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edi-pretrain

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train · 850 rows

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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. Required when this service line involves a referral and the referring provider differs from that reported at the claim level (loop 2310A). If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Example NM1P31XXXXXXXXXXXXXXXXXXX~ 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 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 333/665 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 334/665 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 REFG2XXXX2U>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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 335/665 2420F 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 336/665 2420G Ambulance Pick-up Location Loop Max 1 Optional Variants (all may be used) Rendering Provider Name Loop Purchased Service Provider Name Loop Service Facility Location Name Loop Supervising Provider Name Loop Ordering Provider Name Loop Referring Provider Name Loop Ambulance Drop-off Location Loop NM1 5000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number 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 the ambulance pick-up location for this service line is different than the ambulance pick-up location provided in Loop ID-2310E. If not required by this implementation guide, do not send.; Example NM1PW2~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 337/665 N3 5140 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number 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 N3XXXXXXXXX~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 338/665 N4 5200 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number 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 N4XXXXXXXXXXXXXXX~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 339/665 2420G Ambulance Pick-up Location Loop end Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 340/665 2420H Ambulance Drop-off Location Loop Max 1 Optional Variants (all may be used) Rendering Provider Name Loop Purchased Service Provider Name Loop Service Facility Location Name Loop Supervising Provider Name Loop Ordering Provider Name Loop Referring Provider Name Loop Ambulance Pick-up Location Loop NM1 5000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number 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 the ambulance drop-off location for this service line is different than the ambulance drop-off location provided in Loop ID-2310F. If not required by this implementation guide, do not send. Example NM1452X~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 341/665 N3 5140 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ambulance Drop-off Location Loop > N3 Ambulance Drop-off Location Address To specify the location of the named party Usage notes If the ambulance drop-off 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 N3XXXXXXX~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 342/665 N4 5200 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number 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 N4XXXXXXXXXXX~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 343/665 2420H Ambulance Drop-off Location Loop end Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim:	X12 HIPAA 837 Health Care Claim_ Professional.pdf
ID-2310F. If not required by this implementation guide, do not send. Example NM1452X~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 341/665 N3 5140 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ambulance Drop-off Location Loop > N3 Ambulance Drop-off Location Address To specify the location of the named party Usage notes If the ambulance drop-off 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 N3XXXXXXX~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 342/665 N4 5200 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number 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 N4XXXXXXXXXXX~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 343/665 2420H Ambulance Drop-off Location Loop end Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 344/665 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 SVDXXX00000000IV>XX>XX>XX>XX>XX>XXXX*0000000 00~ 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. Max use 1 Required C003-01 235 Product or Service ID Qualifier Identifier (ID) Required 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 345/665 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. 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. 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 346/665 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 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-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 or Unbundled Line Number Min 1 Max 6 Numeric (N0) Optional Number assigned for differentiation within a transaction set 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 347/665 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 CASCOXXXX000000000XXXX00000000000000000000 00XX00000000000000000000000000XXX00000000000 0000XXXXX0000000XXXXX000000000000000*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 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 Max use 5 Optional 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 348/665 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)	X12 HIPAA 837 Health Care Claim_ Professional.pdf
> 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 CASCOXXXX000000000XXXX00000000000000000000 00XX00000000000000000000000000XXX00000000000 0000XXXXX0000000XXXXX00000000000000000~ 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 If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required Max use 5 Optional 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 348/665 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 CAS07 is the units of service being adjusted. 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 349/665 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 See CODE SOURCE 139: Claim Adjustment Reason Code CAS-15 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 350/665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 351/665 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 DTP573D8XXXXX~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 352/665 2430 Line Adjudication 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 AMTEAF00000000000000~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 353/665 2440 Form Identification Code Loop Max >1 Optional LQ 5510 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Form Identification Code Loop > LQ Form Identification Code To identify standard industry codes Usage notes Required when adjudication is known to be impacted by one of the types of supporting documentation (standardized paper forms) listed in LQ01. If not required by this implementation guide, do not send. Loop ID-2440 is designed to allow providers to attach standardized supplemental information to the claim when required to do so by the payer. The LQ segment contains information to identify the form (LQ01) and the specific form number (LQ02). In the example given below, LQ01=UT which identifies the form as a Medicare DMERC CMN form. LQ02=01.02 identifies which DMERC CMN form is being used. An example application of this Form Identification Code Loop is for Medicare DMERC claims for which the DME provider is required to obtain a Certificate of Medical Necessity (DMERC CMN) or DMERC Information Form (DIF), or Oxygen Therapy Certification from the referring physician. Another example is payer documentation requirements for Home Health services. Example LQUTXX~ If Code List Qualifier Code (LQ-01) is present, then Form Identifier (LQ-02) is required Max use 1 Required LQ-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list AS Form Type Code Code value AS indicates that a Home Health form from External Code Source 656 is being identified in LQ02. UT Centers for Medicare and Medicaid Services (CMS) Durable Medical Equipment Regional Carrier (DMERC) Certificate of Medical Necessity (CMN) Forms LQ-02 1271 Form Identifier Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 354/665 FRM 5520 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Form Identification Code Loop > FRM Supporting Documentation To specify information in response to a codified questionnaire document Usage notes The LQ segment is used to identify the general (LQ01) and specific type (LQ02) for the form being reported in Loop ID-2440. The FRM segment is used to answer specific questions on the form identified in the LQ segment. FRM01 is used to indicate the question being answered. Answers can take one of 4 forms: FRM02 for Yes/No questions, FRM03 for text/uncodified answers, FRM04 for answers which use dates, and FRM05 for answers which are percents. For each FRM01 (question) use a remaining FRM element, choosing the element which has the most appropriate format. One FRM segment is used for each question/answer pair. The example below shows how the FRM can be used to answer all the pertinent questions on DMERC form 0802 (LQUT08.02~). Example FRMXXXXXXYXX20250131*00000~ At least one of Question Response (FRM-02), Question Response (FRM-03), Question Response (FRM-04) or Question Response (FRM-05) is required Max use 99 Required FRM-01 350 Question Number/Letter Min 1 Max 20 String (AN) Required Alphanumeric characters assigned for differentiation within a transaction set FRM01 is the question number on a questionnaire or codified form. FRM-02 1073 Question Response Identifier (ID) Optional Code indicating a Yes or No condition or response FRM02, FRM03, FRM04 and FRM05 are responses which only have meaning in reference to the question identified in FRM01. N No W Not Applicable Y Yes FRM-03 127 Question Response Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier FRM-04 373 Question Response CCYYMMDD format Date (DT) Optional 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 355/665 2440 Form Identification Code Loop end 2400 Service Line Number Loop end 2300 Claim Information Loop end Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year FRM-05 332 Question Response Min 1 Max 6 Decimal number (R) Optional Percent given in decimal format (e.g., 0.0 through 100.0 represents 0% through 100%) 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 356/665 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	X12 HIPAA 837 Health Care Claim_ Professional.pdf
