 Interchange Control Number Min 9 Max 9 Numeric (N0) Required A control number assigned by the interchange sender 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 579/579 | Health Partner Plans 837 Health Care Claim_ Institutional.pdf |
Stedi maintains this guide based on public documentation from Home State Health. Contact Home State Health for official EDI specifications. To report any errors in this guide, please contact us. X12 837 Health Care Claim: Professional (X222A2) X12 Release 5010 Revised November 17, 2023 Go to Stedi Network This X12 Transaction Set contains the format and establishes the data contents of the Health Care Claim Transaction Set (837) for use within the context of an Electronic Data Interchange (EDI) environment. This transaction set can be used to submit health care claim billing information, encounter information, or both, from providers of health care services to payers, either directly or via intermediary billers and claims clearinghouses. It can also be used to transmit health care claims and billing payment information between payers with different payment responsibilities where coordination of benefits is required or between payers and regulatory agencies to monitor the rendering, billing, and/or payment of health care services within a specific health care/insurance industry segment. For purposes of this standard, providers of health care products or services may include entities such as physicians, hospitals and other medical facilities or suppliers, dentists, and pharmacies, and entities providing medical information to meet regulatory requirements. The payer refers to a third party entity that pays claims or administers the insurance product or benefit or both. For example, a payer may be an insurance company, health maintenance organization (HMO), preferred provider organization (PPO), government agency (Medicare, Medicaid, Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), etc.) or an entity such as a third party administrator (TPA) or third party organization (TPO) that may be contracted by one of those groups. A regulatory agency is an entity responsible, by law or rule, for administering and monitoring a statutory benefits program or a specific health care/insurance industry segment. Delimiters ~ Segment * Element > Component ^ Repetition 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 1/665 View the latest version of this implementation guide as an interactive webpage https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional- x222a2/01H25M3DFZT8BN5QV8WP430GEQ POWERED BY Build EDI implementation guides at stedi.com 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 2/665 Overview ISA - Interchange Control Header Max use 1 Required GS - Functional Group Header Max use 1 Required Heading ST 0050 Transaction Set Header Max use 1 Required BHT 0100 Beginning of Hierarchical Transaction Max use 1 Required Submitter Name Loop NM1 0200 Submitter Name Max use 1 Required PER 0450 Submitter EDI Contact Information Max use 2 Required Receiver Name Loop NM1 0200 Receiver Name Max use 1 Required Detail Billing Provider Hierarchical Level Loop HL 0010 Hierarchical Level Max use 1 Required PRV 0030 Billing Provider Specialty Information Max use 1 Optional CUR 0100 Foreign Currency Information Max use 1 Optional Billing Provider Name Loop NM1 0150 Billing Provider Name Max use 1 Required N3 0250 Billing Provider Address Max use 1 Required N4 0300 Billing Provider City, State, ZIP Code Max use 1 Required REF 0350 Billing Provider Tax Identification Max use 1 Required REF 0350 Billing Provider UPIN/License Information Max use 2 Optional PER 0400 Billing Provider Contact Information Max use 2 Optional Pay-to Address Name Loop NM1 0150 Pay-to Address Name Max use 1 Required N3 0250 Pay-to Address - ADDRESS Max use 1 Required N4 0300 Pay-To Address City, State, ZIP Code Max use 1 Required 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 3/665 Pay-To Plan Name Loop NM1 0150 Pay-To Plan Name Max use 1 Required N3 0250 Pay-to Plan Address Max use 1 Required N4 0300 Pay-To Plan City, State, ZIP Code Max use 1 Required REF 0350 Pay-to Plan Secondary Identification Max use 1 Optional REF 0350 Pay-To Plan Tax Identification Number Max use 1 Required Subscriber Hierarchical Level Loop HL 0010 Hierarchical Level Max use 1 Required SBR 0050 Subscriber Information Max use 1 Required PAT 0070 Patient Information Max use 1 Optional Subscriber Name Loop NM1 0150 Subscriber Name Max use 1 Required N3 0250 Subscriber Address Max use 1 Optional N4 0300 Subscriber City, State, ZIP Code Max use 1 Optional DMG 0320 Subscriber Demographic Information Max use 1 Optional REF 0350 Property and Casualty Claim Number Max use 1 Optional REF 0350 Subscriber Secondary Identification Max use 1 Optional PER 0400 Property and Casualty Subscriber Contact Information Max use 1 Optional Payer Name Loop NM1 0150 Payer Name Max use 1 Required N3 0250 Payer Address Max use 1 Optional N4 0300 Payer City, State, ZIP Code Max use 1 Optional REF 0350 Billing Provider Secondary Identification Max use 2 Optional REF 0350 Payer Secondary Identification Max use 3 Optional Claim Information Loop CLM 1300 Claim Information Max use 1 Required DTP 1350 Date - Accident Max use 1 Optional DTP 1350 Date - Acute Manifestation Max use 1 Optional 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 4/665 DTP 1350 Date - Admission Max use 1 Optional DTP 1350 Date - Assumed and Relinquished Care Dates Max use 2 Optional DTP 1350 Date - Authorized Return to Work Max use 1 Optional DTP 1350 Date - Disability Dates Max use 1 Optional DTP 1350 Date - Discharge Max use 1 Optional DTP 1350 Date - Hearing and Vision Prescription Date Max use 1 Optional DTP 1350 Date - Initial Treatment Date Max use 1 Optional DTP 1350 Date - Last Menstrual Period Max use 1 Optional DTP 1350 Date - Last Seen Date Max use 1 Optional DTP 1350 Date - Last Worked Max use 1 Optional DTP 1350 Date - Last X-ray Date Max use 1 Optional DTP 1350 Date - Onset of Current Illness or Symptom Max use 1 Optional DTP 1350 Date - Property and Casualty Date of First Contact Max use 1 Optional DTP 1350 Date - Repricer Received Date Max use 1 Optional PWK 1550 Claim Supplemental Information Max use 10 Optional CN1 1600 Contract Information Max use 1 Optional AMT 1750 Patient Amount Paid Max use 1 Optional REF 1800 Adjusted Repriced Claim Number Max use 1 Optional REF 1800 Care Plan Oversight Max use 1 Optional REF 1800 Claim Identifier For Transmission Intermediaries Max use 1 Optional REF 1800 Clinical Laboratory Improvement Amendment (CLIA) Number Max use 1 Optional REF 1800 Demonstration Project Identifier Max use 1 Optional REF 1800 Investigational Device Exemption Number Max use 1 Optional REF 1800 Mammography Certification Number Max use 1 Optional REF 1800 Mandatory Medicare (Section 4081) Crossover Indicator Max use 1 Optional REF 1800 Medical Record Number Max use 1 Optional REF 1800 Payer Claim Control Number Max use 1 Optional 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 5/665 REF 1800 Prior Authorization Max use 1 Optional REF 1800 Referral Number Max use 1 Optional REF 1800 Repriced Claim Number Max use 1 Optional REF 1800 Service Authorization Exception Code Max use 1 Optional K3 1850 File Information Max use 10 Optional NTE 1900 Claim Note Max use 1 Optional CR1 1950 Ambulance Transport Information Max use 1 Optional CR2 2000 Spinal Manipulation Service Information Max use 1 Optional CRC 2200 Ambulance Certification Max use 3 Optional CRC 2200 EPSDT Referral Max use 1 Optional CRC 2200 Homebound Indicator Max use 1 Optional CRC 2200 Patient Condition Information: Vision Max use 3 Optional HI 2310 Anesthesia Related Procedure Max use 1 Optional HI 2310 Condition Information Max use 2 Optional HI 2310 Health Care Diagnosis Code Max use 1 Required HCP 2410 Claim Pricing/Repricing Information Max use 1 Optional Referring Provider Name Loop NM1 2500 Referring Provider Name Max use 1 Required REF 2710 Referring Provider Secondary Identification Max use 3 Optional Rendering Provider Name Loop NM1 2500 Rendering Provider Name Max use 1 Required PRV 2550 Rendering Provider Specialty Information Max use 1 Optional REF 2710 Rendering Provider Secondary Identification Max use 4 Optional Service Facility Location Name Loop NM1 2500 Service Facility Location Name Max use 1 Required N3 2650 Service Facility Location Address Max use 1 Required N4 2700 Service Facility Location City, State, ZIP Code Max use 1 Required REF 2710 Service Facility Location Secondary Identification Max use 3 Optional 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 6/665 PER 2750 Service Facility Contact Information Max use 1 Optional Supervising Provider Name Loop NM1 2500 Supervising Provider Name Max use 1 Required REF 2710 Supervising Provider Secondary Identification Max use 4 Optional Ambulance Pick-up Location Loop NM1 2500 Ambulance Pick-up Location Max use 1 Required N3 2650 Ambulance Pick-up Location Address Max use 1 Required N4 2700 Ambulance Pick-up Location City, State, ZIP Code Max use 1 Required Ambulance Drop-off Location Loop NM1 2500 Ambulance Drop-off Location Max use 1 Required N3 2650 Ambulance Drop-off Location Address Max use 1 Required N4 2700 Ambulance Drop-off Location City, State, ZIP Code Max use 1 Required Other Subscriber Information Loop SBR 2900 Other Subscriber Information Max use 1 Required CAS 2950 Claim Level Adjustments Max use 5 Optional AMT 3000 Coordination of Benefits (COB) Payer Paid Amount Max use 1 Optional AMT 3000 Coordination of Benefits (COB) Total Non- Covered Amount Max use 1 Optional AMT 3000 Remaining Patient Liability Max use 1 Optional OI 3100 Other Insurance Coverage Information Max use 1 Required MOA 3200 Outpatient Adjudication Information Max use 1 Optional Other Subscriber Name Loop NM1 3250 Other Subscriber Name Max use 1 Required N3 3320 Other Subscriber Address Max use 1 Optional N4 3400 Other Subscriber City, State, ZIP Code Max use 1 Optional REF 3550 Other Subscriber Secondary Identification Max use 1 Optional Other Payer Name Loop 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 7/665 NM1 3250 Other Payer Name Max use 1 Required N3 3320 Other Payer Address Max use 1 Optional N4 3400 Other Payer City, State, ZIP Code Max use 1 Optional DTP 3450 Claim Check or Remittance Date Max use 1 Optional REF 3550 Other Payer Claim Adjustment Indicator Max use 1 Optional REF 3550 Other Payer Claim Control Number Max use 1 Optional REF 3550 Other Payer Prior Authorization Number Max use 1 Optional REF 3550 Other Payer Referral Number Max use 1 Optional REF 3550 Other Payer Secondary Identifier Max use 2 Optional Other Payer Referring Provider Loop NM1 3250 Other Payer Referring Provider Max use 1 Required REF 3550 Other Payer Referring Provider Secondary Identification Max use 3 Required Other Payer Rendering Provider Loop NM1 3250 Other Payer Rendering Provider Max use 1 Required REF 3550 Other Payer Rendering Provider Secondary Identification Max use 3 Required Other Payer Service Facility Location Loop NM1 3250 Other Payer Service Facility Location Max use 1 Required REF 3550 Other Payer Service Facility Location Secondary Identification Max use 3 Required Other Payer Supervising Provider Loop NM1 3250 Other Payer Supervising Provider Max use 1 Required REF 3550 Other Payer Supervising Provider Secondary Identification Max use 3 Required Other Payer Billing Provider Loop NM1 3250 Other Payer Billing Provider Max use 1 Required REF 3550 Other Payer Billing Provider Secondary Identification Max use 2 Required Service Line Number Loop 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 8/665 LX 3650 Service Line Number Max use 1 Required SV1 3700 Professional Service Max use 1 Required SV5 4000 Durable Medical Equipment Service Max use 1 Optional PWK 4200 Durable Medical Equipment Certificate of Medical Necessity Indicator Max use 1 Optional PWK 4200 Line Supplemental Information Max use 10 Optional CR1 4250 Ambulance Transport Information Max use 1 Optional CR3 4350 Durable Medical Equipment Certification Max use 1 Optional CRC 4500 Ambulance Certification Max use 3 Optional CRC 4500 Condition Indicator/Durable Medical Equipment Max use 1 Optional CRC 4500 Hospice Employee Indicator Max use 1 Optional DTP 4550 Date - Begin Therapy Date Max use 1 Optional DTP 4550 DATE - Certification Revision/Recertification Date Max use 1 Optional DTP 4550 Date - Initial Treatment Date Max use 1 Optional DTP 4550 Date - Last Certification Date | Home State Health 837 Health Care Claim_ Professional.pdf |
Optional AMT 3000 Coordination of Benefits (COB) Payer Paid Amount Max use 1 Optional AMT 3000 Coordination of Benefits (COB) Total Non- Covered Amount Max use 1 Optional AMT 3000 Remaining Patient Liability Max use 1 Optional OI 3100 Other Insurance Coverage Information Max use 1 Required MOA 3200 Outpatient Adjudication Information Max use 1 Optional Other Subscriber Name Loop NM1 3250 Other Subscriber Name Max use 1 Required N3 3320 Other Subscriber Address Max use 1 Optional N4 3400 Other Subscriber City, State, ZIP Code Max use 1 Optional REF 3550 Other Subscriber Secondary Identification Max use 1 Optional Other Payer Name Loop 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 7/665 NM1 3250 Other Payer Name Max use 1 Required N3 3320 Other Payer Address Max use 1 Optional N4 3400 Other Payer City, State, ZIP Code Max use 1 Optional DTP 3450 Claim Check or Remittance Date Max use 1 Optional REF 3550 Other Payer Claim Adjustment Indicator Max use 1 Optional REF 3550 Other Payer Claim Control Number Max use 1 Optional REF 3550 Other Payer Prior Authorization Number Max use 1 Optional REF 3550 Other Payer Referral Number Max use 1 Optional REF 3550 Other Payer Secondary Identifier Max use 2 Optional Other Payer Referring Provider Loop NM1 3250 Other Payer Referring Provider Max use 1 Required REF 3550 Other Payer Referring Provider Secondary Identification Max use 3 Required Other Payer Rendering Provider Loop NM1 3250 Other Payer Rendering Provider Max use 1 Required REF 3550 Other Payer Rendering Provider Secondary Identification Max use 3 Required Other Payer Service Facility Location Loop NM1 3250 Other Payer Service Facility Location Max use 1 Required REF 3550 Other Payer Service Facility Location Secondary Identification Max use 3 Required Other Payer Supervising Provider Loop NM1 3250 Other Payer Supervising Provider Max use 1 Required REF 3550 Other Payer Supervising Provider Secondary Identification Max use 3 Required Other Payer Billing Provider Loop NM1 3250 Other Payer Billing Provider Max use 1 Required REF 3550 Other Payer Billing Provider Secondary Identification Max use 2 Required Service Line Number Loop 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 8/665 LX 3650 Service Line Number Max use 1 Required SV1 3700 Professional Service Max use 1 Required SV5 4000 Durable Medical Equipment Service Max use 1 Optional PWK 4200 Durable Medical Equipment Certificate of Medical Necessity Indicator Max use 1 Optional PWK 4200 Line Supplemental Information Max use 10 Optional CR1 4250 Ambulance Transport Information Max use 1 Optional CR3 4350 Durable Medical Equipment Certification Max use 1 Optional CRC 4500 Ambulance Certification Max use 3 Optional CRC 4500 Condition Indicator/Durable Medical Equipment Max use 1 Optional CRC 4500 Hospice Employee Indicator Max use 1 Optional DTP 4550 Date - Begin Therapy Date Max use 1 Optional DTP 4550 DATE - Certification Revision/Recertification Date Max use 1 Optional DTP 4550 Date - Initial Treatment Date Max use 1 Optional DTP 4550 Date - Last Certification Date Max use 1 Optional DTP 4550 Date - Last Seen Date Max use 1 Optional DTP 4550 Date - Last X-ray Date Max use 1 Optional DTP 4550 Date - Prescription Date Max use 1 Optional DTP 4550 Date - Service Date Max use 1 Required DTP 4550 Date - Shipped Date Max use 1 Optional DTP 4550 Date - Test Date Max use 2 Optional QTY 4600 Ambulance Patient Count Max use 1 Optional QTY 4600 Obstetric Anesthesia Additional Units Max use 1 Optional MEA 4620 Test Result Max use 5 Optional CN1 4650 Contract Information Max use 1 Optional REF 4700 Adjusted Repriced Line Item Reference Number Max use 1 Optional REF 4700 Clinical Laboratory Improvement Amendment (CLIA) Number Max use 1 Optional REF 4700 Immunization Batch Number Max use 1 Optional 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 9/665 REF 4700 Line Item Control Number Max use 1 Optional REF 4700 Mammography Certification Number Max use 1 Optional REF 4700 Prior Authorization Max use 5 Optional REF 4700 Referral Number Max use 5 Optional REF 4700 Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification Max use 1 Optional REF 4700 Repriced Line Item Reference Number Max use 1 Optional AMT 4750 Postage Claimed Amount Max use 1 Optional AMT 4750 Sales Tax Amount Max use 1 Optional K3 4800 File Information Max use 10 Optional NTE 4850 Line Note Max use 1 Optional NTE 4850 Third Party Organization Notes Max use 1 Optional PS1 4880 Purchased Service Information Max use 1 Optional HCP 4920 Line Pricing/Repricing Information Max use 1 Optional Drug Identification Loop LIN 4930 Drug Identification Max use 1 Required CTP 4940 Drug Quantity Max use 1 Required REF 4950 Prescription or Compound Drug Association Number Max use 1 Optional Rendering Provider Name Loop NM1 5000 Rendering Provider Name Max use 1 Required PRV 5050 Rendering Provider Specialty Information Max use 1 Optional REF 5250 Rendering Provider Secondary Identification Max use 20 Optional Purchased Service Provider Name Loop NM1 5000 Purchased Service Provider Name Max use 1 Required REF 5250 Purchased Service Provider Secondary Identification Max use 20 Optional Service Facility Location Name Loop NM1 5000 Service Facility Location Name Max use 1 Required N3 5140 Service Facility Location Address Max use 1 Required 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 10/665 N4 5200 Service Facility Location City, State, ZIP Code Max use 1 Required REF 5250 Service Facility Location Secondary Identification Max use 3 Optional Supervising Provider Name Loop NM1 5000 Supervising Provider Name Max use 1 Required REF 5250 Supervising Provider Secondary Identification Max use 20 Optional Ordering Provider Name Loop NM1 5000 Ordering Provider Name Max use 1 Required N3 5140 Ordering Provider Address Max use 1 Optional N4 5200 Ordering Provider City, State, ZIP Code Max use 1 Optional REF 5250 Ordering Provider Secondary Identification Max use 20 Optional PER 5300 Ordering Provider Contact Information Max use 1 Optional Referring Provider Name Loop NM1 5000 Referring Provider Name Max use 1 Required REF 5250 Referring Provider Secondary Identification Max use 20 Optional Ambulance Pick-up Location Loop NM1 5000 Ambulance Pick-up Location Max use 1 Required N3 5140 Ambulance Pick-up Location Address Max use 1 Required N4 5200 Ambulance Pick-up Location City, State, ZIP Code Max use 1 Required Ambulance Drop-off Location Loop NM1 5000 Ambulance Drop-off Location Max use 1 Required N3 5140 Ambulance Drop-off Location Address Max use 1 Required N4 5200 Ambulance Drop-off Location City, State, ZIP Code Max use 1 Required Line Adjudication Information Loop SVD 5400 Line Adjudication Information Max use 1 Required CAS 5450 Line Adjustment Max use 5 Optional DTP 5500 Line Check or Remittance Date Max use 1 Required 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 11/665 AMT 5505 Remaining Patient Liability Max use 1 Optional Form Identification Code Loop LQ 5510 Form Identification Code Max use 1 Required FRM 5520 Supporting Documentation Max use 99 Required Patient Hierarchical Level Loop HL 0010 Hierarchical Level Max use 1 Required PAT 0070 Patient Information Max use 1 Required Patient Name Loop NM1 0150 Patient Name Max use 1 Required N3 0250 Patient Address Max use 1 Required N4 0300 Patient City, State, ZIP Code Max use 1 Required DMG 0320 Patient Demographic Information Max use 1 Required REF 0350 Property and Casualty Claim Number Max use 1 Optional REF 0350 Property and Casualty Patient Identifier Max use 1 Optional PER 0400 Property and Casualty Patient Contact Information Max use 1 Optional Claim Information Loop CLM 1300 Claim Information Max use 1 Required DTP 1350 Date - Accident Max use 1 Optional DTP 1350 Date - Acute Manifestation Max use 1 Optional DTP 1350 Date - Admission Max use 1 Optional DTP 1350 Date - Assumed and Relinquished Care Dates Max use 2 Optional DTP 1350 Date - Authorized Return to Work Max use 1 Optional DTP 1350 Date - Disability Dates Max use 1 Optional DTP 1350 Date - Discharge Max use 1 Optional DTP 1350 Date - Hearing and Vision Prescription Date Max use 1 Optional DTP 1350 Date - Initial Treatment Date Max use 1 Optional DTP 1350 Date - Last Menstrual Period Max use 1 Optional DTP 1350 Date - Last Seen Date Max use 1 Optional 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 12/665 DTP 1350 Date - Last Worked Max use 1 Optional DTP 1350 Date - Last X-ray Date Max use 1 Optional DTP 1350 Date - Onset of Current Illness or Symptom Max use 1 Optional DTP 1350 Date - Property and Casualty Date of First Contact Max use 1 Optional DTP 1350 Date - Repricer Received Date Max use 1 Optional PWK 1550 Claim Supplemental Information Max use 10 Optional CN1 1600 Contract Information Max use 1 Optional AMT 1750 Patient Amount Paid Max use 1 Optional REF 1800 Adjusted Repriced Claim Number Max use 1 Optional REF 1800 Care Plan Oversight Max use 1 Optional REF 1800 Claim Identifier For Transmission Intermediaries Max use 1 Optional REF 1800 Clinical Laboratory Improvement Amendment (CLIA) Number Max use 1 Optional REF 1800 Demonstration Project Identifier Max use 1 Optional REF 1800 Investigational Device Exemption Number Max use 1 Optional REF 1800 Mammography Certification Number Max use 1 Optional REF 1800 Mandatory Medicare (Section 4081) Crossover Indicator Max use 1 Optional REF 1800 Medical Record Number Max use 1 Optional REF 1800 Payer Claim Control Number Max use 1 Optional REF 1800 Prior Authorization Max use 1 Optional REF 1800 Referral Number Max use 1 Optional REF 1800 Repriced Claim Number Max use 1 Optional REF 1800 Service Authorization Exception Code Max use 1 Optional K3 1850 File Information Max use 10 Optional NTE 1900 Claim Note Max use 1 Optional CR1 1950 Ambulance Transport Information Max use 1 Optional CR2 2000 Spinal Manipulation Service Information Max use 1 Optional CRC 2200 Ambulance Certification Max use 3 Optional 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 13/665 CRC 2200 EPSDT Referral Max use 1 Optional CRC 2200 Homebound Indicator Max use 1 Optional CRC 2200 Patient Condition Information: Vision Max use 3 Optional HI 2310 Anesthesia Related Procedure Max use 1 Optional HI 2310 Condition Information Max use 2 Optional HI 2310 Health Care Diagnosis Code Max use 1 Required HCP 2410 Claim Pricing/Repricing Information Max use 1 Optional Referring Provider Name Loop NM1 2500 Referring Provider Name Max use 1 Required REF 2710 Referring Provider Secondary Identification Max use 3 Optional Rendering Provider Name Loop NM1 2500 Rendering Provider Name Max use 1 Required PRV 2550 Rendering Provider Specialty Information Max use 1 Optional REF 2710 Rendering Provider Secondary Identification Max use 4 Optional Service Facility Location Name Loop NM1 2500 Service Facility Location Name Max use 1 Required N3 2650 Service Facility Location Address Max use 1 Required N4 2700 Service Facility Location City, State, ZIP Code Max use 1 Required REF 2710 Service Facility Location Secondary Identification Max use 3 Optional PER 2750 Service Facility Contact Information Max use 1 Optional Supervising Provider Name Loop NM1 2500 Supervising Provider Name Max use 1 Required REF 2710 Supervising Provider Secondary Identification Max use 4 Optional Ambulance Pick-up Location Loop NM1 2500 Ambulance Pick-up Location Max use 1 Required N3 2650 Ambulance Pick-up Location Address Max use 1 Required N4 2700 Ambulance Pick-up Location City, State, ZIP Code Max use 1 Required 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 14/665 Ambulance Drop-off Location Loop NM1 2500 Ambulance Drop-off Location Max use 1 Required N3 2650 Ambulance Drop-off Location Address Max use 1 Required N4 2700 Ambulance Drop-off Location City, State, ZIP Code Max use 1 Required Other Subscriber Information Loop SBR 2900 Other Subscriber Information Max use 1 Required CAS 2950 Claim Level Adjustments Max use 5 Optional AMT 3000 Coordination of Benefits (COB) Payer Paid Amount Max use 1 Optional AMT 3000 Coordination of | Home State Health 837 Health Care Claim_ Professional.pdf |
Oversight Max use 1 Optional REF 1800 Claim Identifier For Transmission Intermediaries Max use 1 Optional REF 1800 Clinical Laboratory Improvement Amendment (CLIA) Number Max use 1 Optional REF 1800 Demonstration Project Identifier Max use 1 Optional REF 1800 Investigational Device Exemption Number Max use 1 Optional REF 1800 Mammography Certification Number Max use 1 Optional REF 1800 Mandatory Medicare (Section 4081) Crossover Indicator Max use 1 Optional REF 1800 Medical Record Number Max use 1 Optional REF 1800 Payer Claim Control Number Max use 1 Optional REF 1800 Prior Authorization Max use 1 Optional REF 1800 Referral Number Max use 1 Optional REF 1800 Repriced Claim Number Max use 1 Optional REF 1800 Service Authorization Exception Code Max use 1 Optional K3 1850 File Information Max use 10 Optional NTE 1900 Claim Note Max use 1 Optional CR1 1950 Ambulance Transport Information Max use 1 Optional CR2 2000 Spinal Manipulation Service Information Max use 1 Optional CRC 2200 Ambulance Certification Max use 3 Optional 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 13/665 CRC 2200 EPSDT Referral Max use 1 Optional CRC 2200 Homebound Indicator Max use 1 Optional CRC 2200 Patient Condition Information: Vision Max use 3 Optional HI 2310 Anesthesia Related Procedure Max use 1 Optional HI 2310 Condition Information Max use 2 Optional HI 2310 Health Care Diagnosis Code Max use 1 Required HCP 2410 Claim Pricing/Repricing Information Max use 1 Optional Referring Provider Name Loop NM1 2500 Referring Provider Name Max use 1 Required REF 2710 Referring Provider Secondary Identification Max use 3 Optional Rendering Provider Name Loop NM1 2500 Rendering Provider Name Max use 1 Required PRV 2550 Rendering Provider Specialty Information Max use 1 Optional REF 2710 Rendering Provider Secondary Identification Max use 4 Optional Service Facility Location Name Loop NM1 2500 Service Facility Location Name Max use 1 Required N3 2650 Service Facility Location Address Max use 1 Required N4 2700 Service Facility Location City, State, ZIP Code Max use 1 Required REF 2710 Service Facility Location Secondary Identification Max use 3 Optional PER 2750 Service Facility Contact Information Max use 1 Optional Supervising Provider Name Loop NM1 2500 Supervising Provider Name Max use 1 Required REF 2710 Supervising Provider Secondary Identification Max use 4 Optional Ambulance Pick-up Location Loop NM1 2500 Ambulance Pick-up Location Max use 1 Required N3 2650 Ambulance Pick-up Location Address Max use 1 Required N4 2700 Ambulance Pick-up Location City, State, ZIP Code Max use 1 Required 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 14/665 Ambulance Drop-off Location Loop NM1 2500 Ambulance Drop-off Location Max use 1 Required N3 2650 Ambulance Drop-off Location Address Max use 1 Required N4 2700 Ambulance Drop-off Location City, State, ZIP Code Max use 1 Required Other Subscriber Information Loop SBR 2900 Other Subscriber Information Max use 1 Required CAS 2950 Claim Level Adjustments Max use 5 Optional AMT 3000 Coordination of Benefits (COB) Payer Paid Amount Max use 1 Optional AMT 3000 Coordination of Benefits (COB) Total Non- Covered Amount Max use 1 Optional AMT 3000 Remaining Patient Liability Max use 1 Optional OI 3100 Other Insurance Coverage Information Max use 1 Required MOA 3200 Outpatient Adjudication Information Max use 1 Optional Other Subscriber Name Loop NM1 3250 Other Subscriber Name Max use 1 Required N3 3320 Other Subscriber Address Max use 1 Optional N4 3400 Other Subscriber City, State, ZIP Code Max use 1 Optional REF 3550 Other Subscriber Secondary Identification Max use 1 Optional Other Payer Name Loop NM1 3250 Other Payer Name Max use 1 Required N3 3320 Other Payer Address Max use 1 Optional N4 3400 Other Payer City, State, ZIP Code Max use 1 Optional DTP 3450 Claim Check or Remittance Date Max use 1 Optional REF 3550 Other Payer Claim Adjustment Indicator Max use 1 Optional REF 3550 Other Payer Claim Control Number Max use 1 Optional REF 3550 Other Payer Prior Authorization Number Max use 1 Optional REF 3550 Other Payer Referral Number Max use 1 Optional REF 3550 Other Payer Secondary Identifier Max use 2 Optional 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 15/665 Other Payer Referring Provider Loop NM1 3250 Other Payer Referring Provider Max use 1 Required REF 3550 Other Payer Referring Provider Secondary Identification Max use 3 Required Other Payer Rendering Provider Loop NM1 3250 Other Payer Rendering Provider Max use 1 Required REF 3550 Other Payer Rendering Provider Secondary Identification Max use 3 Required Other Payer Service Facility Location Loop NM1 3250 Other Payer Service Facility Location Max use 1 Required REF 3550 Other Payer Service Facility Location Secondary Identification Max use 3 Required Other Payer Supervising Provider Loop NM1 3250 Other Payer Supervising Provider Max use 1 Required REF 3550 Other Payer Supervising Provider Secondary Identification Max use 3 Required Other Payer Billing Provider Loop NM1 3250 Other Payer Billing Provider Max use 1 Required REF 3550 Other Payer Billing Provider Secondary Identification Max use 2 Required Service Line Number Loop LX 3650 Service Line Number Max use 1 Required SV1 3700 Professional Service Max use 1 Required SV5 4000 Durable Medical Equipment Service Max use 1 Optional PWK 4200 Durable Medical Equipment Certificate of Medical Necessity Indicator Max use 1 Optional PWK 4200 Line Supplemental Information Max use 10 Optional CR1 4250 Ambulance Transport Information Max use 1 Optional CR3 4350 Durable Medical Equipment Certification Max use 1 Optional CRC 4500 Ambulance Certification Max use 3 Optional CRC 4500 Condition Indicator/Durable Medical Equipment Max use 1 Optional 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 16/665 CRC 4500 Hospice Employee Indicator Max use 1 Optional DTP 4550 Date - Begin Therapy Date Max use 1 Optional DTP 4550 DATE - Certification Revision/Recertification Date Max use 1 Optional DTP 4550 Date - Initial Treatment Date Max use 1 Optional DTP 4550 Date - Last Certification Date Max use 1 Optional DTP 4550 Date - Last Seen Date Max use 1 Optional DTP 4550 Date - Last X-ray Date Max use 1 Optional DTP 4550 Date - Prescription Date Max use 1 Optional DTP 4550 Date - Service Date Max use 1 Required DTP 4550 Date - Shipped Date Max use 1 Optional DTP 4550 Date - Test Date Max use 2 Optional QTY 4600 Ambulance Patient Count Max use 1 Optional QTY 4600 Obstetric Anesthesia Additional Units Max use 1 Optional MEA 4620 Test Result Max use 5 Optional CN1 4650 Contract Information Max use 1 Optional REF 4700 Adjusted Repriced Line Item Reference Number Max use 1 Optional REF 4700 Clinical Laboratory Improvement Amendment (CLIA) Number Max use 1 Optional REF 4700 Immunization Batch Number Max use 1 Optional REF 4700 Line Item Control Number Max use 1 Optional REF 4700 Mammography Certification Number Max use 1 Optional REF 4700 Prior Authorization Max use 5 Optional REF 4700 Referral Number Max use 5 Optional REF 4700 Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification Max use 1 Optional REF 4700 Repriced Line Item Reference Number Max use 1 Optional AMT 4750 Postage Claimed Amount Max use 1 Optional AMT 4750 Sales Tax Amount Max use 1 Optional K3 4800 File Information Max use 10 Optional 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 17/665 NTE 4850 Line