Required Code identifying a specific industry code list AS Form Type Code Code value AS indicates that a Home Health form from External Code Source 656 is being identified in LQ02. UT Centers for Medicare and Medicaid Services (CMS) Durable Medical Equipment Regional Carrier (DMERC) Certificate of Medical Necessity (CMN) Forms LQ-02 1271 Form Identifier Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 354/665 FRM 5520 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Form Identification Code Loop > FRM Supporting Documentation To specify information in response to a codified questionnaire document Usage notes The LQ segment is used to identify the general (LQ01) and specific type (LQ02) for the form being reported in Loop ID-2440. The FRM segment is used to answer specific questions on the form identified in the LQ segment. FRM01 is used to indicate the question being answered. Answers can take one of 4 forms: FRM02 for Yes/No questions, FRM03 for text/uncodified answers, FRM04 for answers which use dates, and FRM05 for answers which are percents. For each FRM01 (question) use a remaining FRM element, choosing the element which has the most appropriate format. One FRM segment is used for each question/answer pair. The example below shows how the FRM can be used to answer all the pertinent questions on DMERC form 0802 (LQUT08.02~). Example FRMXXXXXXYXX2025013100000~ At least one of Question Response (FRM-02), Question Response (FRM-03), Question Response (FRM-04) or Question Response (FRM-05) is required Max use 99 Required FRM-01 350 Question Number/Letter Min 1 Max 20 String (AN) Required Alphanumeric characters assigned for differentiation within a transaction set FRM01 is the question number on a questionnaire or codified form. FRM-02 1073 Question Response Identifier (ID) Optional Code indicating a Yes or No condition or response FRM02, FRM03, FRM04 and FRM05 are responses which only have meaning in reference to the question identified in FRM01. N No W Not Applicable Y Yes FRM-03 127 Question Response Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier FRM-04 373 Question Response CCYYMMDD format Date (DT) Optional 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 355/665 2440 Form Identification Code Loop end 2400 Service Line Number Loop end 2300 Claim Information Loop end Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year FRM-05 332 Question Response Min 1 Max 6 Decimal number (R) Optional Percent given in decimal format (e.g., 0.0 through 100.0 represents 0% through 100%) 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 356/665 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 HL32230~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 357/665 0 No Subordinate HL Segment in This Hierarchical Structure. 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 358/665 PAT 0070 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > PAT Patient Information To supply patient information Example PAT39***D8XXX01000Y~ 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 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 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 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 359/665 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 For this implementation, the listed value takes precedence over the semantic note. Y Yes 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 360/665 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 NM1QC1XXXXXXXXXXX*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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 361/665 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 N3XXXXX~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 362/665 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 N4XXXXXXXXXXXXX~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 363/665 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 DMGD8XXU~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 364/665 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 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 REFY4XXXXXX~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 365/665 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	X12 HIPAA 837 Health Care Claim_ Professional.pdf
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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 363/665 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 DMGD8XXU~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 364/665 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 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 REFY4XXXXXX~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 365/665 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 REF1WXXXXX~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 366/665 PER 0400 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Patient Name Loop > PER Property and Casualty Patient 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 the Subscriber Contact Information PER segment in Loop ID- 2010BA and 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 PERICXTEXXXXEXXXXX~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 367/665 2010CA Patient 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 368/665 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 CLMXX00*X>B>XYCYYPAA>XXX>>XX>XXX03** **15~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 369/665 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 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 Code indicating whether the provider accepts assignment Usage notes 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 370/665 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	X12 HIPAA 837 Health Care Claim_ Professional.pdf
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 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 Code indicating whether the provider accepts assignment Usage notes 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 370/665 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. 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 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 371/665 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 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 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 372/665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 373/665 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient 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 DTP439D8XXXXX~ 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 - Last Menstrual Period DTP Date - Onset of Current Illness or Symptom DTP Date - Initial Treatment Date 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 374/665 Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 375/665 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient 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 DTP453D8XX~ 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 - Last Menstrual Period DTP Date - Onset of Current Illness or Symptom DTP Date - Initial Treatment Date 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 376/665 Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 377/665 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient 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 DTP435D8*XXXX~ 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 - Last Menstrual Period DTP Date - Onset of Current Illness or Symptom DTP Date - Initial Treatment Date 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 378/665 Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 379/665 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient 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	X12 HIPAA 837 Health Care Claim_ Professional.pdf
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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 376/665 Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 377/665 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient 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 DTP435D8XXXX~ 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 - Last Menstrual Period DTP Date - Onset of Current Illness or Symptom DTP Date - Initial Treatment Date 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 378/665 Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 379/665 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient 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 DTP091D8XXXXX~ 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 - Last Menstrual Period DTP Date - Onset of Current Illness or Symptom DTP Date - Initial Treatment Date 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 380/665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 381/665 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient 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 DTP296D8XXX~ 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 - Last Menstrual Period DTP Date - Onset of Current Illness or Symptom DTP Date - Initial Treatment Date 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 382/665 Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 383/665 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient 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 DTP314D8X~ 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 - Last Menstrual Period DTP Date - Onset of Current Illness or Symptom DTP Date - Initial Treatment Date 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 384/665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 385/665 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient 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 DTP096D8XXXX~ 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 - Last Menstrual Period DTP Date - Onset of Current Illness or Symptom DTP Date - Initial Treatment Date 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 386/665 Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 387/665 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient 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 DTP471D8XXXXX~ Variants (all may be used) DTP Date - Accident DTP	X12 HIPAA 837 Health Care Claim_ Professional.pdf
HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 384/665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 385/665 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient 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 DTP096D8XXXX~ 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 - Last Menstrual Period DTP Date - Onset of Current Illness or Symptom DTP Date - Initial Treatment Date 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 386/665 Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 387/665 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient 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 DTP471D8XXXXX~ 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 - Last Menstrual Period DTP Date - Onset of Current Illness or Symptom DTP Date - Initial Treatment Date 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 388/665 Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 389/665 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient 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 DTP484D8XX~ 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 - Onset of Current Illness or Symptom DTP Date - Initial Treatment Date 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 390/665 Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 391/665 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient 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 DTP431D8X~ 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 - Initial Treatment Date 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 392/665 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 393/665 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient 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 DTP454D8XXXXXX~ 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 - Onset of Current Illness or Symptom 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 394/665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 395/665 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient 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 DTP304D8XXXXX~ 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 - Onset of Current Illness or Symptom DTP Date - Initial Treatment 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional	X12 HIPAA 837 Health Care Claim_ Professional.pdf
Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Last Menstrual Period DTP Date - Onset of Current Illness or Symptom 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 394/665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 395/665 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient 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 DTP304D8XXXXX~ 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 - Onset of Current Illness or Symptom DTP Date - Initial Treatment 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 396/665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 397/665 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient 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 DTP297D8XXXXX~ 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 - Onset of Current Illness or Symptom DTP Date - Initial Treatment Date DTP Date - Last Seen Date 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 398/665 Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 399/665 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient 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 DTP455D8XXXXX~ 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 - Onset of Current Illness or Symptom DTP Date - Initial Treatment Date DTP Date - Last Seen Date DTP Date - Last Worked 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 400/665 Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 401/665 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient 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 DTP444D8X~ 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 - Onset of Current Illness or Symptom DTP Date - Initial Treatment Date DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 402/665 Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 403/665 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 DTP050D8XXXX~ 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 - Onset of Current Illness or Symptom DTP Date - Initial Treatment Date DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 404/665 Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 405/665 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 PWKPQEM*ACXXXXXX~ 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	X12 HIPAA 837 Health Care Claim_ Professional.pdf
dates, times or dates and times 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 403/665 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 DTP050D8XXXX~ 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 - Onset of Current Illness or Symptom DTP Date - Initial Treatment Date DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 404/665 Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 405/665 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 PWKPQEM*ACXXXXXX~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 406/665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 407/665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 408/665 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 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 CN1050000000000000000000XXX00XXXXX~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 409/665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 410/665 AMT 1750 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient 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 AMTF500000000000000~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 411/665 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient 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 REFX4XXXXX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Claim Identifier For Transmission Intermediaries REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Prior Authorization REF Payer Claim Control Number REF Referral Number REF Repriced Claim Number REF Medical Record 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 412/665 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 413/665 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 REF9CXXXX~ Variants (all may be used) REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Care Plan Oversight REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Claim Identifier For Transmission Intermediaries REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Prior Authorization REF Payer Claim Control Number REF Referral Number REF Repriced Claim Number REF Medical Record 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 414/665 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient 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	X12 HIPAA 837 Health Care Claim_ Professional.pdf
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 REFX4XXXXX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Claim Identifier For Transmission Intermediaries REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Prior Authorization REF Payer Claim Control Number REF Referral Number REF Repriced Claim Number REF Medical Record 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 412/665 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 413/665 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 REF9CXXXX~ Variants (all may be used) REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Care Plan Oversight REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Claim Identifier For Transmission Intermediaries REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Prior Authorization REF Payer Claim Control Number REF Referral Number REF Repriced Claim Number REF Medical Record 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 414/665 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient 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 REF1JXXXXX~ Variants (all may be used) REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Adjusted Repriced Claim Number REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Claim Identifier For Transmission Intermediaries REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Prior Authorization REF Payer Claim Control Number REF Referral Number REF Repriced Claim Number REF Medical Record 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 415/665 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 REFP4XXX~ Variants (all may be used) REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Investigational Device Exemption Number REF Claim Identifier For Transmission Intermediaries REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Prior Authorization REF Payer Claim Control Number REF Referral Number REF Repriced Claim Number REF Medical Record 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 416/665 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 REFLXX~ Variants (all may be used) REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Demonstration Project Identifier REF Claim Identifier For Transmission Intermediaries REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Prior Authorization REF Payer Claim Control Number REF Referral Number REF Repriced Claim Number REF Medical Record 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 417/665 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 REFD9XXXXX~ Variants (all may be used) REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Prior Authorization REF Payer Claim Control Number REF Referral Number REF Repriced Claim Number REF Medical Record 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 418/665 The value carried in this element is limited to a maximum of 20 positions. 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 419/665 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient 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 REFEWXXXXXX~ Variants (all may be used) REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Claim Identifier For Transmission Intermediaries REF Mandatory Medicare (Section 4081) Crossover Indicator REF Prior Authorization REF Payer Claim Control Number REF Referral Number REF Repriced Claim Number REF Medical Record 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 420/665 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient 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 REFF5XXXX~ Variants (all may be used) REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Claim Identifier For Transmission Intermediaries REF Mammography Certification Number REF Prior Authorization REF Payer Claim Control Number REF Referral Number REF Repriced Claim Number REF Medical Record 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 421/665 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 REFG1XX~ Variants (all may be used) REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Adjusted Repriced Claim	X12 HIPAA 837 Health Care Claim_ Professional.pdf