Note Max use 1 Optional NTE 4850 Third Party Organization Notes Max use 1 Optional PS1 4880 Purchased Service Information Max use 1 Optional HCP 4920 Line Pricing/Repricing Information Max use 1 Optional Drug Identification Loop LIN 4930 Drug Identification Max use 1 Required CTP 4940 Drug Quantity Max use 1 Required REF 4950 Prescription or Compound Drug Association Number Max use 1 Optional Rendering Provider Name Loop NM1 5000 Rendering Provider Name Max use 1 Required PRV 5050 Rendering Provider Specialty Information Max use 1 Optional REF 5250 Rendering Provider Secondary Identification Max use 20 Optional Purchased Service Provider Name Loop NM1 5000 Purchased Service Provider Name Max use 1 Required REF 5250 Purchased Service Provider Secondary Identification Max use 20 Optional Service Facility Location Name Loop NM1 5000 Service Facility Location Name Max use 1 Required N3 5140 Service Facility Location Address Max use 1 Required N4 5200 Service Facility Location City, State, ZIP Code Max use 1 Required REF 5250 Service Facility Location Secondary Identification Max use 3 Optional Supervising Provider Name Loop NM1 5000 Supervising Provider Name Max use 1 Required REF 5250 Supervising Provider Secondary Identification Max use 20 Optional Ordering Provider Name Loop NM1 5000 Ordering Provider Name Max use 1 Required N3 5140 Ordering Provider Address Max use 1 Optional N4 5200 Ordering Provider City, State, ZIP Code Max use 1 Optional 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 18/665 REF 5250 Ordering Provider Secondary Identification Max use 20 Optional PER 5300 Ordering Provider Contact Information Max use 1 Optional Referring Provider Name Loop NM1 5000 Referring Provider Name Max use 1 Required REF 5250 Referring Provider Secondary Identification Max use 20 Optional Ambulance Pick-up Location Loop NM1 5000 Ambulance Pick-up Location Max use 1 Required N3 5140 Ambulance Pick-up Location Address Max use 1 Required N4 5200 Ambulance Pick-up Location City, State, ZIP Code Max use 1 Required Ambulance Drop-off Location Loop NM1 5000 Ambulance Drop-off Location Max use 1 Required N3 5140 Ambulance Drop-off Location Address Max use 1 Required N4 5200 Ambulance Drop-off Location City, State, ZIP Code Max use 1 Required Line Adjudication Information Loop SVD 5400 Line Adjudication Information Max use 1 Required CAS 5450 Line Adjustment Max use 5 Optional DTP 5500 Line Check or Remittance Date Max use 1 Required AMT 5505 Remaining Patient Liability Max use 1 Optional Form Identification Code Loop LQ 5510 Form Identification Code Max use 1 Required FRM 5520 Supporting Documentation Max use 99 Required SE 5550 Transaction Set Trailer Max use 1 Required GE - Functional Group Trailer Max use 1 Required IEA - Interchange Control Trailer Max use 1 Required 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 19/665 ISA Interchange Control Header To start and identify an interchange of zero or more functional groups and interchange- related control segments Example ISA*00* *00* *XX*XXXXXXXXXXXXXX X*XX*XXXXXXXXXXXXXXX*250131*0243*^*00501*00000000 0*X*X*>~ Max use 1 Required ISA-01 I01 Authorization Information Qualifier Identifier (ID) Required Code identifying the type of information in the Authorization Information 00 No Authorization Information Present (No Meaningful Information in I02) ISA-02 I02 Authorization Information Min 10 Max 10 String (AN) Required Information used for additional identification or authorization of the interchange sender or the data in the interchange; the type of information is set by the Authorization Information Qualifier (I01) ISA-03 I03 Security Information Qualifier Identifier (ID) Required Code identifying the type of information in the Security Information 00 No Security Information Present (No Meaningful Information in I04) ISA-04 I04 Security Information Min 10 Max 10 String (AN) Required This is used for identifying the security information about the interchange sender or the data in the interchange; the type of information is set by the Security Information Qualifier (I03) ISA-05 I05 Interchange ID Qualifier Min 2 Max 2 Identifier (ID) Required Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified Codes ISA-06 I06 Interchange Sender ID Min 15 Max 15 String (AN) Required 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 20/665 Identification code published by the sender for other parties to use as the receiver ID to route data to them; the sender always codes this value in the sender ID element ISA-07 I05 Interchange ID Qualifier Min 2 Max 2 Identifier (ID) Required Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified Codes ISA-08 I07 Interchange Receiver ID Min 15 Max 15 String (AN) Required Identification code published by the receiver of the data; When sending, it is used by the sender as their sending ID, thus other parties sending to them will use | Home State Health 837 Health Care Claim_ Professional.pdf |
Optional Ambulance Pick-up Location Loop NM1 5000 Ambulance Pick-up Location Max use 1 Required N3 5140 Ambulance Pick-up Location Address Max use 1 Required N4 5200 Ambulance Pick-up Location City, State, ZIP Code Max use 1 Required Ambulance Drop-off Location Loop NM1 5000 Ambulance Drop-off Location Max use 1 Required N3 5140 Ambulance Drop-off Location Address Max use 1 Required N4 5200 Ambulance Drop-off Location City, State, ZIP Code Max use 1 Required Line Adjudication Information Loop SVD 5400 Line Adjudication Information Max use 1 Required CAS 5450 Line Adjustment Max use 5 Optional DTP 5500 Line Check or Remittance Date Max use 1 Required AMT 5505 Remaining Patient Liability Max use 1 Optional Form Identification Code Loop LQ 5510 Form Identification Code Max use 1 Required FRM 5520 Supporting Documentation Max use 99 Required SE 5550 Transaction Set Trailer Max use 1 Required GE - Functional Group Trailer Max use 1 Required IEA - Interchange Control Trailer Max use 1 Required 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 19/665 ISA Interchange Control Header To start and identify an interchange of zero or more functional groups and interchange- related control segments Example ISA*00* *00* *XX*XXXXXXXXXXXXXX X*XX*XXXXXXXXXXXXXXX*250131*0243*^*00501*00000000 0*X*X*>~ Max use 1 Required ISA-01 I01 Authorization Information Qualifier Identifier (ID) Required Code identifying the type of information in the Authorization Information 00 No Authorization Information Present (No Meaningful Information in I02) ISA-02 I02 Authorization Information Min 10 Max 10 String (AN) Required Information used for additional identification or authorization of the interchange sender or the data in the interchange; the type of information is set by the Authorization Information Qualifier (I01) ISA-03 I03 Security Information Qualifier Identifier (ID) Required Code identifying the type of information in the Security Information 00 No Security Information Present (No Meaningful Information in I04) ISA-04 I04 Security Information Min 10 Max 10 String (AN) Required This is used for identifying the security information about the interchange sender or the data in the interchange; the type of information is set by the Security Information Qualifier (I03) ISA-05 I05 Interchange ID Qualifier Min 2 Max 2 Identifier (ID) Required Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified Codes ISA-06 I06 Interchange Sender ID Min 15 Max 15 String (AN) Required 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 20/665 Identification code published by the sender for other parties to use as the receiver ID to route data to them; the sender always codes this value in the sender ID element ISA-07 I05 Interchange ID Qualifier Min 2 Max 2 Identifier (ID) Required Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified Codes ISA-08 I07 Interchange Receiver ID Min 15 Max 15 String (AN) Required Identification code published by the receiver of the data; When sending, it is used by the sender as their sending ID, thus other parties sending to them will use this as a receiving ID to route data to them ISA-09 I08 Interchange Date YYMMDD format Date (DT) Required Date of the interchange ISA-10 I09 Interchange Time HHMM format Time (TM) Required Time of the interchange ISA-11 I65 Repetition Separator Min 1 Max 1 String (AN) Required Type is not applicable; the repetition separator is a delimiter and not a data element; this field provides the delimiter used to separate repeated occurrences of a simple data element or a composite data structure; this value must be different than the data element separator, component element separator, and the segment terminator ^ Repetition Separator ISA-12 I11 Interchange Control Version Number Identifier (ID) Required Code specifying the version number of the interchange control segments 00501 Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003 ISA-13 I12 Interchange Control Number Min 9 Max 9 Numeric (N0) Required A control number assigned by the interchange sender ISA-14 I13 Acknowledgment Requested Min 1 Max 1 Identifier (ID) Required 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 21/665 Code indicating sender's request for an interchange acknowledgment 0 No Interchange Acknowledgment Requested 1 Interchange Acknowledgment Requested (TA1) ISA-15 I14 Interchange Usage Indicator Min 1 Max 1 Identifier (ID) Required Code indicating whether data enclosed by this interchange envelope is test, production or information I Information P Production Data T Test Data ISA-16 I15 Component Element Separator Min 1 Max 1 String (AN) Required Type is not applicable; the component element separator is a delimiter and not a data element; this field provides the delimiter used to separate component data elements within a composite data structure; this value must be different than the data element separator and the segment terminator > Component Element Separator 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 22/665 GS Functional Group Header To indicate the beginning of a functional group and to provide control information Example GS*HC*XXXXXXX*XXXXXXX*20250130*0541*00*XX*005010X 222A2~ Max use 1 Required GS-01 479 Functional Identifier Code Identifier (ID) Required Code identifying a group of application related transaction sets HC Health Care Claim (837) GS-02 142 Application Sender's Code Min 2 Max 15 String (AN) Required Code identifying party sending transmission; codes agreed to by trading partners GS-03 124 Application Receiver's Code Min 2 Max 15 String (AN) Required Code identifying party receiving transmission; codes agreed to by trading partners GS-04 373 Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year GS-05 337 Time HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format Time (TM) Required Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and DD = hundredths (00-99) GS-06 28 Group Control Number Min 1 Max 9 Numeric (N0) Required Assigned number originated and maintained by the sender GS-07 455 Responsible Agency Code Min 1 Max 2 Identifier (ID) Required Code identifying the issuer of the standard; this code is used in conjunction with Data Element 480 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 23/665 T Transportation Data Coordinating Committee (TDCC) X Accredited Standards Committee X12 GS-08 480 Version / Release / Industry Identifier Code String (AN) Required Code indicating the version, release, subrelease, and industry identifier of the EDI standard being used, including the GS and GE segments; if code in DE455 in GS segment is X, then in DE 480 positions 1-3 are the version number; positions 4-6 are the release and subrelease, level of the version; and positions 7-12 are the industry or trade association identifiers (optionally assigned by user); if code in DE455 in GS segment is T, then other formats are allowed 005010X222A2 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 24/665 Heading ST 0050 Heading > ST Transaction Set Header To indicate the start of a transaction set and to assign a control number Example ST*837*0001*005010X222A2~ Max use 1 Required ST-01 143 Transaction Set Identifier Code Identifier (ID) Required Code uniquely identifying a Transaction Set The transaction set identifier (ST01) is used by the translation routines of the interchange partners to select the appropriate transaction set definition (e.g., 810 selects the Invoice Transaction Set). 837 Health Care Claim ST-02 329 Transaction Set Control Number Min 4 Max 9 Numeric (N) Required Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set Usage notes The Transaction Set Control Number in ST02 and SE02 must be identical. The number must be unique within a specific interchange (ISA-IEA), but can repeat in other interchanges. ST-03 1705 Implementation Guide Version Name String (AN) Required Reference assigned to identify Implementation Convention The implementation convention reference (ST03) is used by the translation routines of the interchange partners to select the appropriate implementation convention to match the transaction set definition. When used, this implementation convention reference takes precedence over the implementation reference specified in the GS08. Usage notes This element must be populated with the guide identifier named in Section 1.2. This field contains the same value as GS08. Some translator products strip off the ISA and GS segments prior to application (ST-SE) processing. Providing the information from the GS08 at this level will ensure that the appropriate application mapping is used at translation time. 005010X222A2 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 25/665 BHT 0100 Heading > BHT Beginning of Hierarchical Transaction To define the business hierarchical structure of the transaction set and identify the business application purpose and reference data, i.e., number, date, and time Usage notes The second example denotes the case where the entire transaction set contains ENCOUNTERS. Example BHT*0019*18*XXXXX*20250130*0700*31~ Max use 1 Required BHT-01 1005 Hierarchical Structure Code Identifier (ID) Required Code indicating the hierarchical application structure of a transaction set that utilizes the HL segment to define the structure of the transaction set 0019 Information Source, Subscriber, Dependent BHT-02 353 Transaction Set Purpose Code Identifier (ID) Required Code identifying purpose of transaction set Usage notes BHT02 is intended to convey the electronic transmission status of the 837 batch contained in this ST-SE envelope. The terms "original" and "reissue" refer to the electronic transmission status of the 837 batch, not the billing status. 00 Original Original transmissions are transmissions which have never been sent to the receiver. 18 Reissue If a transmission was disrupted and the receiver requests a retransmission, the sender uses "Reissue" to indicate the transmission has been previously sent. BHT-03 127 Originator Application Transaction Identifier String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier BHT03 is the number assigned by the originator to identify the transaction within the originator's business application system. Usage notes The inventory file number of the transmission assigned by the submitter's system. This number operates as a batch control number. This field is limited to 30 characters. 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 26/665 BHT-04 373 Transaction Set Creation Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year BHT04 is the date the transaction was created within the business application system. Usage notes This is the date that the original submitter created the claim file from their business application system. BHT-05 337 Transaction Set Creation Time Time (TM) Required HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and DD = hundredths (00-99) BHT05 is the time the transaction was created within the business application system. Usage notes This is the time that the original submitter created the claim file from their business application system. BHT-06 640 Claim or Encounter Identifier Identifier (ID) Required Code specifying the type of transaction 31 Subrogation Demand The subrogation demand code is only for use by state Medicaid agencies performing post payment recovery claiming with willing trading partners. NOTE: At the time of this writing, Subrogation Demand is not a HIPAA mandated use of the 837 transaction. CH Chargeable Use CH when the transaction contains only fee for service claims or claims with at least one chargeable line item. If it is not clear whether a transaction contains claims or capitated encounters, or if the transaction contains a mix of claims and capitated encounters, use CH. RP Reporting Use RP when the entire ST-SE envelope contains only capitated encounters. Use RP when the transaction is being sent to an entity (usually not a payer or a normal provider payer transmission intermediary) for purposes other than adjudication | Home State Health 837 Health Care Claim_ Professional.pdf |
structure of a transaction set that utilizes the HL segment to define the structure of the transaction set 0019 Information Source, Subscriber, Dependent BHT-02 353 Transaction Set Purpose Code Identifier (ID) Required Code identifying purpose of transaction set Usage notes BHT02 is intended to convey the electronic transmission status of the 837 batch contained in this ST-SE envelope. The terms "original" and "reissue" refer to the electronic transmission status of the 837 batch, not the billing status. 00 Original Original transmissions are transmissions which have never been sent to the receiver. 18 Reissue If a transmission was disrupted and the receiver requests a retransmission, the sender uses "Reissue" to indicate the transmission has been previously sent. BHT-03 127 Originator Application Transaction Identifier String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier BHT03 is the number assigned by the originator to identify the transaction within the originator's business application system. Usage notes The inventory file number of the transmission assigned by the submitter's system. This number operates as a batch control number. This field is limited to 30 characters. 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 26/665 BHT-04 373 Transaction Set Creation Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year BHT04 is the date the transaction was created within the business application system. Usage notes This is the date that the original submitter created the claim file from their business application system. BHT-05 337 Transaction Set Creation Time Time (TM) Required HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and DD = hundredths (00-99) BHT05 is the time the transaction was created within the business application system. Usage notes This is the time that the original submitter created the claim file from their business application system. BHT-06 640 Claim or Encounter Identifier Identifier (ID) Required Code specifying the type of transaction 31 Subrogation Demand The subrogation demand code is only for use by state Medicaid agencies performing post payment recovery claiming with willing trading partners. NOTE: At the time of this writing, Subrogation Demand is not a HIPAA mandated use of the 837 transaction. CH Chargeable Use CH when the transaction contains only fee for service claims or claims with at least one chargeable line item. If it is not clear whether a transaction contains claims or capitated encounters, or if the transaction contains a mix of claims and capitated encounters, use CH. RP Reporting Use RP when the entire ST-SE envelope contains only capitated encounters. Use RP when the transaction is being sent to an entity (usually not a payer or a normal provider payer transmission intermediary) for purposes other than adjudication of a claim. Such an entity could be a state health data agency which is using the 837 for health data reporting purposes. 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 27/665 1000A Submitter Name Loop Max 1 Required Variants (all may be used) Receiver Name Loop NM1 0200 Heading > Submitter Name Loop > NM1 Submitter Name To supply the full name of an individual or organizational entity Usage notes The submitter is the entity responsible for the creation and formatting of this transaction. Example NM1*41*2*XXXXX*X*X***46*XX~ Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 41 Submitter NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Submitter Last or Organization Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Submitter First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Submitter Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-08 66 Identification Code Qualifier Identifier (ID) Required 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 28/665 Code designating the system/method of code structure used for Identification Code (67) 46 Electronic Transmitter Identification Number (ETIN) Established by trading partner agreement NM1-09 67 Submitter Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 29/665 PER 0450 Heading > Submitter Name Loop > PER Submitter EDI Contact Information To identify a person or office to whom administrative communications should be directed Usage notes When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number must always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as "1", in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as "ext" or "x-". The contact information in this segment identifies the person in the submitter organization who deals with data transmission issues. If data transmission problems arise, this is the person to contact in the submitter organization. There are 2 repetitions of the PER segment to allow for six possible combinations of communication numbers including extensions. Example PER*IC*X*FX*X*TE*XXX*TE*XXXXX~ If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required If either Communication Number Qualifier (PER-07) or Communication Number (PER-08) is present, then the other is required Max use 2 Required PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named IC Information Contact PER-02 93 Submitter Contact Name Min 1 Max 60 String (AN) Optional Free-form name PER-03 365 Communication Number Qualifier Identifier (ID) Required Code identifying the type of communication number EM Electronic Mail FX Facsimile TE Telephone PER-04 364 Communication Number Min 1 Max 256 String (AN) Required 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 30/665 1000A Submitter Name Loop end Complete communications number including country or area code when applicable PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail EX Telephone Extension FX Facsimile TE Telephone PER-06 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail EX Telephone Extension FX Facsimile TE Telephone PER-08 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 31/665 1000B Receiver Name Loop Max 1 Required Variants (all may be used) Submitter Name Loop 1000B Receiver Name Loop end NM1 0200 Heading > Receiver Name Loop > NM1 Receiver Name To supply the full name of an individual or organizational entity Example NM1*40*2*XXXXXX*****46*XXXXX~ Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 40 Receiver NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Receiver Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system/method of code structure used for Identification Code (67) 46 Electronic Transmitter Identification Number (ETIN) NM1-09 67 Receiver Primary Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 32/665 Heading end 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 33/665 Detail 2000A Billing Provider Hierarchical Level Loop Max >1 Required HL 0010 Detail > Billing Provider Hierarchical Level Loop > HL Hierarchical Level To identify dependencies among and the content of hierarchically related groups of data segments Example HL*1**20*1~ Max use 1 Required HL-01 628 Hierarchical ID Number Min 1 Max 12 String (AN) Required A unique number assigned by the sender to identify a particular data segment in a hierarchical structure HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction. HL-03 735 Hierarchical Level Code Identifier (ID) Required Code defining the characteristic of a level in a hierarchical structure HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information. 20 Information Source HL-04 736 Hierarchical Child Code Identifier (ID) Optional Code indicating if there are hierarchical child data segments subordinate to the level being described HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment. 1 Additional Subordinate HL Data Segment in This Hierarchical Structure. 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 34/665 PRV 0030 Detail > Billing Provider Hierarchical Level Loop > PRV Billing Provider Specialty Information To specify the identifying characteristics of a provider Usage notes Required when the payer's adjudication is known to be impacted by the provider taxonomy code. If not required by this implementation guide, do not send. Example PRV*BI*PXC*XX~ Max use 1 Optional PRV-01 1221 Provider Code Identifier (ID) Required Code identifying the type of provider BI Billing PRV-02 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification PXC Health Care Provider Taxonomy Code PRV-03 127 Provider Taxonomy Code Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 35/665 CUR 0100 Detail > Billing Provider Hierarchical Level Loop > CUR Foreign Currency Information To specify the currency (dollars, pounds, francs, etc.) used in a transaction Usage notes Required when the amounts represented in this transaction are currencies other than the United States dollar. If not required by this implementation guide, do not send. It is REQUIRED that all amounts reported within the transaction are of the currency named in this segment. If this segment is not used, then it is required that all amounts in this transaction be expressed in US dollars. Example CUR*85*XXX~ Max use 1 Optional CUR-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 85 Billing Provider CUR-02 100 Currency Code Min 3 Max 3 Identifier (ID) Required Code (Standard ISO) for country in whose currency the charges are specified Usage notes The submitter must use the Currency Code, not the Country Code, for this element. For example the Currency Code CAD = Canadian dollars would be valid, while CA = Canada would be invalid. 1/30/25, 11:52 AM Home State Health 837 Health | Home State Health 837 Health Care Claim_ Professional.pdf |
HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction. HL-03 735 Hierarchical Level Code Identifier (ID) Required Code defining the characteristic of a level in a hierarchical structure HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information. 20 Information Source HL-04 736 Hierarchical Child Code Identifier (ID) Optional Code indicating if there are hierarchical child data segments subordinate to the level being described HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment. 1 Additional Subordinate HL Data Segment in This Hierarchical Structure. 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 34/665 PRV 0030 Detail > Billing Provider Hierarchical Level Loop > PRV Billing Provider Specialty Information To specify the identifying characteristics of a provider Usage notes Required when the payer's adjudication is known to be impacted by the provider taxonomy code. If not required by this implementation guide, do not send. Example PRV*BI*PXC*XX~ Max use 1 Optional PRV-01 1221 Provider Code Identifier (ID) Required Code identifying the type of provider BI Billing PRV-02 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification PXC Health Care Provider Taxonomy Code PRV-03 127 Provider Taxonomy Code Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 35/665 CUR 0100 Detail > Billing Provider Hierarchical Level Loop > CUR Foreign Currency Information To specify the currency (dollars, pounds, francs, etc.) used in a transaction Usage notes Required when the amounts represented in this transaction are currencies other than the United States dollar. If not required by this implementation guide, do not send. It is REQUIRED that all amounts reported within the transaction are of the currency named in this segment. If this segment is not used, then it is required that all amounts in this transaction be expressed in US dollars. Example CUR*85*XXX~ Max use 1 Optional CUR-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 85 Billing Provider CUR-02 100 Currency Code Min 3 Max 3 Identifier (ID) Required Code (Standard ISO) for country in whose currency the charges are specified Usage notes The submitter must use the Currency Code, not the Country Code, for this element. For example the Currency Code CAD = Canadian dollars would be valid, while CA = Canada would be invalid. 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 36/665 2010AA Billing Provider Name Loop Max 1 Required Variants (all may be used) Pay-to Address Name Loop Pay-To Plan Name Loop NM1 0150 Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > NM1 Billing Provider Name To supply the full name of an individual or organizational entity Usage notes Beginning on the NPI compliance date: When the Billing Provider is an organization health care provider, the organization health care provider's NPI or its subpart's NPI is reported in NM109. When a health care provider organization has determined that it needs to enumerate its subparts, it will report the NPI of a subpart as the Billing Provider. The subpart reported as the Billing Provider MUST always represent the most detailed level of enumeration as determined by the organization health care provider and MUST be the same identifier sent to any trading partner. For additional explanation, see section 1.10.3 Organization Health Care Provider Subpart Presentation. Prior to the NPI compliance date, proprietary identifiers necessary for the receiver to identify the Billing Provider entity are to be reported in the REF segment of Loop ID- 2010BB. The Taxpayer Identifying Number (TIN) of the Billing Provider to be used for 1099 purposes must be reported in the REF segment of this loop. The Billing Provider may be an individual only when the health care provider performing services is an independent, unincorporated entity. In these cases, the Billing Provider is the individual whose social security number is used for 1099 purposes. That individual's NPI is reported in NM109, and the individual's Tax Identification Number must be reported in the REF segment of this loop. The individual's NPI must be reported when the individual provider is eligible for an NPI. See section 1.10.1 (Providers who are Not Eligible for Enumeration). When the individual or the organization is not a health care provider and, thus, not eligible to receive an NPI (For example, personal care services, carpenters, etc), the Billing Provider should be the legal entity. However, willing trading partners may agree upon varying definitions. Proprietary identifiers necessary for the receiver to identify the entity are to be reported in the Loop ID-2010BB REF, Billing Provider Secondary Identification segment. The TIN to be used for 1099 purposes must be reported in the REF (Tax Identification Number) segment of this loop. Example NM1*85*2*XXXXXX*X*XXX**XXXXX*XX*XXXXXX~ If either Identification Code Qualifier (NM1-08) or Billing Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 85 Billing Provider 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 37/665 NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Billing Provider Last or Organizational Name String (AN) Required Min 1 Max 60 Individual last name or organizational name NM1-04 1036 Billing Provider First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Billing Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Billing Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Billing Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 38/665 N3 0250 Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > N3 Billing Provider Address To specify the location of the named party Usage notes The Billing Provider Address must be a street address. Post Office Box or Lock Box addresses are to be sent in the Pay-To Address Loop (Loop ID-2010AB), if necessary. Example N3*X*X~ Max use 1 Required N3-01 166 Billing Provider Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Billing Provider Address Line Min 1 Max 55 String (AN) Optional Address information 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 39/665 N4 0300 Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > N4 Billing Provider City, State, ZIP Code To specify the geographic place of the named party Example N4*XXX*XX*XXX*XX~ Only one of Billing Provider State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Billing Provider City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Billing Provider State or Province Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State/Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Billing Provider Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) Usage notes When reporting the ZIP code for U.S. addresses, the full nine digit ZIP code must be provided. N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 40/665 Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 41/665 REF 0350 Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > REF Billing Provider Tax Identification To specify identifying information Usage notes This is the tax identification number (TIN) of the entity to be paid for the submitted services. Example REF*SY*XXX~ Variants (all may be used) REF Billing Provider UPIN/License Information Max use 1 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification EI Employer's Identification Number The Employer's Identification Number must be a string of exactly nine numbers with no separators. For example, "001122333" would be valid, while sending "001-12-2333" or "00-1122333" would be invalid. SY Social Security Number The Social Security Number must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid. REF-02 127 Billing Provider Tax Identification Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 42/665 REF 0350 Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > REF Billing Provider UPIN/License Information To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when a UPIN and/or license number is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI implementation date when NM109 of this loop is not used and a UPIN or license number is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. Payer specific secondary identifiers are reported in the Loop ID-2010BB REF, Billing Provider Secondary Identification. Example REF*0B*XXXXXX~ Variants (all may be used) REF Billing Provider Tax Identification Max use 2 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. REF-02 127 Billing Provider License and/or UPIN Information String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 43/665 PER 0400 Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > PER Billing Provider Contact Information To identify a person or office to whom administrative communications should be directed Usage notes Required when this information is different than that contained in the Loop ID-1000A - Submitter PER segment. If not required by this implementation guide, do not send.; When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number must always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the | Home State Health 837 Health Care Claim_ Professional.pdf |
0350 Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > REF Billing Provider Tax Identification To specify identifying information Usage notes This is the tax identification number (TIN) of the entity to be paid for the submitted services. Example REF*SY*XXX~ Variants (all may be used) REF Billing Provider UPIN/License Information Max use 1 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification EI Employer's Identification Number The Employer's Identification Number must be a string of exactly nine numbers with no separators. For example, "001122333" would be valid, while sending "001-12-2333" or "00-1122333" would be invalid. SY Social Security Number The Social Security Number must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid. REF-02 127 Billing Provider Tax Identification Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 42/665 REF 0350 Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > REF Billing Provider UPIN/License Information To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when a UPIN and/or license number is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI implementation date when NM109 of this loop is not used and a UPIN or license number is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. Payer specific secondary identifiers are reported in the Loop ID-2010BB REF, Billing Provider Secondary Identification. Example REF*0B*XXXXXX~ Variants (all may be used) REF Billing Provider Tax Identification Max use 2 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. REF-02 127 Billing Provider License and/or UPIN Information String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 43/665 PER 0400 Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > PER Billing Provider Contact Information To identify a person or office to whom administrative communications should be directed Usage notes Required when this information is different than that contained in the Loop ID-1000A - Submitter PER segment. If not required by this implementation guide, do not send.; When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number must always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as "1", in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as "ext" or "x-". There are 2 repetitions of the PER segment to allow for six possible combinations of communication numbers including extensions. Example PER*IC*XXXXXX*EM*XXX*EM*XXXXX*FX*X~ If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required If either Communication Number Qualifier (PER-07) or Communication Number (PER-08) is present, then the other is required Max use 2 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named IC Information Contact PER-02 93 Billing Provider Contact Name Min 1 Max 60 String (AN) Optional Free-form name PER-03 365 Communication Number Qualifier Identifier (ID) Required Code identifying the type of communication number EM Electronic Mail FX Facsimile TE Telephone PER-04 364 Communication Number Min 1 Max 256 String (AN) Required 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 44/665 2010AA Billing Provider Name Loop end Complete communications number including country or area code when applicable PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail EX Telephone Extension FX Facsimile TE Telephone PER-06 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail EX Telephone Extension FX Facsimile TE Telephone PER-08 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 45/665 2010AB Pay-to Address Name Loop Max 1 Optional Variants (all may be used) Billing Provider Name Loop Pay-To Plan Name Loop NM1 0150 Detail > Billing Provider Hierarchical Level Loop > Pay-to Address Name Loop > NM1 Pay-to Address Name To supply the full name of an individual or organizational entity Usage notes Required when the address for payment is different than that of the Billing Provider. If not required by this implementation guide, do not send.; The purpose of Loop ID-2010AB has changed from previous versions. Loop ID-2010AB only contains address information when different from the Billing Provider Address. There are no applicable identifiers for Pay-To Address information. Example NM1*87*1~ Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 87 Pay-to Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 46/665 N3 0250 Detail > Billing Provider Hierarchical Level Loop > Pay-to Address Name Loop > N3 Pay-to Address - ADDRESS To specify the location of the named party Example N3*XXXXX*X~ Max use 1 Required N3-01 166 Pay-To Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Pay-To Address Line Min 1 Max 55 String (AN) Optional Address information 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 47/665 N4 0300 Detail > Billing Provider Hierarchical Level Loop > Pay-to Address Name Loop > N4 Pay-To Address City, State, ZIP Code To specify the geographic place of the named party Example N4*XXXXXXX*XX*XXXXX*XXX~ Only one of Pay-to Address State Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Pay-to Address City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Pay-to Address State Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State/Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Pay-to Address Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 48/665 2010AB Pay-to Address Name Loop end 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 49/665 2010AC Pay-To Plan Name Loop Max 1 Optional Variants (all may be used) Billing Provider Name Loop Pay-to Address Name Loop NM1 0150 Detail > Billing Provider Hierarchical Level Loop > Pay-To Plan Name Loop > NM1 Pay-To Plan Name To supply the full name of an individual or organizational entity Usage notes Required when willing trading partners agree to use this implementation for their subrogation payment requests. This loop may only be used when BHT06 = 31. Example NM1*PE*2*X*****XV*XX~ Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PE Payee PE is used to indicate the subrogated payee. NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Pay-To Plan Organizational Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system/method of code structure used for Identification Code (67) Usage notes Use code value "PI" when reporting Payor Identification. Use code value "XV" when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 50/665 Prior to the mandated implementation date for Health Plan Identifier, willing trading partners may agree to: Follow a dual use approach in which both the HPID or OEID and the Payor Identification are sent. Send XV qualifier in NM108 with HPID or OEID in NM109 and the Payor Identification, that would have been sent using qualifier PI, in the corresponding REF segment using qualifier 2U (Payer Identification Number). OR Follow an early implementation approach in which the HPID or OEID is sent in NM109. PI Payor Identification XV Centers for Medicare and Medicaid Services PlanID NM1-09 67 Pay-To Plan Primary Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 51/665 N3 0250 Detail > Billing Provider Hierarchical Level Loop > Pay-To Plan Name Loop > N3 Pay-to Plan Address To specify the location of the named party Example N3*XXXX*XXXXX~ Max use 1 Required N3-01 166 Pay-To Plan Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Pay-To Plan Address Line Min 1 Max 55 String (AN) Optional Address information 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 52/665 N4 0300 Detail > Billing Provider Hierarchical Level Loop > Pay-To Plan Name Loop > N4 Pay-To Plan City, State, ZIP Code To specify the geographic place of the named party Example N4*XXXXX*XX*XXXX*XX~ Only one of Pay-To Plan State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Pay-To Plan City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Pay-To Plan State or Province Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State/Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Pay-To Plan Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:52 AM Home State Health 837 | Home State Health 837 Health Care Claim_ Professional.pdf |
Code Qualifier Identifier (ID) Required Code designating the system/method of code structure used for Identification Code (67) Usage notes Use code value "PI" when reporting Payor Identification. Use code value "XV" when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 50/665 Prior to the mandated implementation date for Health Plan Identifier, willing trading partners may agree to: Follow a dual use approach in which both the HPID or OEID and the Payor Identification are sent. Send XV qualifier in NM108 with HPID or OEID in NM109 and the Payor Identification, that would have been sent using qualifier PI, in the corresponding REF segment using qualifier 2U (Payer Identification Number). OR Follow an early implementation approach in which the HPID or OEID is sent in NM109. PI Payor Identification XV Centers for Medicare and Medicaid Services PlanID NM1-09 67 Pay-To Plan Primary Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 51/665 N3 0250 Detail > Billing Provider Hierarchical Level Loop > Pay-To Plan Name Loop > N3 Pay-to Plan Address To specify the location of the named party Example N3*XXXX*XXXXX~ Max use 1 Required N3-01 166 Pay-To Plan Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Pay-To Plan Address Line Min 1 Max 55 String (AN) Optional Address information 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 52/665 N4 0300 Detail > Billing Provider Hierarchical Level Loop > Pay-To Plan Name Loop > N4 Pay-To Plan City, State, ZIP Code To specify the geographic place of the named party Example N4*XXXXX*XX*XXXX*XX~ Only one of Pay-To Plan State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Pay-To Plan City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Pay-To Plan State or Province Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State/Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Pay-To Plan Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 53/665 REF 0350 Detail > Billing Provider Hierarchical Level Loop > Pay-To Plan Name Loop > REF Pay-to Plan Secondary Identification To specify identifying information Usage notes Required when an additional identification number to that provided in the NM109 of this loop is necessary to identify the entity. If not required by this implementation guide, do not send. Example REF*FY*XX~ Variants (all may be used) REF Pay-To Plan Tax Identification Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number This code is only allowed when the qualifier XV is reported in NM108 of this loop. FY Claim Office Number NF National Association of Insurance Commissioners (NAIC) Code REF-02 127 Pay-to Plan Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 54/665 2010AC Pay-To Plan Name Loop end REF 0350 Detail > Billing Provider Hierarchical Level Loop > Pay-To Plan Name Loop > REF Pay-To Plan Tax Identification Number To specify identifying information Example REF*EI*XXX~ Variants (all may be used) REF Pay-to Plan Secondary Identification Max use 1 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification EI Employer's Identification Number The Employer's Identification Number must be a string of exactly nine numbers with no separators. For example, "001122333" would be valid, while sending "001-12-2333" or "00-1122333" would be invalid. REF-02 127 Pay-To Plan Tax Identification Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 55/665 2000B Subscriber Hierarchical Level Loop Max >1 Required HL 0010 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > HL Hierarchical Level To identify dependencies among and the content of hierarchically related groups of data segments Example HL*2*1*22*1~ Max use 1 Required HL-01 628 Hierarchical ID Number Min 1 Max 12 String (AN) Required A unique number assigned by the sender to identify a particular data segment in a hierarchical structure HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction. HL-02 734 Hierarchical Parent ID Number Min 1 Max 12 String (AN) Required Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate. HL-03 735 Hierarchical Level Code Identifier (ID) Required Code defining the characteristic of a level in a hierarchical structure HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information. 22 Subscriber HL-04 736 Hierarchical Child Code Identifier (ID) Optional Code indicating if there are hierarchical child data segments subordinate to the level being described HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment. 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 56/665 0 No Subordinate HL Segment in This Hierarchical Structure. 1 Additional Subordinate HL Data Segment in This Hierarchical Structure. 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 57/665 SBR 0050 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > SBR Subscriber Information To record information specific to the primary insured and the insurance carrier for that insured Example SBR*B*18*XXXXX*XXXXX*42****VA~ Max use 1 Required SBR-01 1138 Payer Responsibility Sequence Number Code Identifier (ID) Required Code identifying the insurance carrier's level of responsibility for a payment of a claim Usage notes Within a given claim, the various values for the Payer Responsibility Sequence Number Code (other than value "U") may occur no more than once. A Payer Responsibility Four B Payer Responsibility Five C Payer Responsibility Six D Payer Responsibility Seven E Payer Responsibility Eight F Payer Responsibility Nine G Payer Responsibility Ten H Payer Responsibility Eleven P Primary S Secondary T Tertiary U Unknown This code may only be used in payer to payer COB claims when the original payer determined the presence of this coverage from eligibility files received from this payer or when the original claim did not provide the responsibility sequence for this payer. SBR-02 1069 Individual Relationship Code Identifier (ID) Optional Code indicating the relationship between two individuals or entities SBR02 specifies the relationship to the person insured. 18 Self SBR-03 127 Subscriber Group or Policy Number Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier SBR03 is policy or group number. Usage notes 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 58/665 This is not the number uniquely identifying the subscriber. The unique subscriber number is submitted in Loop ID-2010BA-NM109. SBR-04 93 Subscriber Group Name Min 1 Max 60 String (AN) Optional Free-form name SBR04 is plan name. SBR-05 1336 Insurance Type Code Identifier (ID) Optional Code identifying the type of insurance policy within a specific insurance program 12 Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan 13 Medicare Secondary End-Stage Renal Disease Beneficiary in the Mandated Coordination Period with an Employer's Group Health Plan 14 Medicare Secondary, No-fault Insurance including Auto is Primary 15 Medicare Secondary Worker's Compensation 16 Medicare Secondary Public Health Service (PHS)or Other Federal Agency 41 Medicare Secondary Black Lung 42 Medicare Secondary Veteran's Administration 43 Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP) 47 Medicare Secondary, Other Liability Insurance is Primary SBR-09 1032 Claim Filing Indicator Code Identifier (ID) Required Code identifying type of claim 11 Other Non-Federal Programs 12 Preferred Provider Organization (PPO) 13 Point of Service (POS) 14 Exclusive Provider Organization (EPO) 15 Indemnity Insurance 16 Health Maintenance Organization (HMO) Medicare Risk 17 Dental Maintenance Organization AM Automobile Medical BL Blue Cross/Blue Shield CH Champus CI Commercial Insurance Co. DS Disability FI Federal Employees Program HM Health Maintenance Organization LM Liability Medical MA Medicare Part A MB Medicare Part B MC Medicaid OF Other Federal Program Use code OF when submitting Medicare Part D claims. TV Title V VA Veterans Affairs Plan WC Workers' Compensation Health Claim 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 59/665 ZZ Mutually Defined Use Code ZZ when Type of Insurance is not known. 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 60/665 PAT 0070 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > PAT Patient Information To supply patient information Usage notes Required when the patient is the subscriber or considered to be the subscriber and at least one of the element requirements are met. If not required by this implementation guide, do not send. Example PAT*****D8*XXXX*01*0000*Y~ If either Date Time Period Format Qualifier (PAT-05) or Patient Death Date (PAT-06) is present, then the other is required If either Unit or Basis for Measurement Code (PAT-07) or Patient Weight (PAT-08) is present, then the other is required Max use 1 Optional PAT-05 1250 Date Time Period Format Qualifier Identifier (ID) Optional Code indicating the date format, time format, or date and time format D8 Date Expressed in Format CCYYMMDD PAT-06 1251 Patient Death Date Min 1 Max 35 String (AN) Optional Expression of a date, a time, or range of dates, times or dates and times PAT06 is the date of death. PAT-07 355 Unit or Basis for Measurement Code Identifier (ID) Optional Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken 01 Actual Pounds PAT-08 81 Patient Weight Min 1 Max 10 Decimal number (R) Optional Numeric value of weight PAT08 is the patient's weight. PAT-09 1073 Pregnancy Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response PAT09 indicates whether the patient is pregnant or not pregnant. Code "Y" indicates the patient is pregnant; code "N" indicates the patient is not pregnant. Usage notes 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 61/665 For this implementation, the listed value takes precedence over the semantic note. Y Yes 1/30/25, 11:52 AM Home State Health 837 Health Care | Home State Health 837 Health Care Claim_ Professional.pdf |
Insurance including Auto is Primary 15 Medicare Secondary Worker's Compensation 16 Medicare Secondary Public Health Service (PHS)or Other Federal Agency 41 Medicare Secondary Black Lung 42 Medicare Secondary Veteran's Administration 43 Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP) 47 Medicare Secondary, Other Liability Insurance is Primary SBR-09 1032 Claim Filing Indicator Code Identifier (ID) Required Code identifying type of claim 11 Other Non-Federal Programs 12 Preferred Provider Organization (PPO) 13 Point of Service (POS) 14 Exclusive Provider Organization (EPO) 15 Indemnity Insurance 16 Health Maintenance Organization (HMO) Medicare Risk 17 Dental Maintenance Organization AM Automobile Medical BL Blue Cross/Blue Shield CH Champus CI Commercial Insurance Co. DS Disability FI Federal Employees Program HM Health Maintenance Organization LM Liability Medical MA Medicare Part A MB Medicare Part B MC Medicaid OF Other Federal Program Use code OF when submitting Medicare Part D claims. TV Title V VA Veterans Affairs Plan WC Workers' Compensation Health Claim 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 59/665 ZZ Mutually Defined Use Code ZZ when Type of Insurance is not known. 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 60/665 PAT 0070 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > PAT Patient Information To supply patient information Usage notes Required when the patient is the subscriber or considered to be the subscriber and at least one of the element requirements are met. If not required by this implementation guide, do not send. Example PAT*****D8*XXXX*01*0000*Y~ If either Date Time Period Format Qualifier (PAT-05) or Patient Death Date (PAT-06) is present, then the other is required If either Unit or Basis for Measurement Code (PAT-07) or Patient Weight (PAT-08) is present, then the other is required Max use 1 Optional PAT-05 1250 Date Time Period Format Qualifier Identifier (ID) Optional Code indicating the date format, time format, or date and time format D8 Date Expressed in Format CCYYMMDD PAT-06 1251 Patient Death Date Min 1 Max 35 String (AN) Optional Expression of a date, a time, or range of dates, times or dates and times PAT06 is the date of death. PAT-07 355 Unit or Basis for Measurement Code Identifier (ID) Optional Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken 01 Actual Pounds PAT-08 81 Patient Weight Min 1 Max 10 Decimal number (R) Optional Numeric value of weight PAT08 is the patient's weight. PAT-09 1073 Pregnancy Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response PAT09 indicates whether the patient is pregnant or not pregnant. Code "Y" indicates the patient is pregnant; code "N" indicates the patient is not pregnant. Usage notes 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 61/665 For this implementation, the listed value takes precedence over the semantic note. Y Yes 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 62/665 2010BA Subscriber Name Loop Max 1 Required Variants (all may be used) Payer Name Loop NM1 0150 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > NM1 Subscriber Name To supply the full name of an individual or organizational entity Usage notes In worker's compensation or other property and casualty claims, the "subscriber" may be a non-person entity (for example, the employer). However, this varies by state. Example NM1*IL*1*XXXXX*XXX*XXXX**XXX*MI*XXXXXX~ If either Identification Code Qualifier (NM1-08) or Subscriber Primary Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual IL Insured or Subscriber NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Subscriber Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Subscriber First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Subscriber Middle Name or Initial Min 1 Max 25 String (AN) Optional 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 63/665 Individual middle name or initial NM1-07 1039 Subscriber Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name Usage notes Examples: I, II, III, IV, Jr, Sr This data element is used only to indicate generation or patronymic. NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) II Standard Unique Health Identifier for each Individual in the United States Required if the HIPAA Individual Patient Identifier is mandated use. If not required, use value `MI' instead. MI Member Identification Number The code MI is intended to be the subscriber's identification number as assigned by the payer. (For example, Insured's ID, Subscriber's ID, Health Insurance Claim Number (HIC), etc.) MI is also intended to be used in claims submitted to the Indian Health Service/Contract Health Services (IHS/CHS) Fiscal Intermediary for the purpose of reporting the Tribe Residency Code (Tribe County State). In the event that a Social Security Number (SSN) is also available on an IHS/CHS claim, put the SSN in REF02. When sending the Social Security Number as the Member ID, it must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid. NM1-09 67 Subscriber Primary Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 64/665 N3 0250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > N3 Subscriber Address To specify the location of the named party Usage notes Required when the patient is the subscriber or considered to be the subscriber. If not required by this implementation guide, do not send. Example N3*XXXX*XXXX~ Max use 1 Optional N3-01 166 Subscriber Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Subscriber Address Line Min 1 Max 55 String (AN) Optional Address information 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 65/665 N4 0300 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > N4 Subscriber City, State, ZIP Code To specify the geographic place of the named party Usage notes Required when the patient is the subscriber or considered to be the subscriber. If not required by this implementation guide, do not send. Example N4*XXX*XX*XXXXXX*XX~ Only one of Subscriber State Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Optional N4-01 19 Subscriber City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Subscriber State Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State/Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Subscriber Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 66/665 Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 67/665 DMG 0320 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > DMG Subscriber Demographic Information To supply demographic information Usage notes Required when the patient is the subscriber or considered to be the subscriber. If not required by this implementation guide, do not send. Example DMG*D8*XXX*F~ Max use 1 Optional DMG-01 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format D8 Date Expressed in Format CCYYMMDD DMG-02 1251 Subscriber Birth Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times DMG02 is the date of birth. DMG-03 1068 Subscriber Gender Code Identifier (ID) Required Code indicating the sex of the individual F Female M Male U Unknown 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 68/665 REF 0350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > REF Property and Casualty Claim Number To specify identifying information Usage notes Required when the services included in this claim are to be considered as part of a property and casualty claim. If not required by this implementation guide, do not send. This is a property and casualty payer-assigned claim number. Providers receive this number from the property and casualty payer during eligibility determinations or some other communication with that payer. See Section 1.4.2, Property and Casualty, for additional information about property and casualty claims.; This segment is not a HIPAA requirement as of this writing. Example REF*Y4*X~ Variants (all may be used) REF Subscriber Secondary Identification Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification Y4 Agency Claim Number REF-02 127 Property Casualty Claim Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 69/665 REF 0350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > REF Subscriber Secondary Identification To specify identifying information Usage notes Required when an additional identification number to that provided in NM109 of this loop is necessary for the claim processor to identify the entity. If not required by this implementation guide, do not send. Example REF*SY*X~ Variants (all may be used) REF Property and Casualty Claim Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification SY Social Security Number The Social Security Number must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid. REF-02 127 Subscriber Supplemental Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 70/665 PER 0400 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > PER Property and Casualty Subscriber Contact Information To identify a person or office to whom administrative communications should be directed Usage notes Required for Property and Casualty claims when this information is deemed necessary by the submitter. If not required by this implementation guide, do not send. When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number must always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as "1", in the telephone | Home State Health 837 Health Care Claim_ Professional.pdf |
Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > REF Property and Casualty Claim Number To specify identifying information Usage notes Required when the services included in this claim are to be considered as part of a property and casualty claim. If not required by this implementation guide, do not send. This is a property and casualty payer-assigned claim number. Providers receive this number from the property and casualty payer during eligibility determinations or some other communication with that payer. See Section 1.4.2, Property and Casualty, for additional information about property and casualty claims.; This segment is not a HIPAA requirement as of this writing. Example REF*Y4*X~ Variants (all may be used) REF Subscriber Secondary Identification Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification Y4 Agency Claim Number REF-02 127 Property Casualty Claim Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 69/665 REF 0350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > REF Subscriber Secondary Identification To specify identifying information Usage notes Required when an additional identification number to that provided in NM109 of this loop is necessary for the claim processor to identify the entity. If not required by this implementation guide, do not send. Example REF*SY*X~ Variants (all may be used) REF Property and Casualty Claim Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification SY Social Security Number The Social Security Number must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid. REF-02 127 Subscriber Supplemental Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 70/665 PER 0400 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > PER Property and Casualty Subscriber Contact Information To identify a person or office to whom administrative communications should be directed Usage notes Required for Property and Casualty claims when this information is deemed necessary by the submitter. If not required by this implementation guide, do not send. When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number must always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as "1", in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as "ext" or "x-". Example PER*IC*XXXX*TE*XXX*EX*X~ If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required Max use 1 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named IC Information Contact PER-02 93 Name Min 1 Max 60 String (AN) Optional Free-form name PER-03 365 Communication Number Qualifier Identifier (ID) Required Code identifying the type of communication number TE Telephone PER-04 364 Communication Number Min 1 Max 256 String (AN) Required Complete communications number including country or area code when applicable PER-05 365 Communication Number Qualifier Identifier (ID) Optional 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 71/665 2010BA Subscriber Name Loop end Code identifying the type of communication number EX Telephone Extension PER-06 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 72/665 2010BB Payer Name Loop Max 1 Required Variants (all may be used) Subscriber Name Loop NM1 0150 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Payer Name Loop > NM1 Payer Name To supply the full name of an individual or organizational entity Usage notes This is the destination payer. For the purposes of this implementation the term payer is synonymous with several other terms, such as, repricer and third party administrator. Example NM1*PR*2*XXX*****XV*XXXXXXX~ Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PR Payer NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Payer Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system/method of code structure used for Identification Code (67) Usage notes Use code value "PI" when reporting Payor Identification. Use code value "XV" when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). Prior to the mandated implementation date for Health Plan Identifier, willing trading partners may agree to: Follow a dual use approach in which both the HPID or OEID and the Payor Identification are sent. Send XV qualifier in NM108 with HPID or OEID in NM109 and the Payor 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 73/665 Identification, that would have been sent using qualifier PI, in the corresponding REF segment using qualifier 2U (Payer Identification Number). OR Follow an early implementation approach in which the HPID or OEID is sent in NM109. PI Payor Identification XV Centers for Medicare and Medicaid Services PlanID NM1-09 67 Payer Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 74/665 N3 0250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Payer Name Loop > N3 Payer Address To specify the location of the named party Usage notes Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send. Example N3*XXXXX*XXXXXX~ Max use 1 Optional N3-01 166 Payer Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Payer Address Line Min 1 Max 55 String (AN) Optional Address information 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 75/665 N4 0300 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Payer Name Loop > N4 Payer City, State, ZIP Code To specify the geographic place of the named party Usage notes Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send. Example N4*XXXX*XX*XXXX*XXX~ Only one of Payer State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Optional N4-01 19 Payer City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Payer State or Province Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State/Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Payer Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 76/665 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 77/665 REF 0350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Payer Name Loop > REF Billing Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated NPI Implementation Date when an additional identification number is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in Loop 2010AA is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. Example REF*LU*X~ Variants (all may be used) REF Payer Secondary Identification Max use 2 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Billing Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 78/665 2010BB Payer Name Loop end REF 0350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Payer Name Loop > REF Payer Secondary Identification To specify identifying information Usage notes Required when an additional identification number to that provided in the NM109 of this loop is necessary to identify the entity. If not required by this implementation guide, do not send. Example REF*FY*XXXX~ Variants (all may be used) REF Billing Provider Secondary Identification Max use 3 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number This code is only allowed when the qualifier XV is reported in NM108 of this loop. EI Employer's Identification Number The Employer's Identification Number must be a string of exactly nine numbers with no separators. For example, "001122333" would be valid, while sending "001-12-2333" or "00-1122333" would be invalid. FY Claim Office Number NF National Association of Insurance Commissioners (NAIC) Code REF-02 127 Payer Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 79/665 2300 Claim Information Loop Max 100 Optional CLM 1300 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > CLM Claim Information To specify basic data about the claim Usage notes The developers of this implementation guide recommend that trading partners limit the size of the transaction (ST-SE envelope) to a maximum of 5000 CLM segments. There is no recommended limit to the number of ST-SE transactions within a GS-GE or ISA- IEA. Willing trading partners can agree to set limits higher. For purposes of this documentation, the claim detail information is presented only in the dependent level. Specific claim detail information can be given in either the subscriber or the dependent hierarchical level. Because of this, the claim information is said to "float." Claim information | Home State Health 837 Health Care Claim_ Professional.pdf |
necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in Loop 2010AA is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. Example REF*LU*X~ Variants (all may be used) REF Payer Secondary Identification Max use 2 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Billing Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 78/665 2010BB Payer Name Loop end REF 0350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Payer Name Loop > REF Payer Secondary Identification To specify identifying information Usage notes Required when an additional identification number to that provided in the NM109 of this loop is necessary to identify the entity. If not required by this implementation guide, do not send. Example REF*FY*XXXX~ Variants (all may be used) REF Billing Provider Secondary Identification Max use 3 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number This code is only allowed when the qualifier XV is reported in NM108 of this loop. EI Employer's Identification Number The Employer's Identification Number must be a string of exactly nine numbers with no separators. For example, "001122333" would be valid, while sending "001-12-2333" or "00-1122333" would be invalid. FY Claim Office Number NF National Association of Insurance Commissioners (NAIC) Code REF-02 127 Payer Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 79/665 2300 Claim Information Loop Max 100 Optional CLM 1300 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > CLM Claim Information To specify basic data about the claim Usage notes The developers of this implementation guide recommend that trading partners limit the size of the transaction (ST-SE envelope) to a maximum of 5000 CLM segments. There is no recommended limit to the number of ST-SE transactions within a GS-GE or ISA- IEA. Willing trading partners can agree to set limits higher. For purposes of this documentation, the claim detail information is presented only in the dependent level. Specific claim detail information can be given in either the subscriber or the dependent hierarchical level. Because of this, the claim information is said to "float." Claim information is positioned in the same hierarchical level that describes its owner-participant, either the subscriber or the dependent. In other words, the claim information, Loop ID-2300, is placed following Loop ID-2010BB in the Subscriber Hierarchical Level (HL) when patient information is sent in Loop ID-2010BA of the Subscriber HL. Claim information is placed in the Patient HL when the patient information is sent in Loop ID-2010CA of the Patient HL. When the patient is the subscriber or is considered to be the subscriber, Loop ID-2000C and Loop ID-2010CA are not sent. See Subscriber/Patient HL Segment explanation in section 1.4.3.2.2.1 for details. Example CLM*XXXXXX*00000000000***XX>B>X*N*B*N*Y*P*OA>XXX> >XX>XX*02********5~ Max use 1 Required CLM-01 1028 Patient Control Number Min 1 Max 38 String (AN) Required Identifier used to track a claim from creation by the health care provider through payment Usage notes The number that the submitter transmits in this position is echoed back to the submitter in the 835 and other transactions. This permits the submitter to use the value in this field as a key in the submitter's system to match the claim to the payment information returned in the 835 transaction. The two recommended identifiers are either the Patient Account Number or the Claim Number in the billing submitter's patient management system. The developers of this implementation guide strongly recommend that submitters use unique numbers for this field for each individual claim. When Loop ID-2010AC is present, CLM01 represents the subrogated Medicaid agency's claim number (ICN/DCN) from their original 835 CLP07 - Payer Claim Control Number. See Section 1.4.1.4 of the front matter for a description of post payment recovery claims for subrogated Medicaid agencies. The maximum number of characters to be supported for this field is `20'. Characters beyond the maximum are not required to be stored nor returned by any 837-receiving system. 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 80/665 CLM-02 782 Total Claim Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CLM02 is the total amount of all submitted charges of service segments for this claim. Usage notes The Total Claim Charge Amount must be greater than or equal to zero. The total claim charge amount must balance to the sum of all service line charge amounts reported in the Professional Service (SV1) segments for this claim. CLM-05 C023 Health Care Service Location Information To provide information that identifies the place of service or the type of bill related to the location at which a health care service was rendered Max use 1 Required C023-01 1331 Place of Service Code Min 1 Max 2 String (AN) Required Code identifying where services were, or may be, performed; the first and second positions of the Uniform Bill Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services. C023-02 1332 Facility Code Qualifier Identifier (ID) Required Code identifying the type of facility referenced C023-02 qualifies C023-01 and C023-03. B Place of Service Codes for Professional or Dental Services C023-03 1325 Claim Frequency Code Min 1 Max 1 Identifier (ID) Required Code specifying the frequency of the claim; this is the third position of the Uniform Billing Claim Form Bill Type Usage notes Must contain a value for the National UB Data Element Specification Type List Type of Bill Position 3 CLM-06 1073 Provider or Supplier Signature Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CLM06 is provider signature on file indicator. A "Y" value indicates the provider signature is on file; an "N" value indicates the provider signature is not on file. N No Y Yes CLM-07 1359 Assignment or Plan Participation Code Identifier (ID) Required 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 81/665 Code indicating whether the provider accepts assignment Usage notes Within this element the context of the word assignment is related to the relationship between the provider and the payer. This is NOT the field for reporting whether the patient has or has not assigned benefits to the provider. The benefit assignment indicator is in CLM08. A Assigned Required when the provider accepts assignment and/or has a participation agreement with the destination payer. OR Required when the provider does not accept assignment and/or have a participation agreement, but is advising the payer to adjudicate this specific claim under participating provider benefits as allowed under certain plans. B Assignment Accepted on Clinical Lab Services Only Required when the provider accepts assignment for Clinical Lab Services only. C Not Assigned Required when neither codes A' nor B' apply. CLM-08 1073 Benefits Assignment Certification Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CLM08 is assignment of benefits indicator. A "Y" value indicates insured or authorized person authorizes benefits to be assigned to the provider; an "N" value indicates benefits have not been assigned to the provider. Usage notes This element answers the question whether or not the insured has authorized the plan to remit payment directly to the provider. N No W Not Applicable Use code `W' when the patient refuses to assign benefits. Y Yes CLM-09 1363 Release of Information Code Identifier (ID) Required Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations Usage notes The Release of Information response is limited to the information carried in this claim. 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 82/665 I Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes Required when the provider has not collected a signature AND state or federal laws do not require a signature be collected. Y Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim Required when the provider has collected a signature. OR Required when state or federal laws require a signature be collected. CLM-10 1351 Patient Signature Source Code Identifier (ID) Optional Code indicating how the patient or subscriber authorization signatures were obtained and how they are being retained by the provider P Signature generated by provider because the patient was not physically present for services Signature generated by an entity other than the patient according to State or Federal law. CLM-11 C024 Related Causes Information To identify one or more related causes and associated state or country information Usage notes Required when the services provided are employment related or the result of an accident. If not required by this implementation guide, do not send. Max use 1 Optional C024-01 1362 Related Causes Code Identifier (ID) Required Code identifying an accompanying cause of an illness, injury or an accident AA Auto Accident EM Employment OA Other Accident C024-02 1362 Related Causes Code Min 2 Max 3 Identifier (ID) Optional Code identifying an accompanying cause of an illness, injury or an accident C024-04 156 Auto Accident State or Province Code Identifier (ID) Optional Min 2 Max 2 Code (Standard State/Province) as defined by appropriate government agency C024-04 and C024-05 apply only to auto accidents when C024-01, C024-02, or C024-03 is equal to "AA". C024-05 26 Country Code Min 2 Max 3 Identifier (ID) Optional 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 83/665 Code identifying the country CLM-12 1366 Special Program Indicator Identifier (ID) Optional Code indicating the Special Program under which the services rendered to the patient were performed 02 Physically Handicapped Children's Program This code is used for Medicaid claims only. 03 Special Federal Funding This code is used for Medicaid claims only. 05 Disability This code is used for Medicaid claims only. 09 Second Opinion or Surgery This code is used for Medicaid claims only. CLM-20 1514 Delay Reason Code Identifier (ID) Optional Code indicating the reason why a request was delayed 1 Proof of Eligibility Unknown or Unavailable 2 Litigation 3 Authorization Delays 4 Delay in Certifying Provider 5 Delay in Supplying Billing Forms 6 Delay in Delivery of Custom-made Appliances 7 Third Party Processing Delay 8 Delay in Eligibility Determination 9 Original Claim Rejected or Denied Due to a Reason Unrelated to the Billing Limitation Rules 10 Administration Delay in the Prior Approval Process 11 Other 15 Natural Disaster 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 84/665 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP Date - Accident To specify any or all of a date, a time, or a time period Usage notes Required when CLM11-1 or CLM11-2 has a value of AA' or OA'. OR Required when CLM11-1 or CLM11-2 has a value of `EM' and this claim is the result of an accident. If not required by this implementation guide, do not send. Example DTP*439*D8*XX~ Variants (all may be used) DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision | Home State Health 837 Health Care Claim_ Professional.pdf |
they are being retained by the provider P Signature generated by provider because the patient was not physically present for services Signature generated by an entity other than the patient according to State or Federal law. CLM-11 C024 Related Causes Information To identify one or more related causes and associated state or country information Usage notes Required when the services provided are employment related or the result of an accident. If not required by this implementation guide, do not send. Max use 1 Optional C024-01 1362 Related Causes Code Identifier (ID) Required Code identifying an accompanying cause of an illness, injury or an accident AA Auto Accident EM Employment OA Other Accident C024-02 1362 Related Causes Code Min 2 Max 3 Identifier (ID) Optional Code identifying an accompanying cause of an illness, injury or an accident C024-04 156 Auto Accident State or Province Code Identifier (ID) Optional Min 2 Max 2 Code (Standard State/Province) as defined by appropriate government agency C024-04 and C024-05 apply only to auto accidents when C024-01, C024-02, or C024-03 is equal to "AA". C024-05 26 Country Code Min 2 Max 3 Identifier (ID) Optional 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 83/665 Code identifying the country CLM-12 1366 Special Program Indicator Identifier (ID) Optional Code indicating the Special Program under which the services rendered to the patient were performed 02 Physically Handicapped Children's Program This code is used for Medicaid claims only. 03 Special Federal Funding This code is used for Medicaid claims only. 05 Disability This code is used for Medicaid claims only. 09 Second Opinion or Surgery This code is used for Medicaid claims only. CLM-20 1514 Delay Reason Code Identifier (ID) Optional Code indicating the reason why a request was delayed 1 Proof of Eligibility Unknown or Unavailable 2 Litigation 3 Authorization Delays 4 Delay in Certifying Provider 5 Delay in Supplying Billing Forms 6 Delay in Delivery of Custom-made Appliances 7 Third Party Processing Delay 8 Delay in Eligibility Determination 9 Original Claim Rejected or Denied Due to a Reason Unrelated to the Billing Limitation Rules 10 Administration Delay in the Prior Approval Process 11 Other 15 Natural Disaster 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 84/665 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP Date - Accident To specify any or all of a date, a time, or a time period Usage notes Required when CLM11-1 or CLM11-2 has a value of AA' or OA'. OR Required when CLM11-1 or CLM11-2 has a value of `EM' and this claim is the result of an accident. If not required by this implementation guide, do not send. Example DTP*439*D8*XX~ Variants (all may be used) DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 439 Accident DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Accident Date Min 1 Max 35 String (AN) Required 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 85/665 Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 86/665 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP Date - Acute Manifestation To specify any or all of a date, a time, or a time period Usage notes Required when Loop ID-2300 CR208 = "A" or "M", the claim involves spinal manipulation, and the payer is Medicare. If not required by this implementation guide, do not send. Example DTP*453*D8*XXXXXX~ Variants (all may be used) DTP Date - Accident DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 453 Acute Manifestation of a Chronic Condition DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Acute Manifestation Date Min 1 Max 35 String (AN) Required 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 87/665 Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 88/665 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP Date - Admission To specify any or all of a date, a time, or a time period Usage notes Required on all ambulance claims when the patient was known to be admitted to the hospital. OR Required on all claims involving inpatient medical visits. If not required by this implementation guide, do not send. Example DTP*435*D8*XXXXX~ Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 435 Admission DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Related Hospitalization Admission Date Min 1 Max 35 String (AN) Required 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 89/665 Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 90/665 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP Date - Assumed and Relinquished Care Dates To specify any or all of a date, a time, or a time period Usage notes Required to indicate "assumed care date" or "relinquished care date" when providers share post-operative care (global surgery claims). If not required by this implementation guide, do not send. Assumed Care Date is the date care was assumed by another provider during post- operative care. Relinquished Care Date is the date the provider filing this claim ceased post-operative care. See Medicare guidelines for further explanation of these dates. Example: Surgeon "A" relinquished post-operative care to Physician "B" five days after surgery. When Surgeon "A" submits a claim, "A" will use code "091 - Report End" to indicate the day the surgeon relinquished care of this patient to Physician "B". When Physician "B" submits a claim, "B" will use code "090 - Report Start" to indicate the date they assumed care of this patient from Surgeon "A". Example DTP*090*D8*XXX~ Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 2 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 090 Report Start Assumed Care Date - Use code "090" to indicate the date the provider filing this claim assumed care from another provider during post-operative care. 091 Report End Relinquished Care Date - Use code "091" to indicate the date the provider filing this claim relinquished post-operative care to another provider. 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 91/665 DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Assumed or Relinquished Care Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 92/665 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP Date - Authorized Return to Work To specify any or all of a date, a time, or a time period Usage notes Required on claims where this information is necessary for adjudication of the claim (for example, workers compensation claims involving absence from work). If not required by this implementation guide, do not send. Example DTP*296*D8*XX~ Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 296 Initial Disability Period Return To Work This is the date the provider has authorized the patient to return to work. DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Work Return Date Min 1 Max 35 String (AN) Required 1/30/25, 11:52 AM Home State | Home State Health 837 Health Care Claim_ Professional.pdf |
- Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 2 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 090 Report Start Assumed Care Date - Use code "090" to indicate the date the provider filing this claim assumed care from another provider during post-operative care. 091 Report End Relinquished Care Date - Use code "091" to indicate the date the provider filing this claim relinquished post-operative care to another provider. 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 91/665 DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Assumed or Relinquished Care Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 92/665 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP Date - Authorized Return to Work To specify any or all of a date, a time, or a time period Usage notes Required on claims where this information is necessary for adjudication of the claim (for example, workers compensation claims involving absence from work). If not required by this implementation guide, do not send. Example DTP*296*D8*XX~ Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 296 Initial Disability Period Return To Work This is the date the provider has authorized the patient to return to work. DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Work Return Date Min 1 Max 35 String (AN) Required 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 93/665 Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 94/665 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP Date - Disability Dates To specify any or all of a date, a time, or a time period Usage notes Required on claims involving disability where, in the judgment of the provider, the patient was or will be unable to perform the duties normally associated with his/her work. OR Required on non-HIPAA claims (for example workers compensation or property and casualty) when required by the claims processor. If not required by this implementation guide, do not send. Example DTP*314*RD8*XX~ Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 314 Disability Use code 314 when both disability start and end date are being reported. 360 Initial Disability Period Start Use code 360 if patient is currently disabled and disability end date is unknown. 361 Initial Disability Period End Use code 361 if patient is no longer disabled and the start date is unknown. DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 95/665 Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD Use code D8 when DTP01 is 360 or 361. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD Use code RD8 when DTP01 is 314. DTP-03 1251 Disability From Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 96/665 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP Date - Discharge To specify any or all of a date, a time, or a time period Usage notes Required for inpatient claims when the patient was discharged from the facility and the discharge date is known. If not required by this implementation guide, do not send. Example DTP*096*D8*XXX~ Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 096 Discharge DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Related Hospitalization Discharge Date Min 1 Max 35 String (AN) Required 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 97/665 Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 98/665 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP Date - Hearing and Vision Prescription Date To specify any or all of a date, a time, or a time period Usage notes Required on claims where a prescription has been written for hearing devices or vision frames and lenses and it is being billed on this claim. If not required by this implementation guide, do not send. Example DTP*471*D8*XXXX~ Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 471 Prescription DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Prescription Date Min 1 Max 35 String (AN) Required 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 99/665 Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 100/665 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP Date - Initial Treatment Date To specify any or all of a date, a time, or a time period Usage notes Required when the Initial Treatment Date is known to impact adjudication for claims involving spinal manipulation, physical therapy, occupational therapy, speech language pathology, dialysis, optical refractions, or pregnancy. If not required by this implementation guide, do not send. Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in Loop ID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300 for that service line only. Example DTP*454*D8*XXXXX~ Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 454 Initial Treatment DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 101/665 DTP-03 1251 Initial Treatment Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 102/665 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP Date - Last Menstrual Period To specify any or all of a date, a time, or a time period Usage notes Required when, in the judgment of the provider, the services on this claim are related to the patient's pregnancy. If not required by this implementation guide, do not send. Example DTP*484*D8*XXXX~ Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date | Home State Health 837 Health Care Claim_ Professional.pdf |