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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 420/665 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient 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 REFF5XXXX~ Variants (all may be used) REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Claim Identifier For Transmission Intermediaries REF Mammography Certification Number REF Prior Authorization REF Payer Claim Control Number REF Referral Number REF Repriced Claim Number REF Medical Record 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 421/665 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 REFG1XX~ Variants (all may be used) REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Claim Identifier For Transmission Intermediaries REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Payer Claim Control Number REF Referral Number REF Repriced Claim Number REF Medical Record 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 422/665 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 423/665 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 REFF8XXXXXX~ Variants (all may be used) REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Claim Identifier For Transmission Intermediaries REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Medical Record 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 424/665 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 REF9FX~ Variants (all may be used) REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Claim Identifier For Transmission Intermediaries REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Prior Authorization REF Payer Claim Control Number REF Repriced Claim Number REF Medical Record 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 425/665 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 426/665 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 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 REF9AX~ Variants (all may be used) REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Claim Identifier For Transmission Intermediaries REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Prior Authorization REF Payer Claim Control Number REF Referral Number REF Medical Record 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 427/665 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 REFEAXXXX~ Variants (all may be used) REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Claim Identifier For Transmission Intermediaries REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Prior Authorization 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 428/665 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 REF4NXX~ Variants (all may be used) REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Claim Identifier For Transmission Intermediaries REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Prior Authorization REF Payer Claim Control Number REF Referral Number REF Repriced Claim Number REF Medical Record 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 429/665 6 Request for Override Pending 7 Special Handling 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 430/665 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	X12 HIPAA 837 Health Care Claim_ Professional.pdf
for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 428/665 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 REF4NXX~ Variants (all may be used) REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Claim Identifier For Transmission Intermediaries REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Prior Authorization REF Payer Claim Control Number REF Referral Number REF Repriced Claim Number REF Medical Record 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 429/665 6 Request for Override Pending 7 Special Handling 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 430/665 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 K3X~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 431/665 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. 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 NTETPOXXXXXX~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 432/665 CR1 1950 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient 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 when it is necessary to justify the medical necessity of the level of ambulance services. If not required by this implementation guide, do not send. 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 CR1LB0000000000CDH00000000*XXXXXXXX~ 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 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 433/665 CR1-06 380 Transport Distance Min 1 Max 15 Decimal number (R) Required 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 434/665 CR2 2000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient 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******EXXXXXXXX~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 435/665 CRC 2200 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient 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 CRC07N01XXXXXXXXXX~ Variants (all may be used) CRC Patient Condition Information: Vision CRC Homebound Indicator CRC EPSDT Referral 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 436/665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 437/665 CRC 2200 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient 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	X12 HIPAA 837 Health Care Claim_ Professional.pdf
description to clarify the related data elements and their content CR211 is an additional description of the patient's condition. 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 435/665 CRC 2200 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient 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 CRC07N01XXXXXXXXXX~ Variants (all may be used) CRC Patient Condition Information: Vision CRC Homebound Indicator CRC EPSDT Referral 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 436/665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 437/665 CRC 2200 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient 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 CRCE3NL3XXXXXXXXXX~ Variants (all may be used) CRC Ambulance Certification CRC Homebound Indicator CRC EPSDT Referral 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 438/665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 439/665 CRC 2200 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient 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 CRC75YIH~ Variants (all may be used) CRC Ambulance Certification CRC Patient Condition Information: Vision CRC EPSDT Referral 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 440/665 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 CRCZZYS2XXXX~ Variants (all may be used) CRC Ambulance Certification CRC Patient Condition Information: Vision CRC Homebound Indicator 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 441/665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 442/665 HI 2310 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient 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 HIABK>XXXXXABF>XXABF>XXABF>XXXXBF>XXXXABF>X XXXXXBF>XXXXBF>XXXXXBF>XXXXXABF>XXXXXABF>X XBF>XXXX~ 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 Max use 1 Optional 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 443/665 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 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, 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 444/665 OR For claims which are not covered under	X12 HIPAA 837 Health Care Claim_ Professional.pdf
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 Max use 1 Optional 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 443/665 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 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, 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 444/665 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-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 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 445/665 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-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. 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 446/665 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 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 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 447/665 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-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 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 448/665 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-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	X12 HIPAA 837 Health Care Claim_ Professional.pdf
X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 447/665 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-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 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 448/665 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-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 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 449/665 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 450/665 HI 2310 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient 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 HIBP>XXXXXBO>X~ Variants (all may be used) HI Health Care Diagnosis Code HI Condition 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. 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 451/665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 452/665 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 condition information applies to the claim. If not required by this implementation guide, do not send. Example HIBG>XXBG>XBG>XXXBG>XXXXXXBG>XXXBG>XXXXXXB G>XXXXXBG>XXXXBG>XXXXBG>XXBG>XBG>XXXX~ Variants (all may be used) HI Health Care Diagnosis Code HI Anesthesia Related Procedure 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 453/665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 454/665 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	X12 HIPAA 837 Health Care Claim_ Professional.pdf
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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 454/665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 455/665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 456/665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 457/665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 458/665 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 HCP100000000000000X00000000XXXX000000000* ***T32*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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 459/665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 460/665 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	X12 HIPAA 837 Health Care Claim_ Professional.pdf
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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 459/665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 460/665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 461/665 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 > 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 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 NM1DN1XXXXXXXXXXXXXXXXX~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 462/665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 463/665 2310A 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 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 REFG2XX~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 464/665 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 > 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 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 NM1822XXXXXXXXXXX*XXXXXXXXX~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 465/665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 466/665 PRV 2550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient 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 PRVPEPXCXXXXX~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 467/665 2310B 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 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	X12 HIPAA 837 Health Care Claim_ Professional.pdf
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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 465/665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 466/665 PRV 2550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient 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 PRVPEPXCXXXXX~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 467/665 2310B 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 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 REF1GXXX~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 468/665 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 > 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. 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 NM1772XXXXXX****XXXXXXXX~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 469/665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 470/665 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 N3XXXXX~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 471/665 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 N4XXXXXXXXXXXXX~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 472/665 Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 473/665 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 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 REF0BXXXX~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 474/665 PER 2750 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient 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 PERICXXXXTEXXXXEXXXXX~ 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	X12 HIPAA 837 Health Care Claim_ Professional.pdf
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 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 REF0BXXXX~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 474/665 PER 2750 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient 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 PERICXXXXTEXXXXEXXXXX~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 475/665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 476/665 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 > Patient 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 NM1DQ1XXXXXXXXXXXXXXX~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 477/665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 478/665 2310D Supervising Provider Name Loop end REF 2710 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient 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 REF1GXX~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 479/665 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 > Patient 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 NM1PW2~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 480/665 N3 2650 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient 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 N3XXXXXXXXX~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 481/665 N4 2700 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient 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 N4XXXXXXXXXXXXXXX~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 482/665 2310E Ambulance Pick-up Location Loop end Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 483/665 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 > Patient 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 NM1452XXXXXX~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) -	X12 HIPAA 837 Health Care Claim_ Professional.pdf
(AN) Optional Address information 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 481/665 N4 2700 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient 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 N4XXXXXXXXXXXXXXX~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 482/665 2310E Ambulance Pick-up Location Loop end Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 483/665 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 > Patient 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 NM1452XXXXXX~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 484/665 N3 2650 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient 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 N3XXXXXXXX~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 485/665 N4 2700 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient 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 N4XXXXXXXXXXXX~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 486/665 2310F Ambulance Drop-off Location Loop end Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 487/665 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 SBRH53XXXXX41***MA~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 488/665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 489/665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 490/665 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 CASCOX000000000000000XXX00000000XXX00000 000000XXX0000000X000000000000000000XXXX0 00000000000000~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 491/665 If Adjustment	X12 HIPAA 837 Health Care Claim_ Professional.pdf
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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 490/665 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 CASCOX000000000000000XXX00000000XXX00000 000000XXX0000000X000000000000000000XXXX0 00000000000000~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 491/665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 492/665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 493/665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 494/665 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 AMTD0000~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 495/665 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 AMTA8000000000~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 496/665 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 AMTEAF00~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 497/665 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*YP**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-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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2)	X12 HIPAA 837 Health Care Claim_ Professional.pdf