99/665 Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 100/665 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP Date - Initial Treatment Date To specify any or all of a date, a time, or a time period Usage notes Required when the Initial Treatment Date is known to impact adjudication for claims involving spinal manipulation, physical therapy, occupational therapy, speech language pathology, dialysis, optical refractions, or pregnancy. If not required by this implementation guide, do not send. Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in Loop ID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300 for that service line only. Example DTP*454*D8*XXXXX~ Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 454 Initial Treatment DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 101/665 DTP-03 1251 Initial Treatment Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 102/665 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP Date - Last Menstrual Period To specify any or all of a date, a time, or a time period Usage notes Required when, in the judgment of the provider, the services on this claim are related to the patient's pregnancy. If not required by this implementation guide, do not send. Example DTP*484*D8*XXXX~ Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 484 Last Menstrual Period DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Last Menstrual Period Date Min 1 Max 35 String (AN) Required 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 103/665 Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 104/665 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP Date - Last Seen Date To specify any or all of a date, a time, or a time period Usage notes Required when claims involve services for routine foot care and it is known to impact the payer's adjudication process. If not required by this implementation guide, do not send. This is the date that the patient was seen by the attending or supervising physician for the qualifying medical condition related to the services performed. Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in Loop ID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300 for that service line only. Example DTP*304*D8*X~ Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 304 Latest Visit or Consultation DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 105/665 D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Last Seen Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 106/665 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP Date - Last Worked To specify any or all of a date, a time, or a time period Usage notes Required on claims where this information is necessary for adjudication of the claim (for example, workers compensation claims involving absence from work). If not required by this implementation guide, do not send. Example DTP*297*D8*XX~ Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 297 Initial Disability Period Last Day Worked DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Last Worked Date Min 1 Max 35 String (AN) Required 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 107/665 Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 108/665 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP Date - Last X-ray Date To specify any or all of a date, a time, or a time period Usage notes Required when claim involves spinal manipulation and an x-ray was taken. If not required by this implementation guide, do not send. Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in Loop ID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300 for that service line only. Example DTP*455*D8*XXXXXX~ Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 455 Last X-Ray DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Last X-Ray Date Min 1 Max 35 String (AN) Required 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 109/665 Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 110/665 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP Date - Onset of Current Illness or Symptom To specify any or all of a date, a time, or a time period Usage notes Required for the initial medical service or visit performed in response to a medical emergency when the date is available and is different than the date of service. If not required by this implementation guide, do not send. This date is the onset of acute symptoms for the current illness or condition. Example DTP*431*D8*XXXXXX~ Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 431 Onset of Current Symptoms or Illness DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Onset of Current Illness or Injury Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 111/665 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ | Home State Health 837 Health Care Claim_ Professional.pdf |
DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 455 Last X-Ray DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Last X-Ray Date Min 1 Max 35 String (AN) Required 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 109/665 Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 110/665 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP Date - Onset of Current Illness or Symptom To specify any or all of a date, a time, or a time period Usage notes Required for the initial medical service or visit performed in response to a medical emergency when the date is available and is different than the date of service. If not required by this implementation guide, do not send. This date is the onset of acute symptoms for the current illness or condition. Example DTP*431*D8*XXXXXX~ Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Property and Casualty Date of First Contact DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 431 Onset of Current Symptoms or Illness DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Onset of Current Illness or Injury Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 111/665 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 112/665 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP Date - Property and Casualty Date of First Contact To specify any or all of a date, a time, or a time period Usage notes Required for Property and Casualty claims when state mandated. If not required by this implementation guide, do not send. This is the date the patient first consulted the service provider for this condition. The date of first contact is the date the patient first consulted the provider by any means. It is not necessarily the Initial Treatment Date. Example DTP*444*D8*XXXXXX~ Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Repricer Received Date Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 444 First Visit or Consultation DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Date Time Period Min 1 Max 35 String (AN) Required 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 113/665 Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 114/665 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP Date - Repricer Received Date To specify any or all of a date, a time, or a time period Usage notes Required when a repricer is passing the claim onto the payer. If not required by this implementation guide, do not send. Example DTP*050*D8*XXX~ Variants (all may be used) DTP Date - Accident DTP Date - Acute Manifestation DTP Date - Admission DTP Date - Assumed and Relinquished Care Dates DTP Date - Authorized Return to Work DTP Date - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Initial Treatment Date DTP Date - Last Menstrual Period DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date DTP Date - Onset of Current Illness or Symptom DTP Date - Property and Casualty Date of First Contact Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 050 Received DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Repricer Received Date Min 1 Max 35 String (AN) Required 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 115/665 Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 116/665 PWK 1550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > PWK Claim Supplemental Information To identify the type or transmission or both of paperwork or supporting information Usage notes Required when there is a paper attachment following this claim. OR Required when attachments are sent electronically (PWK02 = EL) but are transmitted in another functional group (for example, 275) rather than by paper. PWK06 is then used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment. OR Required when the provider deems it necessary to identify additional information that is being held at the provider's office and is available upon request by the payer (or appropriate entity), but the information is not being submitted with the claim. Use the value of "AA" in PWK02 to convey this specific use of the PWK segment. If not required by this implementation guide, do not send. Example PWK*I5*EM***AC*XXXXXX~ If either Identification Code Qualifier (PWK-05) or Attachment Control Number (PWK-06) is present, then the other is required Max use 10 Optional PWK-01 755 Attachment Report Type Code Identifier (ID) Required Code indicating the title or contents of a document, report or supporting item 03 Report Justifying Treatment Beyond Utilization Guidelines 04 Drugs Administered 05 Treatment Diagnosis 06 Initial Assessment 07 Functional Goals 08 Plan of Treatment 09 Progress Report 10 Continued Treatment 11 Chemical Analysis 13 Certified Test Report 15 Justification for Admission 21 Recovery Plan A3 Allergies/Sensitivities Document A4 Autopsy Report AM Ambulance Certification AS Admission Summary B2 Prescription B3 Physician Order B4 Referral Form BR Benchmark Testing Results BS Baseline BT Blanket Test Results CB Chiropractic Justification 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 117/665 CK Consent Form(s) CT Certification D2 Drug Profile Document DA Dental Models DB Durable Medical Equipment Prescription DG Diagnostic Report DJ Discharge Monitoring Report DS Discharge Summary EB Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payor) HC Health Certificate HR Health Clinic Records I5 Immunization Record IR State School Immunization Records LA Laboratory Results M1 Medical Record Attachment MT Models NN Nursing Notes OB Operative Note OC Oxygen Content Averaging Report OD Orders and Treatments Document OE Objective Physical Examination (including vital signs) Document OX Oxygen Therapy Certification OZ Support Data for Claim P4 Pathology Report P5 Patient Medical History Document PE Parenteral or Enteral Certification PN Physical Therapy Notes PO Prosthetics or Orthotic Certification PQ Paramedical Results PY Physician's Report PZ Physical Therapy Certification RB Radiology Films RR Radiology Reports RT Report of Tests and Analysis Report RX Renewable Oxygen Content Averaging Report SG Symptoms Document V5 Death Notification XP Photographs PWK-02 756 Attachment Transmission Code Identifier (ID) Required Code defining timing, transmission method or format by which reports are to be sent AA Available on Request at Provider Site This means that the additional information is not being sent with the claim at this time. Instead, it is available to the payer (or appropriate entity) at their request. BM By Mail EL Electronically Only Indicates that the attachment is being transmitted in a separate X12 functional group. EM E-Mail FT File Transfer 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 118/665 Required when the actual attachment is maintained by an attachment warehouse or similar vendor. FX By Fax PWK-05 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) PWK05 and PWK06 may be used to identify the addressee by a code number. AC Attachment Control Number PWK-06 67 Attachment Control Number Min 2 Max 80 String (AN) Optional Code identifying a party or other code Usage notes PWK06 is used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment. For the purpose of this implementation, the maximum field length is 50. 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 119/665 CN1 1600 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > CN1 Contract Information To specify basic data about the contract or contract line item Usage notes The developers of this implementation guide note that the CN1 segment is for use only for post-adjudicated claims, which do not meet the definition of a health care claim under HIPAA. Consequently, at the time of this writing, the CN1 segment is for non- HIPAA use only. Required when the submitter is contractually obligated to supply this information on post-adjudicated claims. If not required by this implementation guide, do not send. Example CN1*03*0000000000*0000*XXXX*00000*X~ Max use 1 Optional CN1-01 1166 Contract Type Code Identifier (ID) Required Code identifying a contract type 01 Diagnosis Related Group (DRG) 02 Per Diem 03 Variable Per Diem 04 Flat 05 Capitated 06 Percent 09 Other CN1-02 782 Contract Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CN102 is the contract amount. CN1-03 332 Contract Percentage Min 1 Max 6 Decimal number (R) Optional Percent given in decimal format (e.g., 0.0 through 100.0 represents 0% through 100%) CN103 is the allowance or charge percent. CN1-04 127 Contract Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier CN104 | Home State Health 837 Health Care Claim_ Professional.pdf |
P4 Pathology Report P5 Patient Medical History Document PE Parenteral or Enteral Certification PN Physical Therapy Notes PO Prosthetics or Orthotic Certification PQ Paramedical Results PY Physician's Report PZ Physical Therapy Certification RB Radiology Films RR Radiology Reports RT Report of Tests and Analysis Report RX Renewable Oxygen Content Averaging Report SG Symptoms Document V5 Death Notification XP Photographs PWK-02 756 Attachment Transmission Code Identifier (ID) Required Code defining timing, transmission method or format by which reports are to be sent AA Available on Request at Provider Site This means that the additional information is not being sent with the claim at this time. Instead, it is available to the payer (or appropriate entity) at their request. BM By Mail EL Electronically Only Indicates that the attachment is being transmitted in a separate X12 functional group. EM E-Mail FT File Transfer 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 118/665 Required when the actual attachment is maintained by an attachment warehouse or similar vendor. FX By Fax PWK-05 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) PWK05 and PWK06 may be used to identify the addressee by a code number. AC Attachment Control Number PWK-06 67 Attachment Control Number Min 2 Max 80 String (AN) Optional Code identifying a party or other code Usage notes PWK06 is used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment. For the purpose of this implementation, the maximum field length is 50. 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 119/665 CN1 1600 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > CN1 Contract Information To specify basic data about the contract or contract line item Usage notes The developers of this implementation guide note that the CN1 segment is for use only for post-adjudicated claims, which do not meet the definition of a health care claim under HIPAA. Consequently, at the time of this writing, the CN1 segment is for non- HIPAA use only. Required when the submitter is contractually obligated to supply this information on post-adjudicated claims. If not required by this implementation guide, do not send. Example CN1*03*0000000000*0000*XXXX*00000*X~ Max use 1 Optional CN1-01 1166 Contract Type Code Identifier (ID) Required Code identifying a contract type 01 Diagnosis Related Group (DRG) 02 Per Diem 03 Variable Per Diem 04 Flat 05 Capitated 06 Percent 09 Other CN1-02 782 Contract Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CN102 is the contract amount. CN1-03 332 Contract Percentage Min 1 Max 6 Decimal number (R) Optional Percent given in decimal format (e.g., 0.0 through 100.0 represents 0% through 100%) CN103 is the allowance or charge percent. CN1-04 127 Contract Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier CN104 is the contract code. CN1-05 338 Terms Discount Percentage Min 1 Max 6 Decimal number (R) Optional 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 120/665 Terms discount percentage, expressed as a percent, available to the purchaser if an invoice is paid on or before the Terms Discount Due Date CN1-06 799 Contract Version Identifier Min 1 Max 30 String (AN) Optional Revision level of a particular format, program, technique or algorithm CN106 is an additional identifying number for the contract. 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 121/665 AMT 1750 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > AMT Patient Amount Paid To indicate the total monetary amount Usage notes Required when patient has made payment specifically toward this claim. If not required by this implementation guide, do not send. Patient Amount Paid refers to the sum of all amounts paid on the claim by the patient or his or her representative(s). Example AMT*F5*00~ Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount F5 Patient Amount Paid AMT-02 782 Patient Amount Paid Min 1 Max 15 Decimal number (R) Required Monetary amount 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 122/665 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF Adjusted Repriced Claim Number To specify identifying information Usage notes Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send. This information is specific to the destination payer reported in Loop ID-2010BB. Example REF*9C*XXXXX~ Variants (all may be used) REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9C Adjusted Repriced Claim Reference Number REF-02 127 Adjusted Repriced Claim Reference Number String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 123/665 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF Care Plan Oversight To specify identifying information Usage notes Required when the physician is billing Medicare for Care Plan Oversight (CPO). If not required by this implementation guide, do not send. This is the number of the home health agency or hospice providing Medicare covered services to the patient for the period during which CPO services were furnished. Prior to the mandated HIPAA National Provider Identifier (NPI) implementation date this number is the Medicare Number. On or after the mandated HIPAA National Provider Identifier (NPI) implementation date this is the NPI. Example REF*1J*XX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 1J Facility ID Number REF-02 127 Care Plan Oversight Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 124/665 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF Claim Identifier For Transmission Intermediaries To specify identifying information Usage notes Required when this information is deemed necessary by transmission intermediaries (Automated Clearinghouses, and others) who need to attach their own unique claim number. If not required by this implementation guide, do not send. Although this REF is supplied for transmission intermediaries to attach their own unique claim number to a claim, 837-recipients are not required under HIPAA to return this number in any HIPAA transaction. Trading partners may voluntarily agree to this interaction if they wish. Example REF*D9*XX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification Usage notes Number assigned by clearinghouse, van, etc. D9 Claim Number REF-02 127 Value Added Network Trace Number Min 1 Max 30 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 125/665 The value carried in this element is limited to a maximum of 20 positions. 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 126/665 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF Clinical Laboratory Improvement Amendment (CLIA) Number To specify identifying information Usage notes Required for all CLIA certified facilities performing CLIA covered laboratory services. If not required by this implementation guide, do not send. If a CLIA number is indicated at the line level (Loop ID-2400) in addition to the claim level (Loop ID-2300), that would indicate an exception to the CLIA number at the claim level for that individual line. In cases where this claim contains both in-house and outsourced laboratory services, the CLIA Number for laboratory services performed by the Billing or Rendering Provider is reported in this loop. The CLIA number for laboratory services which were outsourced is reported in Loop ID-2400. Example REF*X4*XX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification X4 Clinical Laboratory Improvement Amendment Number REF-02 127 Clinical Laboratory Improvement Amendment Number String (AN) Required Min 1 Max 50 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 127/665 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 128/665 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF Demonstration Project Identifier To specify identifying information Usage notes Required when it is necessary to identify claims which are atypical in ways such as content, purpose, and/or payment, as could be the case for a demonstration or other special project, or a clinical trial. If not required by this implementation guide, do not send. Example REF*P4*XXX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification P4 Project Code REF-02 127 Demonstration Project Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 129/665 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF Investigational Device Exemption Number To specify identifying information Usage notes Required when claim involves a Food and Drug Administration (FDA) assigned investigational device exemption (IDE) number. When more than one | Home State Health 837 Health Care Claim_ Professional.pdf |
performing CLIA covered laboratory services. If not required by this implementation guide, do not send. If a CLIA number is indicated at the line level (Loop ID-2400) in addition to the claim level (Loop ID-2300), that would indicate an exception to the CLIA number at the claim level for that individual line. In cases where this claim contains both in-house and outsourced laboratory services, the CLIA Number for laboratory services performed by the Billing or Rendering Provider is reported in this loop. The CLIA number for laboratory services which were outsourced is reported in Loop ID-2400. Example REF*X4*XX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification X4 Clinical Laboratory Improvement Amendment Number REF-02 127 Clinical Laboratory Improvement Amendment Number String (AN) Required Min 1 Max 50 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 127/665 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 128/665 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF Demonstration Project Identifier To specify identifying information Usage notes Required when it is necessary to identify claims which are atypical in ways such as content, purpose, and/or payment, as could be the case for a demonstration or other special project, or a clinical trial. If not required by this implementation guide, do not send. Example REF*P4*XXX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification P4 Project Code REF-02 127 Demonstration Project Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 129/665 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF Investigational Device Exemption Number To specify identifying information Usage notes Required when claim involves a Food and Drug Administration (FDA) assigned investigational device exemption (IDE) number. When more than one IDE applies, they must be split into separate claims. If not required by this implementation guide, do not send. Example REF*LX*XXX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification LX Qualified Products List REF-02 127 Investigational Device Exemption Identifier String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 130/665 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF Mammography Certification Number To specify identifying information Usage notes Required when mammography services are rendered by a certified mammography provider. If not required by this implementation guide, do not send. Example REF*EW*XXXXX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification EW Mammography Certification Number REF-02 127 Mammography Certification Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 131/665 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF Mandatory Medicare (Section 4081) Crossover Indicator To specify identifying information Usage notes Required when the submitter is Medicare and the claim is a Medigap or COB crossover claim. If not required by this implementation guide, do not send. Example REF*F5*XXXXXX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography Certification Number REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification F5 Medicare Version Code REF-02 127 Medicare Section 4081 Indicator Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The allowed values for this element are: Y 4081 N Regular crossover 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 132/665 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF Medical Record Number To specify identifying information Usage notes Required when the provider needs to identify for future inquiries, the actual medical record of the patient identified in either Loop ID-2010BA or Loop ID-2010CA for this episode of care. If not required by this implementation guide, do not send. Example REF*EA*XXX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification EA Medical Record Identification Number REF-02 127 Medical Record Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 133/665 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF Payer Claim Control Number To specify identifying information Usage notes Required when CLM05-3 (Claim Frequency Code) indicates this claim is a replacement or void to a previously adjudicated claim. If not required by this implementation guide, do not send. This information is specific to the destination payer reported in Loop ID-2010BB. Example REF*F8*XXXXX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification F8 Original Reference Number REF-02 127 Payer Claim Control Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 134/665 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF Prior Authorization To specify identifying information Usage notes Generally, preauthorization numbers are assigned by the payer or UMO to authorize a service prior to its being performed. The UMO (Utilization Management Organization) is generally the entity empowered to make a decision regarding the outcome of a health services review or the owner of information. The prior authorization number carried in this REF is specific to the destination payer reported in the Loop ID-2010BB. If other payers have similar numbers for this claim, report that information in the Loop ID-2330 loop REF which holds that payer's information. Numbers at this position apply to the entire claim unless they are overridden in the REF segment in Loop ID-2400. A reference identification is considered to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line. Required when an authorization number is assigned by the payer or UMO AND the services on this claim were preauthorized. If not required by this implementation guide, do not send. Example REF*G1*XXXX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Payer Claim Control Number REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification G1 Prior Authorization Number REF-02 127 Prior Authorization Number Min 1 Max 50 String (AN) Required 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 135/665 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 136/665 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF Referral Number To specify identifying information Usage notes Required when a referral number is assigned by the payer or Utilization Management Organization (UMO) AND a referral is involved. If not required by this implementation guide, do not send. Numbers at this position apply to the entire claim unless they are overridden in the REF segment in Loop ID-2400. A reference identification is considered to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line. Example REF*9F*XXXX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification | Home State Health 837 Health Care Claim_ Professional.pdf |
a decision regarding the outcome of a health services review or the owner of information. The prior authorization number carried in this REF is specific to the destination payer reported in the Loop ID-2010BB. If other payers have similar numbers for this claim, report that information in the Loop ID-2330 loop REF which holds that payer's information. Numbers at this position apply to the entire claim unless they are overridden in the REF segment in Loop ID-2400. A reference identification is considered to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line. Required when an authorization number is assigned by the payer or UMO AND the services on this claim were preauthorized. If not required by this implementation guide, do not send. Example REF*G1*XXXX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Payer Claim Control Number REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification G1 Prior Authorization Number REF-02 127 Prior Authorization Number Min 1 Max 50 String (AN) Required 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 135/665 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 136/665 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF Referral Number To specify identifying information Usage notes Required when a referral number is assigned by the payer or Utilization Management Organization (UMO) AND a referral is involved. If not required by this implementation guide, do not send. Numbers at this position apply to the entire claim unless they are overridden in the REF segment in Loop ID-2400. A reference identification is considered to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line. Example REF*9F*XXXX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9F Referral Number REF-02 127 Referral Number Min 1 Max 50 String (AN) Required 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 137/665 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 138/665 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF Repriced Claim Number To specify identifying information Usage notes Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send. This information is specific to the destination payer reported in Loop ID-2010BB. Example REF*9A*XXXXX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9A Repriced Claim Reference Number REF-02 127 Repriced Claim Reference Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 139/665 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF Service Authorization Exception Code To specify identifying information Usage notes Required when mandated by government law or regulation to obtain authorization for specific service(s) but, for the reasons listed in REF02, the service was performed without obtaining the authorization. If not required by this implementation guide, do not send. Example REF*4N*X~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Claim Identifier For Transmission Intermediaries REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 4N Special Payment Reference Number REF-02 127 Service Authorization Exception Code Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes Allowable values for this element are: 1 Immediate/Urgent Care 2 Services Rendered in a Retroactive Period 3 Emergency Care 4 Client has Temporary Medicaid 5 Request from County for Second Opinion to Determine if Recipient Can Work 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 140/665 6 Request for Override Pending 7 Special Handling 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 141/665 K3 1850 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > K3 File Information To transmit a fixed-format record or matrix contents Usage notes Required when ALL of the following conditions are met: A regulatory agency concludes it must use the K3 to meet an emergency legislative requirement; The administering regulatory agency or other state organization has completed each one of the following steps: contacted the X12N workgroup, requested a review of the K3 data requirement to ensure there is not an existing method within the implementation guide to meet this requirement X12N determines that there is no method to meet the requirement. If not required by this implementation guide, do not send. At the time of publication of this implementation, K3 segments have no specific use. The K3 segment is expected to be used only when necessary to meet the unexpected data requirement of a legislative authority. Before this segment can be used : The X12N Health Care Claim workgroup must conclude there is no other available option in the implementation guide to meet the emergency legislative requirement. The requestor must submit a proposal for approval accompanied by the relevant business documentation to the X12N Health Care Claim workgroup chairs and receive approval for the request. Upon review of the request, X12N will issue an approval or denial decision to the requesting entity. Approved usage(s) of the K3 segment will be reviewed by the X12N Health Care Claim workgroup to develop a permanent change to include the business case in future transaction implementations. Only when all of the requirements above have been met, may the regulatory agency require the temporary use of the K3 segment. X12N will submit the necessary data maintenance and refer the request to the appropriate data content committee(s). Example K3*XXXX~ Max use 10 Optional K3-01 449 Fixed Format Information Min 1 Max 80 String (AN) Required Data in fixed format agreed upon by sender and receiver 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 142/665 NTE 1900 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > NTE Claim Note To transmit information in a free-form format, if necessary, for comment or special instruction Usage notes Required when in the judgment of the provider, the information is needed to substantiate the medical treatment and is not supported elsewhere within the claim data set. If not required by this implementation guide, do not send. Information in the NTE segment in Loop ID-2300 applies to the entire claim unless overridden by information in the NTE segment in Loop ID-2400. Information is considered to be overridden when the value in NTE01 in Loop ID-2400 is the same as the value in NTE01 in Loop ID-2300. The developers of this implementation guide discourage using narrative information within the 837. Trading partners who use narrative information with claims are strongly encouraged to codify that information within the X12 environment.; Example NTE*CER*XXXXXX~ Max use 1 Optional NTE-01 363 Note Reference Code Identifier (ID) Required Code identifying the functional area or purpose for which the note applies ADD Additional Information CER Certification Narrative DCP Goals, Rehabilitation Potential, or Discharge Plans DGN Diagnosis Description TPO Third Party Organization Notes NTE-02 352 Claim Note Text Min 1 Max 80 String (AN) Required A free-form description to clarify the related data elements and their content 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 143/665 CR1 1950 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > CR1 Ambulance Transport Information To supply information related to the ambulance service rendered to a patient Usage notes Required on all claims involving ambulance transport services. If not required by this implementation guide, do not send. The CR1 segment in Loop ID-2300 applies to the entire claim unless overridden by a CR1 segment at the service line level in Loop ID-2400 with the same value in CR101. Example CR1*LB*0000**E*DH*000000000000***XX*XXXX~ If either Unit or Basis for Measurement Code (CR1-01) or Patient Weight (CR1-02) is present, then the other is required Max use 1 Optional CR1-01 355 Unit or Basis for Measurement Code Identifier (ID) Optional Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken LB Pound CR1-02 81 Patient Weight Min 1 Max 10 Decimal number (R) Optional Numeric value of weight CR102 is the weight of the patient at time of transport. CR1-04 1317 Ambulance Transport Reason Code Identifier (ID) Required Code indicating the reason for ambulance transport A Patient was transported to nearest facility for care of symptoms, complaints, or both Can be used to indicate that the patient was transferred to a residential facility. B Patient was transported for the benefit of a preferred physician C Patient was transported for the nearness of family members D Patient was transported for the care of a specialist or for availability of specialized equipment E Patient Transferred to Rehabilitation Facility CR1-05 355 Unit or Basis for Measurement Code Identifier (ID) Required Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken DH Miles CR1-06 380 Transport Distance Min 1 Max 15 Decimal number (R) Required 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 144/665 Numeric value of quantity CR106 is the distance traveled during transport. Usage notes 0 (zero) is a valid value when ambulance services do not include a charge for mileage. CR1-09 352 Round Trip Purpose Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content CR109 is the purpose for the round trip ambulance service. CR1-10 352 Stretcher Purpose Description | Home State Health 837 Health Care Claim_ Professional.pdf |