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 AMTEAF00~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 497/665 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**YP*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-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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 498/665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 499/665 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 returned in the remittance advice. If not required by this implementation guide, do not send. 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 MOA00000000000000XXXXXXXXXXXXXXXXX0000000 00000000000000~ 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 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 500/665 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 501/665 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 > 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 NM1IL2XXXXXXXXXXXXXXXXMIXXXXX~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 502/665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 503/665 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 N3XXXXXXX~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 504/665 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 N4XXXXXXXXXXXXXX*XXX~ 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 Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 505/665 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 506/665 2330A Other Subscriber Name Loop end REF 3550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level	X12 HIPAA 837 Health Care Claim_ Professional.pdf
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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 503/665 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 N3XXXXXXX~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 504/665 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 N4XXXXXXXXXXXXXXXXX~ 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 Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 505/665 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 506/665 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 REFSYXX~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 507/665 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 > 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 NM1PR2XXXXX***PIXXXX~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 508/665 (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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 509/665 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 N3XXX~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 510/665 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 N4XXXXXXXXXXXXXXXX~ 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 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 511/665 Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 512/665 DTP 3450 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 DTP573D8XXX~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 513/665 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 REF2UXXXXX~ Variants (all may be used) REF Other Payer Prior Authorization Number REF Other Payer Referral Number REF Other Payer Claim Adjustment Indicator REF Other Payer Claim Control 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 514/665 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 REFG1*XXX~	X12 HIPAA 837 Health Care Claim_ Professional.pdf
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 DTP573D8XXX~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 513/665 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 REF2UXXXXX~ Variants (all may be used) REF Other Payer Prior Authorization Number REF Other Payer Referral Number REF Other Payer Claim Adjustment Indicator REF Other Payer Claim Control 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 514/665 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 REFG1XXX~ Variants (all may be used) REF Other Payer Secondary Identifier REF Other Payer Referral Number REF Other Payer Claim Adjustment Indicator REF Other Payer Claim Control Number 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 515/665 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 REF9FX~ Variants (all may be used) REF Other Payer Secondary Identifier REF Other Payer Prior Authorization Number REF Other Payer Claim Adjustment Indicator REF Other Payer Claim Control Number 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 516/665 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 REFT4X~ Variants (all may be used) REF Other Payer Secondary Identifier REF Other Payer Prior Authorization Number REF Other Payer Referral Number REF Other Payer Claim Control Number 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 517/665 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 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 REFF8XXXX~ Variants (all may be used) REF Other Payer Secondary Identifier REF Other Payer Prior Authorization Number REF Other Payer Referral Number REF Other Payer Claim Adjustment Indicator 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 518/665 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 > 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 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 NM1DN1~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 519/665 1 Person 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 520/665 2330C 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 REFG2XXXXX~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 521/665 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 > Patient 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 NM182*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 82 Rendering Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 522/665 1 Person 2 Non-Person Entity 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 523/665 2330D Other Payer Rendering Provider Loop end REF 3550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Other Subscriber	X12 HIPAA 837 Health Care Claim_ Professional.pdf
> 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 REFG2XXXXX~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 521/665 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 > Patient 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 NM1822~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 522/665 1 Person 2 Non-Person Entity 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 523/665 2330D Other Payer Rendering 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 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 REF1GX~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 524/665 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 > 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 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 NM1772~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 525/665 2330E 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 Example REF0BXXX~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 526/665 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 > Patient 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 NM1DQ1~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 527/665 2330F Other Payer Supervising 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 Supervising Provider Loop > REF Other Payer Supervising Provider Secondary Identification To specify identifying information Example REFG2XXXXX~ 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 Supervising 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 528/665 2330G Other Payer Billing 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 Supervising 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 NM1851~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 529/665 1 Person 2 Non-Person Entity 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 530/665 2330G 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 REFLUX~ Max use	X12 HIPAA 837 Health Care Claim_ Professional.pdf
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 Supervising 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 528/665 2330G Other Payer Billing 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 Supervising 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 NM1851~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 529/665 1 Person 2 Non-Person Entity 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 530/665 2330G 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 REFLUX~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 531/665 2400 Service Line Number Loop Max 50 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 LX0000~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 532/665 SV1 3700 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > SV1 Professional Service To specify the service line item detail for a health care professional Example SV1WK>XX>XX>XX>XX>XX>XXXXXX0000000MJ0000XX* 0>0>0>00YYY***0~ Max use 1 Required SV1-01 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers Max use 1 Required 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. Usage notes The NDC number is used for reporting prescribed drugs and biologics when required by government regulation, or as deemed by the provider to enhance claim reporting or adjudication processes. The NDC number is reported in the LIN segment of Loop ID- 2410 only. 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. 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; 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 533/665 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 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. SV1-02 782 Line Item Charge Amount Min 1 Max 15 Decimal number (R) Required 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 534/665 Monetary amount SV102 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 and/or postage claimed amounts reported within this line's AMT segments. Zero "0" is an acceptable value for this element. SV1-03 355 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 MJ Minutes Required for Anesthesia claims. Anesthesia time is counted from the moment that the practitioner, having completed the preoperative evaluation, starts an intravenous line, places monitors, administers pre- anesthesia sedation, or otherwise physically begins to prepare the patient for anesthesia. Time continues throughout the case and while the practitioner accompanies the patient to the post-anesthesia recovery unit (PACU). Time stops when the practitioner releases the patient to the care of PACU personnel. UN Unit SV1-04 380 Service Unit Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity Usage notes Note: When a decimal is needed to report units, include it in this element, for example, "15.6". 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. SV1-05 1331 Place of Service Code Min 1 Max 2 String (AN) Optional 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. SV105 is the place of service. Usage notes See CODE SOURCE 237: Place of Service Codes for Professional Claims SV1-07 C004 Composite Diagnosis Code Pointer To identify one or more diagnosis code pointers Max use 1 Required C004-01 1328 Diagnosis Code Pointer Min 1 Max 2 Numeric (N0) Required 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 535/665 A pointer to the diagnosis code in the order of importance to this service C004-01 identifies the primary diagnosis code for this service line. Usage notes This first pointer designates the primary diagnosis for this service line. Remaining diagnosis pointers indicate declining level of importance to service line. Acceptable values are 1 through 12, and correspond to Composite Data Elements 01 through 12 in the Health Care Diagnosis Code HI segment in the Claim Loop ID-2300. C004-02 1328 Diagnosis Code Pointer Min 1 Max 2 Numeric (N0) Optional A pointer to the diagnosis code in the order of importance to this service C004-02 identifies the second diagnosis code for this service line. C004-03 1328 Diagnosis Code Pointer Min 1 Max 2 Numeric (N0) Optional A pointer to the diagnosis code in the order of importance to this service C004-03 identifies the third diagnosis code for this service line. C004-04 1328 Diagnosis Code Pointer Min 1 Max 2 Numeric (N0) Optional A pointer to the diagnosis code in the order of importance to this service C004-04 identifies the fourth diagnosis code for this service line. SV1-09 1073 Emergency Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response SV109 is the emergency-related indicator; a "Y" value indicates service provided was emergency related; an "N" value indicates service provided was not emergency related. Usage notes For this implementation, the listed value takes precedence over the semantic note. Emergency definition: The patient requires immediate medical intervention as a result of severe, life threatening, or potentially disabling conditions. Y Yes SV1-11 1073 EPSDT	X12 HIPAA 837 Health Care Claim_ Professional.pdf
claims. Anesthesia time is counted from the moment that the practitioner, having completed the preoperative evaluation, starts an intravenous line, places monitors, administers pre- anesthesia sedation, or otherwise physically begins to prepare the patient for anesthesia. Time continues throughout the case and while the practitioner accompanies the patient to the post-anesthesia recovery unit (PACU). Time stops when the practitioner releases the patient to the care of PACU personnel. UN Unit SV1-04 380 Service Unit Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity Usage notes Note: When a decimal is needed to report units, include it in this element, for example, "15.6". 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. SV1-05 1331 Place of Service Code Min 1 Max 2 String (AN) Optional 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. SV105 is the place of service. Usage notes See CODE SOURCE 237: Place of Service Codes for Professional Claims SV1-07 C004 Composite Diagnosis Code Pointer To identify one or more diagnosis code pointers Max use 1 Required C004-01 1328 Diagnosis Code Pointer Min 1 Max 2 Numeric (N0) Required 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 535/665 A pointer to the diagnosis code in the order of importance to this service C004-01 identifies the primary diagnosis code for this service line. Usage notes This first pointer designates the primary diagnosis for this service line. Remaining diagnosis pointers indicate declining level of importance to service line. Acceptable values are 1 through 12, and correspond to Composite Data Elements 01 through 12 in the Health Care Diagnosis Code HI segment in the Claim Loop ID-2300. C004-02 1328 Diagnosis Code Pointer Min 1 Max 2 Numeric (N0) Optional A pointer to the diagnosis code in the order of importance to this service C004-02 identifies the second diagnosis code for this service line. C004-03 1328 Diagnosis Code Pointer Min 1 Max 2 Numeric (N0) Optional A pointer to the diagnosis code in the order of importance to this service C004-03 identifies the third diagnosis code for this service line. C004-04 1328 Diagnosis Code Pointer Min 1 Max 2 Numeric (N0) Optional A pointer to the diagnosis code in the order of importance to this service C004-04 identifies the fourth diagnosis code for this service line. SV1-09 1073 Emergency Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response SV109 is the emergency-related indicator; a "Y" value indicates service provided was emergency related; an "N" value indicates service provided was not emergency related. Usage notes For this implementation, the listed value takes precedence over the semantic note. Emergency definition: The patient requires immediate medical intervention as a result of severe, life threatening, or potentially disabling conditions. Y Yes SV1-11 1073 EPSDT Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response SV111 is early and periodic screen for diagnosis and treatment of children (EPSDT) involvement; a "Y" value indicates EPSDT involvement; an "N" value indicates no EPSDT involvement. Usage notes For this implementation, the listed value takes precedence over the semantic note. 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 536/665 When this element is used, this service is not the screening service. Y Yes SV1-12 1073 Family Planning Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response SV112 is the family planning involvement indicator. A "Y" value indicates family planning services involvement; an "N" value indicates no family planning services involvement. Usage notes For this implementation, the listed value takes precedence over the semantic note. Y Yes SV1-15 1327 Co-Pay Status Code Identifier (ID) Optional Code indicating whether or not co-payment requirements were met on a line by line basis 0 Copay exempt 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 537/665 SV5 4000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > SV5 Durable Medical Equipment Service To specify the claim service detail for durable medical equipment Usage notes Required when necessary to report both the rental and purchase price information for durable medical equipment. This is not used for claims where the provider is reporting only the rental price or only the purchase price. If not required by this implementation guide, do not send. Example SV5HC>XXXDA000000000000000000000000000000000 00006~ If Rental Unit Price Indicator (SV5-06) is present, then DME Rental Price (SV5-04) is required Max use 1 Optional SV5-01 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers Max use 1 Required C003-01 235 Procedure Identifier 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. 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. 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. Usage notes This value must be the same as that reported in SV101-2. SV5-02 355 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 SV5-03 380 Length of Medical Necessity Min 1 Max 15 Decimal number (R) Required 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 538/665 Numeric value of quantity SV503 is the length of medical treatment required. SV5-04 782 DME Rental Price Min 1 Max 15 Decimal number (R) Required Monetary amount SV504 is the rental price. SV5-05 782 DME Purchase Price Min 1 Max 15 Decimal number (R) Required Monetary amount SV505 is the purchase price. SV5-06 594 Rental Unit Price Indicator Identifier (ID) Required Code indicating frequency or type of activities or actions being reported SV506 is the frequency at which the rental equipment is billed. 1 Weekly 4 Monthly 6 Daily 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 539/665 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 PWKOBFT**ACXX~ Variants (all may be used) PWK Durable Medical Equipment Certificate of Medical Necessity Indicator 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 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 540/665 BS Baseline BT Blanket Test Results CB Chiropractic Justification 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 Usage notes Required when the actual attachment is maintained by an attachment warehouse or similar vendor. AA Available on Request at Provider Site 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 541/665 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 542/665 PWK 4200 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > PWK Durable Medical Equipment Certificate of Medical Necessity Indicator To identify the type or transmission or both of paperwork or supporting information Usage notes Required on claims that include a Durable Medical Equipment Regional Carrier (DMERC) Certificate of Medical Necessity (CMN). If not required by this implementation guide, do not send.; Example PWKCTNS~ Variants (all may be used) PWK Line Supplemental Information Max use 1 Optional PWK-01 755 Attachment Report Type Code Identifier (ID) Required Code indicating the title or contents of a document, report or supporting item CT Certification PWK-02 756 Attachment Transmission Code Identifier (ID) Required Code defining timing, transmission method or format by which reports are to be sent Usage notes Required when the actual attachment is maintained by an attachment warehouse or similar vendor. AB Previously Submitted to Payer AD Certification Included in this Claim AF Narrative Segment Included in this Claim AG No Documentation is Required NS Not Specified NS = Paperwork is available on request at the provider's site. This means that the paperwork is not being sent with the claim at this time. Instead, it is available to the payer (or appropriate entity) at their request. 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides	X12 HIPAA 837 Health Care Claim_ Professional.pdf