The developers of this implementation guide discourage using narrative information within the 837. Trading partners who use narrative information with claims are strongly encouraged to codify that information within the X12 environment.; Example NTE*CER*XXXXXX~ Max use 1 Optional NTE-01 363 Note Reference Code Identifier (ID) Required Code identifying the functional area or purpose for which the note applies ADD Additional Information CER Certification Narrative DCP Goals, Rehabilitation Potential, or Discharge Plans DGN Diagnosis Description TPO Third Party Organization Notes NTE-02 352 Claim Note Text Min 1 Max 80 String (AN) Required A free-form description to clarify the related data elements and their content 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 143/665 CR1 1950 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > CR1 Ambulance Transport Information To supply information related to the ambulance service rendered to a patient Usage notes Required on all claims involving ambulance transport services. If not required by this implementation guide, do not send. The CR1 segment in Loop ID-2300 applies to the entire claim unless overridden by a CR1 segment at the service line level in Loop ID-2400 with the same value in CR101. Example CR1*LB*0000**E*DH*000000000000***XX*XXXX~ If either Unit or Basis for Measurement Code (CR1-01) or Patient Weight (CR1-02) is present, then the other is required Max use 1 Optional CR1-01 355 Unit or Basis for Measurement Code Identifier (ID) Optional Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken LB Pound CR1-02 81 Patient Weight Min 1 Max 10 Decimal number (R) Optional Numeric value of weight CR102 is the weight of the patient at time of transport. CR1-04 1317 Ambulance Transport Reason Code Identifier (ID) Required Code indicating the reason for ambulance transport A Patient was transported to nearest facility for care of symptoms, complaints, or both Can be used to indicate that the patient was transferred to a residential facility. B Patient was transported for the benefit of a preferred physician C Patient was transported for the nearness of family members D Patient was transported for the care of a specialist or for availability of specialized equipment E Patient Transferred to Rehabilitation Facility CR1-05 355 Unit or Basis for Measurement Code Identifier (ID) Required Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken DH Miles CR1-06 380 Transport Distance Min 1 Max 15 Decimal number (R) Required 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 144/665 Numeric value of quantity CR106 is the distance traveled during transport. Usage notes 0 (zero) is a valid value when ambulance services do not include a charge for mileage. CR1-09 352 Round Trip Purpose Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content CR109 is the purpose for the round trip ambulance service. CR1-10 352 Stretcher Purpose Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content CR110 is the purpose for the usage of a stretcher during ambulance service. 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 145/665 CR2 2000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > CR2 Spinal Manipulation Service Information To supply information related to the chiropractic service rendered to a patient Usage notes Required on chiropractic claims involving spinal manipulation when the information is known to impact the payer's adjudication process. If not required by this implementation guide, do not send. Example CR2********A**XXXXXX*XXXX~ Max use 1 Optional CR2-08 1342 Patient Condition Code Identifier (ID) Required Code indicating the nature of a patient's condition A Acute Condition C Chronic Condition D Non-acute E Non-Life Threatening F Routine G Symptomatic M Acute Manifestation of a Chronic Condition CR2-10 352 Patient Condition Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content CR210 is a description of the patient's condition. CR2-11 352 Patient Condition Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content CR211 is an additional description of the patient's condition. 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 146/665 CRC 2200 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > CRC Ambulance Certification To supply information on conditions Usage notes Required when the claim involves ambulance transport services AND when reporting condition codes in any of CRC03 through CRC07. If not required by this implementation guide, do not send. The CRC segment in Loop ID-2300 applies to the entire claim unless overridden by a CRC segment at the service line level in Loop ID-2400 with the same value in CRC01. Repeat this segment only when it is necessary to report additional unique values to those reported in CRC03 thru CRC07. Example CRC*07*Y*01*XX*XXX*XX*XX~ Variants (all may be used) CRC EPSDT Referral CRC Homebound Indicator CRC Patient Condition Information: Vision Max use 3 Optional CRC-01 1136 Code Category Identifier (ID) Required Specifies the situation or category to which the code applies CRC01 qualifies CRC03 through CRC07. 07 Ambulance Certification CRC-02 1073 Certification Condition Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply. N No Y Yes CRC-03 1321 Condition Code Identifier (ID) Required Code indicating a condition Usage notes The codes for CRC03 also can be used for CRC04 through CRC07. 01 Patient was admitted to a hospital 04 Patient was moved by stretcher 05 Patient was unconscious or in shock 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 147/665 06 Patient was transported in an emergency situation 07 Patient had to be physically restrained 08 Patient had visible hemorrhaging 09 Ambulance service was medically necessary 12 Patient is confined to a bed or chair Use code 12 to indicate patient was bedridden during transport. CRC-04 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. CRC-05 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. CRC-06 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. CRC-07 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 148/665 CRC 2200 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > CRC EPSDT Referral To supply information on conditions Usage notes Required on Early & Periodic Screening, Diagnosis, and Treatment (EPSDT) claims when the screening service is being billed in this claim. If not required by this implementation guide, do not send. Example CRC*ZZ*Y*S2*XX*XXX~ Variants (all may be used) CRC Ambulance Certification CRC Homebound Indicator CRC Patient Condition Information: Vision Max use 1 Optional CRC-01 1136 Code Qualifier Identifier (ID) Required Specifies the situation or category to which the code applies CRC01 qualifies CRC03 through CRC07. ZZ Mutually Defined EPSDT Screening referral information. CRC-02 1073 Certification Condition Code Applies Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply. Usage notes The response answers the question: Was an EPSDT referral given to the patient? N No If no, then choose "NU" in CRC03 indicating no referral given. Y Yes CRC-03 1321 Condition Indicator Identifier (ID) Required Code indicating a condition Usage notes The codes for CRC03 also can be used for CRC04 through CRC05. AV Available - Not Used Patient refused referral. 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 149/665 NU Not Used This conditioner indicator must be used when the submitter answers "N" in CRC02. S2 Under Treatment Patient is currently under treatment for referred diagnostic or corrective health problem. ST New Services Requested Patient is referred to another provider for diagnostic or corrective treatment for at least one health problem identified during an initial or periodic screening service (not including dental referrals). OR Patient is scheduled for another appointment with screening provider for diagnostic or corrective treatment for at least one health problem identified during an initial or periodic screening service (not including dental referrals).; CRC-04 1321 Condition Indicator Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. CRC-05 1321 Condition Indicator Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 150/665 CRC 2200 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > CRC Homebound Indicator To supply information on conditions Usage notes Required for Medicare claims when an independent laboratory renders an EKG tracing or obtains a specimen from a homebound or institutionalized patient. If not required by this implementation guide, do not send. Example CRC*75*Y*IH~ Variants (all may be used) CRC Ambulance Certification CRC EPSDT Referral CRC Patient Condition Information: Vision Max use 1 Optional CRC-01 1136 Code Category Identifier (ID) Required Specifies the situation or category to which the code applies CRC01 qualifies CRC03 through CRC07. 75 Functional Limitations CRC-02 1073 Certification Condition Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply. Y Yes CRC-03 1321 Homebound Indicator Identifier (ID) Required Code indicating a condition IH Independent at Home 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 151/665 CRC 2200 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > CRC Patient Condition Information: Vision To supply information on conditions Usage notes Required on vision claims involving replacement lenses or frames when this information is known to impact reimbursement. If not required by this implementation guide, do not send. Example CRC*E1*N*L5*XX*XX*XX*XXX~ Variants (all may be used) CRC Ambulance Certification CRC EPSDT Referral CRC Homebound Indicator Max use 3 Optional CRC-01 1136 Code Category Identifier (ID) Required Specifies the situation or category to which the code applies CRC01 qualifies CRC03 through CRC07. E1 Spectacle Lenses E2 Contact Lenses E3 Spectacle Frames CRC-02 1073 Certification Condition Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply. N No Y Yes CRC-03 1321 Condition Code Identifier (ID) Required Code indicating a condition L1 General Standard of 20 Degree or .5 Diopter Sphere or Cylinder Change Met L2 Replacement Due to Loss or Theft L3 Replacement Due to Breakage or Damage L4 Replacement Due to Patient Preference L5 Replacement Due to Medical Reason CRC-04 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 152/665 Code indicating a condition Usage notes Use the codes listed in CRC03. CRC-05 1321 Condition Code Min 2 Max 3 | Home State Health 837 Health Care Claim_ Professional.pdf |
Optional Code indicating a condition Usage notes Use the codes listed in CRC03. CRC-05 1321 Condition Indicator Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 150/665 CRC 2200 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > CRC Homebound Indicator To supply information on conditions Usage notes Required for Medicare claims when an independent laboratory renders an EKG tracing or obtains a specimen from a homebound or institutionalized patient. If not required by this implementation guide, do not send. Example CRC*75*Y*IH~ Variants (all may be used) CRC Ambulance Certification CRC EPSDT Referral CRC Patient Condition Information: Vision Max use 1 Optional CRC-01 1136 Code Category Identifier (ID) Required Specifies the situation or category to which the code applies CRC01 qualifies CRC03 through CRC07. 75 Functional Limitations CRC-02 1073 Certification Condition Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply. Y Yes CRC-03 1321 Homebound Indicator Identifier (ID) Required Code indicating a condition IH Independent at Home 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 151/665 CRC 2200 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > CRC Patient Condition Information: Vision To supply information on conditions Usage notes Required on vision claims involving replacement lenses or frames when this information is known to impact reimbursement. If not required by this implementation guide, do not send. Example CRC*E1*N*L5*XX*XX*XX*XXX~ Variants (all may be used) CRC Ambulance Certification CRC EPSDT Referral CRC Homebound Indicator Max use 3 Optional CRC-01 1136 Code Category Identifier (ID) Required Specifies the situation or category to which the code applies CRC01 qualifies CRC03 through CRC07. E1 Spectacle Lenses E2 Contact Lenses E3 Spectacle Frames CRC-02 1073 Certification Condition Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply. N No Y Yes CRC-03 1321 Condition Code Identifier (ID) Required Code indicating a condition L1 General Standard of 20 Degree or .5 Diopter Sphere or Cylinder Change Met L2 Replacement Due to Loss or Theft L3 Replacement Due to Breakage or Damage L4 Replacement Due to Patient Preference L5 Replacement Due to Medical Reason CRC-04 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 152/665 Code indicating a condition Usage notes Use the codes listed in CRC03. CRC-05 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. CRC-06 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. CRC-07 1321 Condition Code Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 153/665 HI 2310 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HI Anesthesia Related Procedure To supply information related to the delivery of health care Usage notes Required on claims where anesthesiology services are being billed or reported when the provider knows the surgical code and knows the adjudication of the claim will depend on provision of the surgical code. If not required by this implementation guide, do not send. Example HI*BP>X*BO>XXXX~ Variants (all may be used) HI Condition Information HI Health Care Diagnosis Code Max use 1 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BP Health Care Financing Administration Common Procedural Coding System Principal Procedure C022-02 1271 Anesthesia Related Surgical Procedure String (AN) Required Min 1 Max 30 Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 154/665 BO Health Care Financing Administration Common Procedural Coding System C022-02 1271 Industry Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 155/665 HI 2310 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HI Condition Information To supply information related to the delivery of health care Usage notes Required when condition information applies to the claim. If not required by this implementation guide, do not send. Example HI*BG>XXXX*BG>XX*BG>XXXXX*BG>X*BG>X*BG>XX*BG>XX*B G>XXXXX*BG>XXXXX*BG>XXX*BG>XXXXX*BG>XXXX~ Variants (all may be used) HI Anesthesia Related Procedure HI Health Care Diagnosis Code Max use 2 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 156/665 BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 157/665 If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-06 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-07 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Max use 1 Optional 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 158/665 Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. | Home State Health 837 Health Care Claim_ Professional.pdf |
data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-06 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-07 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Max use 1 Optional 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 158/665 Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 159/665 Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-10 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 160/665 Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 161/665 HI 2310 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HI Health Care Diagnosis Code To supply information related to the delivery of health care Usage notes Do not transmit the decimal point for ICD codes. The decimal point is implied. Example HI*BK>XXX*BF>XXX*BF>XX*BF>XXXXX*ABF>XXXX*BF>XXXX X*BF>X*ABF>XXX*BF>XX*BF>X*ABF>XXXXX*BF>X~ Variants (all may be used) HI Anesthesia Related Procedure HI Condition Information Max use 1 Required HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Diagnosis Type Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABK International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BK International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis C022-02 1271 Diagnosis Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 162/665 C022-01 1270 Diagnosis Type Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Diagnosis Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Diagnosis Type Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Diagnosis Code Min 1 Max 30 String (AN) Required 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 163/665 Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Diagnosis Type Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Diagnosis Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Diagnosis Type Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 164/665 If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification | Home State Health 837 Health Care Claim_ Professional.pdf |
C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Diagnosis Code Min 1 Max 30 String (AN) Required 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 163/665 Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Diagnosis Type Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Diagnosis Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Diagnosis Type Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 164/665 If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Diagnosis Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-06 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Diagnosis Type Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Diagnosis Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-07 C022 Health Care Code Information Max use 1 Optional 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 165/665 To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. C022-01 1270 Diagnosis Type Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis ICD-9 Codes C022-02 1271 Diagnosis Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Diagnosis Type Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 166/665 OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Diagnosis Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Diagnosis Type Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Diagnosis Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-10 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Diagnosis Type Code Identifier (ID) Required 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 167/665 Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Diagnosis Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Diagnosis Type Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Diagnosis Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 168/665 HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Diagnosis Type Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Diagnosis Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 169/665 HCP 2410 Detail > Billing Provider Hierarchical Level Loop | Home State Health 837 Health Care Claim_ Professional.pdf |
exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Diagnosis Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Diagnosis Type Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Diagnosis Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 168/665 HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Diagnosis Type Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Diagnosis Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 169/665 HCP 2410 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HCP Claim Pricing/Repricing Information To specify pricing or repricing information about a health care claim or line item Usage notes Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send. This information is specific to the destination payer reported in Loop ID-2010BB. For capitated encounters, pricing or repricing information usually is not applicable and is provided to qualify other information within the claim. Example HCP*10*00000000000000*00*XXXX*00000*XXXX*00000000 00******T4*3*1~ Max use 1 Optional HCP-01 1473 Pricing Methodology Identifier (ID) Required Code specifying pricing methodology at which the claim or line item has been priced or repriced Usage notes Specific code use is determined by Trading Partner Agreement due to the variances in contracting policies in the industry. 00 Zero Pricing (Not Covered Under Contract) 01 Priced as Billed at 100% 02 Priced at the Standard Fee Schedule 03 Priced at a Contractual Percentage 04 Bundled Pricing 05 Peer Review Pricing 07 Flat Rate Pricing 08 Combination Pricing 09 Maternity Pricing 10 Other Pricing 11 Lower of Cost 12 Ratio of Cost 13 Cost Reimbursed 14 Adjustment Pricing HCP-02 782 Repriced Allowed Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HCP02 is the allowed amount. HCP-03 782 Repriced Saving Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 170/665 HCP03 is the savings amount. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-04 127 Repricing Organization Identifier Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier HCP04 is the repricing organization identification number. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-05 118 Repricing Per Diem or Flat Rate Amount Decimal number (R) Optional Min 1 Max 9 Rate expressed in the standard monetary denomination for the currency specified HCP05 is the pricing rate associated with per diem or flat rate repricing. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-06 127 Repriced Approved Ambulatory Patient Group Code String (AN) Optional Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier HCP06 is the approved DRG code. HCP06, HCP07, HCP08, HCP10, and HCP12 are fields that will contain different values from the original submitted values. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-07 782 Repriced Approved Ambulatory Patient Group Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount HCP07 is the approved DRG amount. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-13 901 Reject Reason Code Identifier (ID) Optional 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 171/665 Code assigned by issuer to identify reason for rejection HCP13 is the rejection message returned from the third party organization. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. T1 Cannot Identify Provider as TPO (Third Party Organization) Participant T2 Cannot Identify Payer as TPO (Third Party Organization) Participant T3 Cannot Identify Insured as TPO (Third Party Organization) Participant T4 Payer Name or Identifier Missing T5 Certification Information Missing T6 Claim does not contain enough information for re-pricing HCP-14 1526 Policy Compliance Code Identifier (ID) Optional Code specifying policy compliance Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. 1 Procedure Followed (Compliance) 2 Not Followed - Call Not Made (Non-Compliance Call Not Made) 3 Not Medically Necessary (Non-Compliance Non-Medically Necessary) 4 Not Followed Other (Non-Compliance Other) 5 Emergency Admit to Non-Network Hospital HCP-15 1527 Exception Code Identifier (ID) Optional Code specifying the exception reason for consideration of out-of-network health care services HCP15 is the exception reason generated by a third party organization. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. 1 Non-Network Professional Provider in Network Hospital 2 Emergency Care 3 Services or Specialist not in Network 4 Out-of-Service Area 5 State Mandates 6 Other 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 172/665 2310A Referring Provider Name Loop Max 2 Optional Variants (all may be used) Rendering Provider Name Loop Service Facility Location Name Loop Supervising Provider Name Loop Ambulance Pick-up Location Loop Ambulance Drop-off Location Loop NM1 2500 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Referring Provider Name Loop > NM1 Referring Provider Name To supply the full name of an individual or organizational entity Usage notes Required when this claim involves a referral. If not required by this implementation guide, do not send. When reporting the provider who ordered services such as diagnostic and lab, use Loop ID-2310A at the claim level. For ordered services such as Durable Medical Equipment, use Loop ID-2420E at the line level. When there is only one referral on the claim, use code "DN - Referring Provider". When more than one referral exists and there is a requirement to report the additional referral, use code DN in the first iteration of this loop to indicate the referral received by the rendering provider on this claim. Use code "P3 - Primary Care Provider" in the second iteration of the loop to indicate the initial referral from the primary care provider or whatever provider wrote the initial referral for this patient's episode of care being billed/reported in this transaction. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Example NM1*DN*1*XXXX*XXX*XXXXXX**XXX*XX*XXX~ If either Identification Code Qualifier (NM1-08) or Referring Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual DN Referring Provider Use on the first iteration of this loop. Use if loop is used only once. P3 Primary Care Provider Use only if loop is used twice. Use only on second iteration of this loop. NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 173/665 NM102 qualifies NM103. 1 Person NM1-03 1035 Referring Provider Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Referring Provider First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Referring Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Referring Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Referring Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 174/665 2310A Referring Provider Name Loop end REF 2710 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Referring Provider Name Loop > REF Referring Provider Secondary Identification To specify identifying information Usage notes The REF segment in Loop ID-2310 applies to the entire claim unless overridden on the service line level by the presence of a REF segment with the same value in REF01. Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. Example REF*0B*XXXX~ Max use 3 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. REF-02 127 Referring Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 175/665 2310B Rendering Provider Name Loop Max 1 Optional Variants (all may | Home State Health 837 Health Care Claim_ Professional.pdf |
Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual DN Referring Provider Use on the first iteration of this loop. Use if loop is used only once. P3 Primary Care Provider Use only if loop is used twice. Use only on second iteration of this loop. NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 173/665 NM102 qualifies NM103. 1 Person NM1-03 1035 Referring Provider Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Referring Provider First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Referring Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Referring Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Referring Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 174/665 2310A Referring Provider Name Loop end REF 2710 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Referring Provider Name Loop > REF Referring Provider Secondary Identification To specify identifying information Usage notes The REF segment in Loop ID-2310 applies to the entire claim unless overridden on the service line level by the presence of a REF segment with the same value in REF01. Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. Example REF*0B*XXXX~ Max use 3 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. REF-02 127 Referring Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 175/665 2310B Rendering Provider Name Loop Max 1 Optional Variants (all may be used) Referring Provider Name Loop Service Facility Location Name Loop Supervising Provider Name Loop Ambulance Pick-up Location Loop Ambulance Drop-off Location Loop NM1 2500 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Rendering Provider Name Loop > NM1 Rendering Provider Name To supply the full name of an individual or organizational entity Usage notes Required when the Rendering Provider information is different than that carried in Loop ID-2010AA - Billing Provider. If not required by this implementation guide, do not send. Used for all types of rendering providers including laboratories. The Rendering Provider is the person or company (laboratory or other facility) who rendered the care. In the case where a substitute provider (locum tenens) was used, enter that provider's information here. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Example NM1*82*2*XXX*XXX*XXXXXX**X*XX*XX~ If either Identification Code Qualifier (NM1-08) or Rendering Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 82 Rendering Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Rendering Provider Last or Organization Name String (AN) Required Min 1 Max 60 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 176/665 Individual last name or organizational name NM1-04 1036 Rendering Provider First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Rendering Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Rendering Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Rendering Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 177/665 PRV 2550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Rendering Provider Name Loop > PRV Rendering Provider Specialty Information To specify the identifying characteristics of a provider Usage notes Required when adjudication is known to be impacted by the provider taxonomy code. If not required by this implementation guide, do not send. The PRV segment in Loop ID-2310 applies to the entire claim unless overridden on the service line level by the presence of a PRV segment with the same value in PRV01. Example PRV*PE*PXC*XXXX~ Max use 1 Optional PRV-01 1221 Provider Code Identifier (ID) Required Code identifying the type of provider PE Performing PRV-02 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification PXC Health Care Provider Taxonomy Code PRV-03 127 Provider Taxonomy Code Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 178/665 2310B Rendering Provider Name Loop end REF 2710 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Rendering Provider Name Loop > REF Rendering Provider Secondary Identification To specify identifying information Usage notes The REF segment in Loop ID-2310 applies to the entire claim unless overridden on the service line level by the presence of a REF segment with the same value in REF01. Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. Example REF*LU*X~ Max use 4 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Rendering Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 179/665 2310C Service Facility Location Name Loop Max 1 Optional Variants (all may be used) Referring Provider Name Loop Rendering Provider Name Loop Supervising Provider Name Loop Ambulance Pick-up Location Loop Ambulance Drop-off Location Loop NM1 2500 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Facility Location Name Loop > NM1 Service Facility Location Name To supply the full name of an individual or organizational entity Usage notes Required when the location of health care service is different than that carried in Loop ID-2010AA (Billing Provider). If not required by this implementation guide, do not send. When an organization health care provider's NPI is provided to identify the Service Location, the organization health care provider must be external to the entity identified as the Billing Provider (for example, reference lab). It is not permissible to report an organization health care provider NPI as the Service Location if the entity being identified is a component (for example, subpart) of the Billing Provider. In that case, the subpart must be the Billing Provider. The purpose of this loop is to identify specifically where the service was rendered. When reporting ambulance services, do not use this loop. Use Loop ID-2310E - Ambulance Pick-up Location and Loop ID-2310F - Ambulance Drop-off Location. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Example NM1*77*2*XXXXXX*****XX*XXXX~ If either Identification Code Qualifier (NM1-08) or Laboratory or Facility Primary Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 77 Service Location NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 180/665 NM1-03 1035 Laboratory or Facility Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Laboratory or Facility Primary Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 181/665 N3 2650 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Facility Location Name Loop > N3 Service Facility Location Address To specify the location of the named party Usage notes If service facility location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".) Example N3*XXX*XXX~ Max use 1 Required N3-01 166 Laboratory or Facility Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Laboratory or Facility Address Line Min 1 Max 55 String (AN) Optional Address information 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 182/665 N4 2700 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Facility Location Name Loop > N4 Service Facility Location City, State, ZIP Code To specify the geographic place of the named party Example N4*XXX*XX*XXXX*XX~ Only one of Laboratory or Facility State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Laboratory or Facility City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Laboratory or Facility State or Province Code Identifier (ID) Optional Min 2 Max 2 Code (Standard State/Province) as defined by | Home State Health 837 Health Care Claim_ Professional.pdf |
this loop is to identify specifically where the service was rendered. When reporting ambulance services, do not use this loop. Use Loop ID-2310E - Ambulance Pick-up Location and Loop ID-2310F - Ambulance Drop-off Location. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Example NM1*77*2*XXXXXX*****XX*XXXX~ If either Identification Code Qualifier (NM1-08) or Laboratory or Facility Primary Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 77 Service Location NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 180/665 NM1-03 1035 Laboratory or Facility Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Laboratory or Facility Primary Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 181/665 N3 2650 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Facility Location Name Loop > N3 Service Facility Location Address To specify the location of the named party Usage notes If service facility location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".) Example N3*XXX*XXX~ Max use 1 Required N3-01 166 Laboratory or Facility Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Laboratory or Facility Address Line Min 1 Max 55 String (AN) Optional Address information 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 182/665 N4 2700 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Facility Location Name Loop > N4 Service Facility Location City, State, ZIP Code To specify the geographic place of the named party Example N4*XXX*XX*XXXX*XX~ Only one of Laboratory or Facility State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Laboratory or Facility City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Laboratory or Facility State or Province Code Identifier (ID) Optional Min 2 Max 2 Code (Standard State/Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Laboratory or Facility Postal Zone or ZIP Code Identifier (ID) Optional Min 3 Max 15 Code defining international postal zone code excluding punctuation and blanks (zip code for United States) Usage notes When reporting the ZIP code for U.S. addresses, the full nine digit ZIP code must be provided. N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 183/665 Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 184/665 REF 2710 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Facility Location Name Loop > REF Service Facility Location Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. Example REF*LU*XXXX~ Max use 3 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Laboratory or Facility Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 185/665 PER 2750 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Facility Location Name Loop > PER Service Facility Contact Information To identify a person or office to whom administrative communications should be directed Usage notes Required for Property and Casualty claims when this information is different than the information provided in Loop ID-1000A Submitter EDI Contact Information PER Segment, and Loop ID-2010AA Billing Provider Contact Information PER segment and when deemed necessary by the submitter. If not required by this implementation guide, do not send. When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number must always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as "1", in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as "ext" or "x-". Example PER*IC*XXXX*TE*XXXXX*EX*XXX~ If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required Max use 1 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named IC Information Contact PER-02 93 Name Min 1 Max 60 String (AN) Optional Free-form name PER-03 365 Communication Number Qualifier Identifier (ID) Required Code identifying the type of communication number TE Telephone PER-04 364 Communication Number Min 1 Max 256 String (AN) Required Complete communications number including country or area code when applicable 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 186/665 2310C Service Facility Location Name Loop end PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EX Telephone Extension PER-06 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 187/665 2310D Supervising Provider Name Loop Max 1 Optional Variants (all may be used) Referring Provider Name Loop Rendering Provider Name Loop Service Facility Location Name Loop Ambulance Pick-up Location Loop Ambulance Drop-off Location Loop NM1 2500 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Supervising Provider Name Loop > NM1 Supervising Provider Name To supply the full name of an individual or organizational entity Usage notes Required when the rendering provider is supervised by a physician. If not required by this implementation guide, do not send. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Example NM1*DQ*1*XXXXXX*XX*XXX**XXX*XX*XXXXXX~ If either Identification Code Qualifier (NM1-08) or Supervising Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual DQ Supervising Physician NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Supervising Provider Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Supervising Provider First Name Min 1 Max 35 String (AN) Optional 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 188/665 Individual first name NM1-05 1037 Supervising Provider Middle Name or Initial String (AN) Optional Min 1 Max 25 Individual middle name or initial NM1-07 1039 Supervising Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Supervising Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 189/665 2310D Supervising Provider Name Loop end REF 2710 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Supervising Provider Name Loop > REF Supervising Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI implementation date when the entity is not a Health Care provider (a.k.a. an atypical provider), and an identifier is necessary for the claims processor to identify the entity. If not required by this implementation guide, do not send. Example REF*0B*XXXX~ Max use 4 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Supervising Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 190/665 2310E Ambulance Pick-up Location Loop Max 1 Optional Variants (all may be used) Referring Provider Name Loop Rendering Provider Name Loop Service Facility Location Name Loop Supervising Provider Name Loop Ambulance Drop-off Location Loop NM1 2500 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Ambulance Pick-up Location Loop > NM1 Ambulance Pick-up Location To supply the full name of an individual or organizational entity Usage notes Required when billing for ambulance or non-emergency transportation services. If not required by this implementation guide, do not send. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Example NM1*PW*2~ Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PW Pickup Address NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying | Home State Health 837 Health Care Claim_ Professional.pdf |
188/665 Individual first name NM1-05 1037 Supervising Provider Middle Name or Initial String (AN) Optional Min 1 Max 25 Individual middle name or initial NM1-07 1039 Supervising Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Supervising Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 189/665 2310D Supervising Provider Name Loop end REF 2710 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Supervising Provider Name Loop > REF Supervising Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI implementation date when the entity is not a Health Care provider (a.k.a. an atypical provider), and an identifier is necessary for the claims processor to identify the entity. If not required by this implementation guide, do not send. Example REF*0B*XXXX~ Max use 4 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Supervising Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 190/665 2310E Ambulance Pick-up Location Loop Max 1 Optional Variants (all may be used) Referring Provider Name Loop Rendering Provider Name Loop Service Facility Location Name Loop Supervising Provider Name Loop Ambulance Drop-off Location Loop NM1 2500 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Ambulance Pick-up Location Loop > NM1 Ambulance Pick-up Location To supply the full name of an individual or organizational entity Usage notes Required when billing for ambulance or non-emergency transportation services. If not required by this implementation guide, do not send. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Example NM1*PW*2~ Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PW Pickup Address NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 191/665 N3 2650 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Ambulance Pick-up Location Loop > N3 Ambulance Pick-up Location Address To specify the location of the named party Usage notes If the ambulance pickup location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".) Example N3*XXXXX*X~ Max use 1 Required N3-01 166 Ambulance Pick-up Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Ambulance Pick-up Address Line Min 1 Max 55 String (AN) Optional Address information 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 192/665 N4 2700 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Ambulance Pick-up Location Loop > N4 Ambulance Pick-up Location City, State, ZIP Code To specify the geographic place of the named party Example N4*XXXX*XX*XXXXXXX*XXX~ Only one of Ambulance Pick-up State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Ambulance Pick-up City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Ambulance Pick-up State or Province Code Identifier (ID) Optional Min 2 Max 2 Code (Standard State/Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Ambulance Pick-up Postal Zone or ZIP Code Identifier (ID) Optional Min 3 Max 15 Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 193/665 2310E Ambulance Pick-up Location Loop end Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 194/665 2310F Ambulance Drop-off Location Loop Max 1 Optional Variants (all may be used) Referring Provider Name Loop Rendering Provider Name Loop Service Facility Location Name Loop Supervising Provider Name Loop Ambulance Pick-up Location Loop NM1 2500 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Ambulance Drop-off Location Loop > NM1 Ambulance Drop-off Location To supply the full name of an individual or organizational entity Usage notes Required when billing for ambulance or non-emergency transportation services. If not required by this implementation guide, do not send. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Example NM1*45*2*X~ Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 45 Drop-off Location NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Ambulance Drop-off Location Min 1 Max 60 String (AN) Optional Individual last name or organizational name 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 195/665 N3 2650 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Ambulance Drop-off Location Loop > N3 Ambulance Drop-off Location Address To specify the location of the named party Example N3*XXXXXX*XX~ Max use 1 Required N3-01 166 Ambulance Drop-off Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Ambulance Drop-off Address Line Min 1 Max 55 String (AN) Optional Address information 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 196/665 N4 2700 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Ambulance Drop-off Location Loop > N4 Ambulance Drop-off Location City, State, ZIP Code To specify the geographic place of the named party Example N4*XXX*XX*XXXX*XX~ Only one of Ambulance Drop-off State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Ambulance Drop-off City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Ambulance Drop-off State or Province Code Identifier (ID) Optional Min 2 Max 2 Code (Standard State/Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Ambulance Drop-off Postal Zone or ZIP Code Identifier (ID) Optional Min 3 Max 15 Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 197/665 2310F Ambulance Drop-off Location Loop end Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 198/665 2320 Other Subscriber Information Loop Max 10 Optional SBR 2900 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > SBR Other Subscriber Information To record information specific to the primary insured and the insurance carrier for that insured Usage notes Required when other payers are known to potentially be involved in paying on this claim. If not required by this implementation guide, do not send. All information contained in Loop ID-2320 applies only to the payer identified in Loop ID-2330B of this iteration of Loop ID-2320. It is specific only to that payer. If information for an additional payer is necessary, repeat Loop ID-2320 with its respective 2330 Loops.; See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example SBR*B*19*XXXX*XXXXX*14****TV~ Max use 1 Required SBR-01 1138 Payer Responsibility Sequence Number Code Identifier (ID) Required Code identifying the insurance carrier's level of responsibility for a payment of a claim Usage notes Within a given claim, the various values for the Payer Responsibility Sequence Number Code (other than value "U") may occur no more than once. A Payer Responsibility Four B Payer Responsibility Five C Payer Responsibility Six D Payer Responsibility Seven E Payer Responsibility Eight F Payer Responsibility Nine G Payer Responsibility Ten H Payer Responsibility Eleven P Primary S Secondary T Tertiary U Unknown This code may only be used in payer to payer COB claims when the original payer determined the presence of this coverage from eligibility files received from this payer or when the original claim did not provide the responsibility sequence for this payer. SBR-02 1069 Individual Relationship Code Identifier (ID) Required Code indicating the relationship between two individuals or entities SBR02 specifies the relationship to the person insured. 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 199/665 01 Spouse 18 Self 19 Child 20 Employee 21 Unknown 39 Organ Donor 40 Cadaver Donor 53 Life Partner G8 Other Relationship SBR-03 127 Insured Group or Policy Number Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier SBR03 is policy or group number. Usage notes This is not the number uniquely identifying the subscriber. The unique subscriber number is submitted in Loop 2330A-NM109 for this iteration of Loop ID-2320. SBR-04 93 Other Insured Group Name Min 1 Max 60 String (AN) Optional Free-form name SBR04 is plan name. SBR-05 1336 Insurance Type Code Identifier (ID) Optional Code identifying the type of insurance policy within a specific insurance program 12 Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan 13 Medicare Secondary End-Stage Renal Disease Beneficiary in the Mandated Coordination Period with an Employer's Group Health Plan 14 Medicare Secondary, No-fault Insurance including Auto is Primary 15 Medicare Secondary Worker's Compensation 16 Medicare Secondary Public Health Service (PHS)or Other Federal Agency 41 Medicare Secondary Black Lung 42 Medicare Secondary Veteran's Administration 43 Medicare | Home State Health 837 Health Care Claim_ Professional.pdf |
https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 198/665 2320 Other Subscriber Information Loop Max 10 Optional SBR 2900 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > SBR Other Subscriber Information To record information specific to the primary insured and the insurance carrier for that insured Usage notes Required when other payers are known to potentially be involved in paying on this claim. If not required by this implementation guide, do not send. All information contained in Loop ID-2320 applies only to the payer identified in Loop ID-2330B of this iteration of Loop ID-2320. It is specific only to that payer. If information for an additional payer is necessary, repeat Loop ID-2320 with its respective 2330 Loops.; See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example SBR*B*19*XXXX*XXXXX*14****TV~ Max use 1 Required SBR-01 1138 Payer Responsibility Sequence Number Code Identifier (ID) Required Code identifying the insurance carrier's level of responsibility for a payment of a claim Usage notes Within a given claim, the various values for the Payer Responsibility Sequence Number Code (other than value "U") may occur no more than once. A Payer Responsibility Four B Payer Responsibility Five C Payer Responsibility Six D Payer Responsibility Seven E Payer Responsibility Eight F Payer Responsibility Nine G Payer Responsibility Ten H Payer Responsibility Eleven P Primary S Secondary T Tertiary U Unknown This code may only be used in payer to payer COB claims when the original payer determined the presence of this coverage from eligibility files received from this payer or when the original claim did not provide the responsibility sequence for this payer. SBR-02 1069 Individual Relationship Code Identifier (ID) Required Code indicating the relationship between two individuals or entities SBR02 specifies the relationship to the person insured. 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 199/665 01 Spouse 18 Self 19 Child 20 Employee 21 Unknown 39 Organ Donor 40 Cadaver Donor 53 Life Partner G8 Other Relationship SBR-03 127 Insured Group or Policy Number Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier SBR03 is policy or group number. Usage notes This is not the number uniquely identifying the subscriber. The unique subscriber number is submitted in Loop 2330A-NM109 for this iteration of Loop ID-2320. SBR-04 93 Other Insured Group Name Min 1 Max 60 String (AN) Optional Free-form name SBR04 is plan name. SBR-05 1336 Insurance Type Code Identifier (ID) Optional Code identifying the type of insurance policy within a specific insurance program 12 Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan 13 Medicare Secondary End-Stage Renal Disease Beneficiary in the Mandated Coordination Period with an Employer's Group Health Plan 14 Medicare Secondary, No-fault Insurance including Auto is Primary 15 Medicare Secondary Worker's Compensation 16 Medicare Secondary Public Health Service (PHS)or Other Federal Agency 41 Medicare Secondary Black Lung 42 Medicare Secondary Veteran's Administration 43 Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP) 47 Medicare Secondary, Other Liability Insurance is Primary SBR-09 1032 Claim Filing Indicator Code Identifier (ID) Required Code identifying type of claim 11 Other Non-Federal Programs 12 Preferred Provider Organization (PPO) 13 Point of Service (POS) 14 Exclusive Provider Organization (EPO) 15 Indemnity Insurance 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 200/665 16 Health Maintenance Organization (HMO) Medicare Risk 17 Dental Maintenance Organization AM Automobile Medical BL Blue Cross/Blue Shield CH Champus CI Commercial Insurance Co. DS Disability FI Federal Employees Program HM Health Maintenance Organization LM Liability Medical MA Medicare Part A MB Medicare Part B MC Medicaid OF Other Federal Program Use code OF when submitting Medicare Part D claims. TV Title V VA Veterans Affairs Plan WC Workers' Compensation Health Claim ZZ Mutually Defined Use Code ZZ when Type of Insurance is not known. 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 201/665 CAS 2950 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > CAS Claim Level Adjustments To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid Usage notes Required when the claim has been adjudicated by the payer identified in this loop, and the claim has claim level adjustment information. If not required by this implementation guide, do not send. Submitters must use this CAS segment to report prior payers' claim level adjustments that cause the amount paid to differ from the amount originally charged. Only one Group Code is allowed per CAS. If it is necessary to send more than one Group Code at the claim level, repeat the CAS segment. Codes and associated amounts must come from either paper remittance advice or 835s (Electronic Remittance Advice) received on the claim. When the information originates from a paper remittance advice that does not use the standard Claim Adjustment Reason Codes, the paper values must be converted to standard Claim Adjustment Reason Codes.; A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a particular Claim Adjustment Group Code (CAS01). The first non-zero adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19). Example CAS*OA*XXXX*0000*0000000*XXX*00000000000000*00000 0000000000*XXXXX*0000000000*00000000000*XXXX*0000 00000000*00000*XXXX*00*0000*XXXX*0000000*00000000 000000~ If Adjustment Reason Code (CAS-05) is present, then at least one of Adjustment Amount (CAS-06) or Adjustment Quantity (CAS-07) is required If Adjustment Amount (CAS-06) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Quantity (CAS-07) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Reason Code (CAS-08) is present, then at least one of Adjustment Amount (CAS-09) or Adjustment Quantity (CAS-10) is required If Adjustment Amount (CAS-09) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Quantity (CAS-10) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Reason Code (CAS-11) is present, then at least one of Adjustment Amount (CAS-12) or Adjustment Quantity (CAS-13) is required If Adjustment Amount (CAS-12) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Quantity (CAS-13) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS-16) is required Max use 5 Optional 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 202/665 If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS-19) is required If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required CAS-01 1033 Claim Adjustment Group Code Identifier (ID) Required Code identifying the general category of payment adjustment CO Contractual Obligations CR Correction and Reversals OA Other adjustments PI Payor Initiated Reductions PR Patient Responsibility CAS-02 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Required Code identifying the detailed reason the adjustment was made Usage notes See CODE SOURCE 139: Claim Adjustment Reason Code CAS-03 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CAS03 is the amount of adjustment. CAS-04 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS04 is the units of service being adjusted. CAS-05 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-06 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 203/665 CAS06 is the amount of the adjustment. CAS-07 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS07 is the units of service being adjusted. CAS-08 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-09 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS09 is the amount of the adjustment. CAS-10 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS10 is the units of service being adjusted. CAS-11 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-12 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS12 is the amount of the adjustment. CAS-13 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS13 is the units of service being adjusted. CAS-14 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 204/665 CAS-15 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS15 is the amount of the adjustment. CAS-16 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS16 is the units of service being adjusted. CAS-17 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-18 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS18 is the amount of the adjustment. CAS-19 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS19 is the units of service being adjusted. 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 205/665 AMT 3000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > AMT Coordination of Benefits (COB) Payer Paid Amount To indicate the total monetary amount Usage notes Required when the claim has been adjudicated by the payer identified in Loop ID- 2330B of this loop. OR Required when Loop ID-2010AC is present. In this case, the claim is a post payment recovery claim submitted by a subrogated Medicaid agency. If not required by this implementation guide, do not send.; Example AMT*D*00000000~ Variants (all may be used) AMT Coordination of Benefits (COB) Total Non-Covered Amount AMT Remaining Patient Liability Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount D Payor Amount Paid AMT-02 782 Payer Paid Amount Min 1 Max 15 Decimal number (R) Required Monetary amount Usage notes It is acceptable to show "0" as the amount paid. When Loop ID-2010AC is present, this is the amount the Medicaid agency actually paid. 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 206/665 AMT 3000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > AMT Coordination of Benefits (COB) Total Non-Covered Amount To indicate the total monetary amount Usage notes Required when the destination payer's cost avoidance policy allows providers to bypass claim submission to the otherwise prior payer identified in Loop ID-2330B. If not required by this implementation guide, do not send. When this segment is used, the amount reported in AMT02 must equal the total claim charge amount reported in CLM02. Neither the prior payer paid AMT, nor any CAS segments are used as this claim has not been adjudicated by this payer. Example AMT*A8*0~ Variants (all may be used) AMT Coordination of Benefits (COB) Payer Paid Amount AMT Remaining Patient Liability Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code | Home State Health 837 Health Care Claim_ Professional.pdf |
is the units of service being adjusted. CAS-14 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 204/665 CAS-15 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS15 is the amount of the adjustment. CAS-16 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS16 is the units of service being adjusted. CAS-17 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-18 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS18 is the amount of the adjustment. CAS-19 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS19 is the units of service being adjusted. 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 205/665 AMT 3000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > AMT Coordination of Benefits (COB) Payer Paid Amount To indicate the total monetary amount Usage notes Required when the claim has been adjudicated by the payer identified in Loop ID- 2330B of this loop. OR Required when Loop ID-2010AC is present. In this case, the claim is a post payment recovery claim submitted by a subrogated Medicaid agency. If not required by this implementation guide, do not send.; Example AMT*D*00000000~ Variants (all may be used) AMT Coordination of Benefits (COB) Total Non-Covered Amount AMT Remaining Patient Liability Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount D Payor Amount Paid AMT-02 782 Payer Paid Amount Min 1 Max 15 Decimal number (R) Required Monetary amount Usage notes It is acceptable to show "0" as the amount paid. When Loop ID-2010AC is present, this is the amount the Medicaid agency actually paid. 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 206/665 AMT 3000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > AMT Coordination of Benefits (COB) Total Non-Covered Amount To indicate the total monetary amount Usage notes Required when the destination payer's cost avoidance policy allows providers to bypass claim submission to the otherwise prior payer identified in Loop ID-2330B. If not required by this implementation guide, do not send. When this segment is used, the amount reported in AMT02 must equal the total claim charge amount reported in CLM02. Neither the prior payer paid AMT, nor any CAS segments are used as this claim has not been adjudicated by this payer. Example AMT*A8*0~ Variants (all may be used) AMT Coordination of Benefits (COB) Payer Paid Amount AMT Remaining Patient Liability Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount A8 Noncovered Charges - Actual AMT-02 782 Non-Covered Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 207/665 AMT 3000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > AMT Remaining Patient Liability To indicate the total monetary amount Usage notes Required when the Other Payer identified in Loop ID-2330B (of this iteration of Loop ID-2320) has adjudicated this claim and provided claim level information only. OR Required when the Other Payer identified in Loop ID-2330B (of this iteration of Loop ID-2320) has adjudicated this claim and the provider received a paper remittance advice and the provider does not have the ability to report line item information. If not required by this implementation guide, do not send. In the judgment of the provider, this is the remaining amount to be paid after adjudication by the Other Payer identified in Loop ID-2330B of this iteration of Loop ID-2320. This segment is only used in provider submitted claims. It is not used in Payer-to-Payer Coordination of Benefits (COB). This segment is not used if the line level (Loop ID-2430) Remaining Patient Liability AMT segment is used for this Other Payer. Example AMT*EAF*00000~ Variants (all may be used) AMT Coordination of Benefits (COB) Payer Paid Amount AMT Coordination of Benefits (COB) Total Non-Covered Amount Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount EAF Amount Owed AMT-02 782 Remaining Patient Liability Min 1 Max 15 Decimal number (R) Required Monetary amount 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 208/665 OI 3100 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > OI Other Insurance Coverage Information To specify information associated with other health insurance coverage Usage notes All information contained in the OI segment applies only to the payer identified in Loop ID-2330B in this iteration of Loop ID-2320. Example OI***W*P**I~ Max use 1 Required OI-03 1073 Benefits Assignment Certification Indicator Identifier (ID) Required Code indicating a Yes or No condition or response OI03 is the assignment of benefits indicator. A "Y" value indicates insured or authorized person authorizes benefits to be assigned to the provider; an "N" value indicates benefits have not been assigned to the provider. Usage notes This is a crosswalk from CLM08 when doing COB. This element answers the question whether or not the insured has authorized the plan to remit payment directly to the provider. N No W Not Applicable Use code `W' when the patient refuses to assign benefits. Y Yes OI-04 1351 Patient Signature Source Code Identifier (ID) Optional Code indicating how the patient or subscriber authorization signatures were obtained and how they are being retained by the provider Usage notes This is a crosswalk from CLM10 when doing COB. P Signature generated by provider because the patient was not physically present for services Signature generated by an entity other than the patient according to State or Federal law. OI-06 1363 Release of Information Code Identifier (ID) Required Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations Usage notes This is a crosswalk from CLM09 when doing COB. The Release of Information response is limited to the information carried in this claim. I Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 209/665 Required when the provider has not collected a signature AND state or federal laws do not require a signature be collected. Y Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim Required when the provider has collected a signature. OR Required when state or federal laws require a signature be collected. 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 210/665 MOA 3200 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > MOA Outpatient Adjudication Information To convey claim-level data related to the adjudication of Medicare claims not related to an inpatient setting Usage notes Required when outpatient adjudication information is reported in the remittance advice OR Required when it is necessary to report remark codes. If not required by this implementation guide, do not send. Example MOA*0000000000*00000000000000*XXX*XXXX*XXXXX*XXX X*X*0000000000*0000000000000~ Max use 1 Optional MOA-01 954 Reimbursement Rate Min 1 Max 10 Decimal number (R) Optional Percentage expressed as a decimal (e.g., 0.0 through 1.0 represents 0% through 100%) MOA01 is the reimbursement rate. MOA-02 782 HCPCS Payable Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MOA02 is the claim Health Care Financing Administration Common Procedural Coding System (HCPCS) payable amount. MOA-03 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA03 is the Claim Payment Remark Code. See Code Source 411. MOA-04 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA04 is the Claim Payment Remark Code. See Code Source 411. MOA-05 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 211/665 MOA05 is the Claim Payment Remark Code. See Code Source 411. MOA-06 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA06 is the Claim Payment Remark Code. See Code Source 411. MOA-07 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA07 is the Claim Payment Remark Code. See Code Source 411. MOA-08 782 End Stage Renal Disease Payment Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MOA08 is the End Stage Renal Disease (ESRD) payment amount. MOA-09 782 Non-Payable Professional Component Billed Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MOA09 is the professional component amount billed but not payable. 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 212/665 2330A Other Subscriber Name Loop Max 1 Required Variants (all may be used) Other Payer Name Loop Other Payer Referring Provider Loop Other Payer Rendering Provider Loop Other Payer Service Facility Location Loop Other Payer Supervising Provider Loop Other Payer Billing Provider Loop NM1 3250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Subscriber Name Loop > NM1 Other Subscriber Name To supply the full name of an individual or organizational entity Usage notes If the patient can be uniquely identified to the Other Payer indicated in this iteration of Loop ID-2320 by a unique Member Identification Number, then the patient is the subscriber or is considered to be the subscriber and is identified in this Other Subscriber's Name Loop ID-2330A.; If the patient is a dependent of the subscriber for this other coverage and cannot be uniquely identified to the Other Payer indicated in this iteration of Loop ID-2320 by a unique Member Identification Number, then the subscriber for this other coverage is identified in this Other Subscriber's Name Loop ID-2330A. See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example NM1*IL*1*XX*XXXX*XX**XXXX*II*XXXX~ Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual IL Insured or Subscriber NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Other Insured Last Name Min 1 Max 60 String (AN) Required 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 213/665 Individual last name or organizational name NM1-04 1036 Other Insured First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Other Insured Middle Name Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Other Insured Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system/method of code structure used for Identification Code (67) II Standard Unique Health Identifier for each Individual in the United States Required if the HIPAA Individual Patient Identifier is mandated use. If not required, use value `MI' instead. | Home State Health 837 Health Care Claim_ Professional.pdf |
Payment Remark Code. See Code Source 411. MOA-07 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA07 is the Claim Payment Remark Code. See Code Source 411. MOA-08 782 End Stage Renal Disease Payment Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MOA08 is the End Stage Renal Disease (ESRD) payment amount. MOA-09 782 Non-Payable Professional Component Billed Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MOA09 is the professional component amount billed but not payable. 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 212/665 2330A Other Subscriber Name Loop Max 1 Required Variants (all may be used) Other Payer Name Loop Other Payer Referring Provider Loop Other Payer Rendering Provider Loop Other Payer Service Facility Location Loop Other Payer Supervising Provider Loop Other Payer Billing Provider Loop NM1 3250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Subscriber Name Loop > NM1 Other Subscriber Name To supply the full name of an individual or organizational entity Usage notes If the patient can be uniquely identified to the Other Payer indicated in this iteration of Loop ID-2320 by a unique Member Identification Number, then the patient is the subscriber or is considered to be the subscriber and is identified in this Other Subscriber's Name Loop ID-2330A.; If the patient is a dependent of the subscriber for this other coverage and cannot be uniquely identified to the Other Payer indicated in this iteration of Loop ID-2320 by a unique Member Identification Number, then the subscriber for this other coverage is identified in this Other Subscriber's Name Loop ID-2330A. See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example NM1*IL*1*XX*XXXX*XX**XXXX*II*XXXX~ Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual IL Insured or Subscriber NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Other Insured Last Name Min 1 Max 60 String (AN) Required 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 213/665 Individual last name or organizational name NM1-04 1036 Other Insured First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Other Insured Middle Name Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Other Insured Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system/method of code structure used for Identification Code (67) II Standard Unique Health Identifier for each Individual in the United States Required if the HIPAA Individual Patient Identifier is mandated use. If not required, use value `MI' instead. MI Member Identification Number The code MI is intended to be the subscriber's identification number as assigned by the payer. (For example, Insured's ID, Subscriber's ID, Health Insurance Claim Number (HIC), etc.) MI is also intended to be used in claims submitted to the Indian Health Service/Contract Health Services (IHS/CHS) Fiscal Intermediary for the purpose of reporting the Tribe Residency Code (Tribe County State). In the event that a Social Security Number (SSN) is also available on an IHS/CHS claim, put the SSN in REF02. When sending the Social Security Number as the Member ID, it must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid. NM1-09 67 Other Insured Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 214/665 N3 3320 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Subscriber Name Loop > N3 Other Subscriber Address To specify the location of the named party Usage notes Required when the information is available. If not required by this implementation guide, do not send. Example N3*XXXXXX*XXX~ Max use 1 Optional N3-01 166 Other Subscriber Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Other Insured Address Line Min 1 Max 55 String (AN) Optional Address information 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 215/665 N4 3400 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Subscriber Name Loop > N4 Other Subscriber City, State, ZIP Code To specify the geographic place of the named party Usage notes Required when the information is available. If not required by this implementation guide, do not send. Example N4*XXX*XX*XXXXXXXX*XX~ Only one of Other Subscriber State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Optional N4-01 19 Other Subscriber City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Other Subscriber State or Province Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State/Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Other Subscriber Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 216/665 Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 217/665 2330A Other Subscriber Name Loop end REF 3550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Subscriber Name Loop > REF Other Subscriber Secondary Identification To specify identifying information Usage notes Required when an additional identification number to that provided in NM109 of this loop is necessary for the claim processor to identify the entity. If not required by this implementation guide, do not send. Example REF*SY*XXXXXX~ Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification SY Social Security Number The Social Security Number must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid. REF-02 127 Other Insured Additional Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 218/665 2330B Other Payer Name Loop Max 1 Required Variants (all may be used) Other Subscriber Name Loop Other Payer Referring Provider Loop Other Payer Rendering Provider Loop Other Payer Service Facility Location Loop Other Payer Supervising Provider Loop Other Payer Billing Provider Loop NM1 3250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > NM1 Other Payer Name To supply the full name of an individual or organizational entity Usage notes See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example NM1*PR*2*X*****PI*XXXXX~ Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PR Payer NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Other Payer Organization Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system/method of code structure used for Identification Code (67) Usage notes Use code value "PI" when reporting Payor Identification. Use code value "XV" when reporting Health Plan ID (HPID) or Other Entity Identifier 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 219/665 (OEID). Prior to the mandated implementation date for Health Plan Identifier, willing trading partners may agree to: Follow a dual use approach in which both the HPID or OEID and the Payor Identification are sent. Send XV qualifier in NM108 with HPID or OEID in NM109 and the Payor Identification, that would have been sent using qualifier PI, in the corresponding REF segment using qualifier 2U (Payer Identification Number). OR Follow an early implementation approach in which the HPID or OEID is sent in NM109. PI Payor Identification XV Centers for Medicare and Medicaid Services PlanID NM1-09 67 Other Payer Primary Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code Usage notes When sending Line Adjudication Information for this payer, the identifier sent in SVD01 (Payer Identifier) of Loop ID-2430 (Line Adjudication Information) must match this value.; 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 220/665 N3 3320 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > N3 Other Payer Address To specify the location of the named party Usage notes Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send. Example N3*XXXXX*XXXX~ Max use 1 Optional N3-01 166 Other Payer Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Other Payer Address Line Min 1 Max 55 String (AN) Optional Address information 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 221/665 N4 3400 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > N4 Other Payer City, State, ZIP Code To specify the geographic place of the named party Usage notes Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send. Example N4*XX*XX*XXX*XXX~ Only one of Other Payer State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Optional N4-01 19 Other Payer City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Other Payer State or Province Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State/Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Other Payer Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision | Home State Health 837 Health Care Claim_ Professional.pdf |
OEID in NM109 and the Payor Identification, that would have been sent using qualifier PI, in the corresponding REF segment using qualifier 2U (Payer Identification Number). OR Follow an early implementation approach in which the HPID or OEID is sent in NM109. PI Payor Identification XV Centers for Medicare and Medicaid Services PlanID NM1-09 67 Other Payer Primary Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code Usage notes When sending Line Adjudication Information for this payer, the identifier sent in SVD01 (Payer Identifier) of Loop ID-2430 (Line Adjudication Information) must match this value.; 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 220/665 N3 3320 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > N3 Other Payer Address To specify the location of the named party Usage notes Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send. Example N3*XXXXX*XXXX~ Max use 1 Optional N3-01 166 Other Payer Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Other Payer Address Line Min 1 Max 55 String (AN) Optional Address information 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 221/665 N4 3400 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > N4 Other Payer City, State, ZIP Code To specify the geographic place of the named party Usage notes Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send. Example N4*XX*XX*XXX*XXX~ Only one of Other Payer State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Optional N4-01 19 Other Payer City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Other Payer State or Province Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State/Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Other Payer Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 222/665 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 223/665 DTP 3450 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > DTP Claim Check or Remittance Date To specify any or all of a date, a time, or a time period Usage notes Required when the payer identified in this loop has previously adjudicated the claim and Loop ID-2430, Line Check or Remittance Date, is not used. If not required by this implementation guide, do not send.; Example DTP*573*D8*XXXXXX~ Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 573 Date Claim Paid DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Adjudication or Payment Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 224/665 REF 3550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > REF Other Payer Claim Adjustment Indicator To specify identifying information Usage notes Required when the claim is being sent in the payer-to-payer COB model, AND the destination payer is secondary to the payer identified in this Loop ID-2330B, AND the payer identified in this Loop ID-2330B has re-adjudicated the claim. If not required by this implementation guide, do not send. Example REF*T4*XX~ Variants (all may be used) REF Other Payer Claim Control Number REF Other Payer Prior Authorization Number REF Other Payer Referral Number REF Other Payer Secondary Identifier Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification T4 Signal Code REF-02 127 Other Payer Claim Adjustment Indicator Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The only valid value for this element is `Y'. 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 225/665 REF 3550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > REF Other Payer Claim Control Number To specify identifying information Usage notes Required when it is necessary to identify the Other Payer's Claim Control Number in a payer-to-payer COB situation. OR Required when the Other Payer's Claim Control Number is available. If not required by this implementation guide, do not send. Example REF*F8*XXXXXX~ Variants (all may be used) REF Other Payer Claim Adjustment Indicator REF Other Payer Prior Authorization Number REF Other Payer Referral Number REF Other Payer Secondary Identifier Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification F8 Original Reference Number REF-02 127 Other Payer's Claim Control Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 226/665 REF 3550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > REF Other Payer Prior Authorization Number To specify identifying information Usage notes Required when the payer identified in this loop has assigned a prior authorization number to this claim. If not required by this implementation guide, do not send. Example REF*G1*XX~ Variants (all may be used) REF Other Payer Claim Adjustment Indicator REF Other Payer Claim Control Number REF Other Payer Referral Number REF Other Payer Secondary Identifier Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification G1 Prior Authorization Number REF-02 127 Other Payer Prior Authorization Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 227/665 REF 3550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > REF Other Payer Referral Number To specify identifying information Usage notes Required when the payer identified in this loop has assigned a referral number to this claim. If not required by this implementation guide, do not send. Example REF*9F*X~ Variants (all may be used) REF Other Payer Claim Adjustment Indicator REF Other Payer Claim Control Number REF Other Payer Prior Authorization Number REF Other Payer Secondary Identifier Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9F Referral Number REF-02 127 Other Payer Prior Authorization or Referral Number String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 228/665 2330B Other Payer Name Loop end REF 3550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > REF Other Payer Secondary Identifier To specify identifying information Usage notes Required when an additional identification number to that provided in the NM109 of this loop is necessary to identify the entity. If not required by this implementation guide, do not send. Example REF*FY*XX~ Variants (all may be used) REF Other Payer Claim Adjustment Indicator REF Other Payer Claim Control Number REF Other Payer Prior Authorization Number REF Other Payer Referral Number Max use 2 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number This code is only allowed when the qualifier XV is reported in NM108 of this loop. EI Employer's Identification Number The Employer's Identification Number must be a string of exactly nine numbers with no separators. For example, "001122333" would be valid, while sending "001-12-2333" or "00-1122333" would be invalid. FY Claim Office Number NF National Association of Insurance Commissioners (NAIC) Code REF-02 127 Other Payer Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 229/665 2330C Other Payer Referring Provider Loop Max 2 Optional Variants (all may be used) Other Subscriber Name Loop Other Payer Name Loop Other Payer Rendering Provider Loop Other Payer Service Facility Location Loop Other Payer Supervising Provider Loop Other Payer Billing Provider Loop NM1 3250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Referring Provider Loop > NM1 Other Payer Referring Provider To supply the full name of an individual or organizational entity Usage notes See Crosswalking COB Data Elements section for more information on handling COB in the 837. Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. If not required by this implementation guide, do not send. Example NM1*P3*1~ Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual DN Referring Provider Use on the first iteration of this loop. Use if loop is used only once. P3 Primary Care Provider Use only if loop is used twice. Use only on second iteration of this loop. NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 230/665 1 Person 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - | Home State Health 837 Health Care Claim_ Professional.pdf |
an additional identification number to that provided in the NM109 of this loop is necessary to identify the entity. If not required by this implementation guide, do not send. Example REF*FY*XX~ Variants (all may be used) REF Other Payer Claim Adjustment Indicator REF Other Payer Claim Control Number REF Other Payer Prior Authorization Number REF Other Payer Referral Number Max use 2 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number This code is only allowed when the qualifier XV is reported in NM108 of this loop. EI Employer's Identification Number The Employer's Identification Number must be a string of exactly nine numbers with no separators. For example, "001122333" would be valid, while sending "001-12-2333" or "00-1122333" would be invalid. FY Claim Office Number NF National Association of Insurance Commissioners (NAIC) Code REF-02 127 Other Payer Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 229/665 2330C Other Payer Referring Provider Loop Max 2 Optional Variants (all may be used) Other Subscriber Name Loop Other Payer Name Loop Other Payer Rendering Provider Loop Other Payer Service Facility Location Loop Other Payer Supervising Provider Loop Other Payer Billing Provider Loop NM1 3250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Referring Provider Loop > NM1 Other Payer Referring Provider To supply the full name of an individual or organizational entity Usage notes See Crosswalking COB Data Elements section for more information on handling COB in the 837. Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. If not required by this implementation guide, do not send. Example NM1*P3*1~ Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual DN Referring Provider Use on the first iteration of this loop. Use if loop is used only once. P3 Primary Care Provider Use only if loop is used twice. Use only on second iteration of this loop. NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 230/665 1 Person 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 231/665 2330C Other Payer Referring Provider Loop end REF 3550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Referring Provider Loop > REF Other Payer Referring Provider Secondary Identification To specify identifying information Usage notes Non-destination (COB) payer's provider identification number(s). See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example REF*0B*X~ Max use 3 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan. REF-02 127 Other Payer Referring Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 232/665 2330D Other Payer Rendering Provider Loop Max 1 Optional Variants (all may be used) Other Subscriber Name Loop Other Payer Name Loop Other Payer Referring Provider Loop Other Payer Service Facility Location Loop Other Payer Supervising Provider Loop Other Payer Billing Provider Loop NM1 3250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Rendering Provider Loop > NM1 Other Payer Rendering Provider To supply the full name of an individual or organizational entity Usage notes See Crosswalking COB Data Elements section for more information on handling COB in the 837. Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. If not required by this implementation guide, do not send. Example NM1*82*1~ Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 82 Rendering Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 233/665 2330D Other Payer Rendering Provider Loop end REF 3550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Rendering Provider Loop > REF Other Payer Rendering Provider Secondary Identification To specify identifying information Usage notes Required when an additional identification number to that provided in NM109 of this loop is necessary for the claim processor to identify the entity. If not required by this implementation guide, do not send. See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example REF*LU*XXXX~ Max use 3 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan. LU Location Number REF-02 127 Other Payer Rendering Provider Secondary Identifier String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 234/665 2330E Other Payer Service Facility Location Loop Max 1 Optional Variants (all may be used) Other Subscriber Name Loop Other Payer Name Loop Other Payer Referring Provider Loop Other Payer Rendering Provider Loop Other Payer Supervising Provider Loop Other Payer Billing Provider Loop NM1 3250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Service Facility Location Loop > NM1 Other Payer Service Facility Location To supply the full name of an individual or organizational entity Usage notes See Crosswalking COB Data Elements section for more information on handling COB in the 837. Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. If not required by this implementation guide, do not send. Example NM1*77*2~ Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 77 Service Location NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 235/665 2330E Other Payer Service Facility Location Loop end REF 3550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Service Facility Location Loop > REF Other Payer Service Facility Location Secondary Identification To specify identifying information Example REF*LU*XXX~ Max use 3 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number G2 Provider Commercial Number This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan. LU Location Number REF-02 127 Other Payer Service Facility Location Secondary Identifier String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 236/665 2330F Other Payer Supervising Provider Loop Max 1 Optional Variants (all may be used) Other Subscriber Name Loop Other Payer Name Loop Other Payer Referring Provider Loop Other Payer Rendering Provider Loop Other Payer Service Facility Location Loop Other Payer Billing Provider Loop NM1 3250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Supervising Provider Loop > NM1 Other Payer Supervising Provider To supply the full name of an individual or organizational entity Usage notes See Crosswalking COB Data Elements section for more information on handling COB in the 837. Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. OR Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider. If not required by this implementation guide, do not send. Example NM1*DQ*1~ Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual DQ Supervising Physician NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 1/30/25, 11:52 AM Home State Health 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/home-state-health/health-care-claim-professional-x222a2/01H25M3DFZT8BN5QV8WP430GEQ 237/665 2330F Other Payer Supervising Provider Loop end REF 3550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Supervising Provider Loop > REF Other Payer Supervising Provider Secondary Identification To specify identifying information Example REF*0B*X~ Max use 3 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code | Home State Health 837 Health Care Claim_ Professional.pdf |
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