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 Usage notes Required when the actual attachment is maintained by an attachment warehouse or similar vendor. AA Available on Request at Provider Site 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 541/665 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 542/665 PWK 4200 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > PWK Durable Medical Equipment Certificate of Medical Necessity Indicator To identify the type or transmission or both of paperwork or supporting information Usage notes Required on claims that include a Durable Medical Equipment Regional Carrier (DMERC) Certificate of Medical Necessity (CMN). If not required by this implementation guide, do not send.; Example PWKCTNS~ Variants (all may be used) PWK Line Supplemental Information Max use 1 Optional PWK-01 755 Attachment Report Type Code Identifier (ID) Required Code indicating the title or contents of a document, report or supporting item CT Certification PWK-02 756 Attachment Transmission Code Identifier (ID) Required Code defining timing, transmission method or format by which reports are to be sent Usage notes Required when the actual attachment is maintained by an attachment warehouse or similar vendor. AB Previously Submitted to Payer AD Certification Included in this Claim AF Narrative Segment Included in this Claim AG No Documentation is Required NS Not Specified NS = Paperwork is available on request at the provider's site. This means that the paperwork is not being sent with the claim at this time. Instead, it is available to the payer (or appropriate entity) at their request. 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 543/665 CR1 4250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > CR1 Ambulance Transport Information To supply information related to the ambulance service rendered to a patient Usage notes Required when CR102 is used. If not required by this implementation guide, do not send. Required on ambulance transport services when the information applicable to any one of the segment's elements is different than the information reported in the CR1 at the claim level (Loop ID-2300). If not required by this implementation guide, do not send. Example CR1LB000*CDH000*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 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 Numeric value of quantity 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 544/665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 545/665 CR3 4350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > CR3 Durable Medical Equipment Certification To supply information regarding a physician's certification for durable medical equipment Usage notes Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN) or a DMERC Information Form (DIF) or Oxygen Therapy Certification is included on this service line. If not required by this implementation guide, do not send. Example CR3IMO00000000~ Max use 1 Optional CR3-01 1322 Certification Type Code Identifier (ID) Required Code indicating the type of certification I Initial R Renewal S Revised CR3-02 355 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 CR302 and CR303 specify the time period covered by this certification. MO Months CR3-03 380 Durable Medical Equipment Duration Min 1 Max 15 Decimal number (R) Required Numeric value of quantity Usage notes Length of time DME equipment is needed. 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 546/665 CRC 4500 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > CRC Ambulance Certification To supply information on conditions Usage notes The maximum number of CRC segments which can occur per Loop ID-2400 is 3. Submitters are free to mix and match the three types of service line level CRC segments shown in this implementation guide to meet their billing or reporting needs but no more than a total of 3 CRC segments per Loop ID-2400 are allowed. Required on ambulance transport services when the information applicable to any one of the segment's elements is different than the information reported in the Ambulance Certification CRC at the claim level (Loop ID-2300). If not required by this implementation guide, do not send. Example CRC07Y06XXXXXXXXXX~ Variants (all may be used) CRC Hospice Employee Indicator CRC Condition Indicator/Durable Medical Equipment 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 06 Patient was transported in an emergency situation 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 547/665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 548/665 CRC 4500 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > CRC Hospice Employee Indicator To supply information on conditions Usage notes Required on all Medicare claims involving physician services to hospice patients. If not required by this implementation guide, do not send. The maximum number of CRC segments which can occur per Loop ID-2400 is 3. Submitters are free to mix and match the three types of service line level CRC segments shown in this implementation guide to meet their billing or reporting needs but no more than a total of 3 CRC segments per Loop ID-2400 are allowed. The example shows the method used to indicate whether the rendering provider is an employee of the hospice. Example CRC70N*65~ Variants (all may be used) CRC Ambulance Certification CRC Condition Indicator/Durable Medical Equipment 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. 70 Hospice CRC-02 1073 Hospice Employed Provider 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 A "Y" value indicates the provider is employed by the hospice. A "N" value indicates the provider is not employed by the hospice. N No Y Yes CRC-03 1321 Condition Indicator Identifier (ID) Required Code indicating a condition 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 549/665 65 Open This code value is a placeholder to satisfy the Mandatory Data Element syntax requirement. 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 550/665 CRC 4500 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > CRC Condition Indicator/Durable Medical Equipment To supply information on conditions Usage notes Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN) or a DMERC Information Form (DIF), or Oxygen Therapy Certification is included on this service line and the information is necessary for adjudication. If not required by this implementation guide, do not send. The maximum number of CRC segments which can occur per Loop ID-2400 is 3. Submitters are free to mix and match the three types of service line	X12 HIPAA 837 Health Care Claim_ Professional.pdf
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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 548/665 CRC 4500 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > CRC Hospice Employee Indicator To supply information on conditions Usage notes Required on all Medicare claims involving physician services to hospice patients. If not required by this implementation guide, do not send. The maximum number of CRC segments which can occur per Loop ID-2400 is 3. Submitters are free to mix and match the three types of service line level CRC segments shown in this implementation guide to meet their billing or reporting needs but no more than a total of 3 CRC segments per Loop ID-2400 are allowed. The example shows the method used to indicate whether the rendering provider is an employee of the hospice. Example CRC70N65~ Variants (all may be used) CRC Ambulance Certification CRC Condition Indicator/Durable Medical Equipment 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. 70 Hospice CRC-02 1073 Hospice Employed Provider 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 A "Y" value indicates the provider is employed by the hospice. A "N" value indicates the provider is not employed by the hospice. N No Y Yes CRC-03 1321 Condition Indicator Identifier (ID) Required Code indicating a condition 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 549/665 65 Open This code value is a placeholder to satisfy the Mandatory Data Element syntax requirement. 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 550/665 CRC 4500 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > CRC Condition Indicator/Durable Medical Equipment To supply information on conditions Usage notes Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN) or a DMERC Information Form (DIF), or Oxygen Therapy Certification is included on this service line and the information is necessary for adjudication. If not required by this implementation guide, do not send. The maximum number of CRC segments which can occur per Loop ID-2400 is 3. Submitters are free to mix and match the three types of service line level CRC segments shown in this implementation guide to meet their billing or reporting needs but no more than a total of 3 CRC segments per Loop ID-2400 are allowed. The first example shows a case where an item billed was not a replacement item. Example CRC09Y38XX~ Variants (all may be used) CRC Ambulance Certification CRC Hospice Employee Indicator 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. 09 Durable Medical Equipment 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 Indicator Identifier (ID) Required Code indicating a condition 38 Certification signed by the physician is on file at the supplier's office ZV Replacement Item CRC-04 1321 Condition Indicator Min 2 Max 3 Identifier (ID) Optional 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 551/665 Code indicating a condition Usage notes Use the codes listed in CRC03. 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 552/665 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 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. Example DTP472D8XXXXXX~ Variants (all may be used) DTP Date - Prescription Date DTP DATE - Certification Revision/Recertification Date DTP Date - Begin Therapy Date DTP Date - Initial Treatment Date DTP Date - Last Certification Date DTP Date - Last Seen Date DTP Date - Last X-ray Date DTP Date - Shipped Date DTP Date - Test Date 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 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. 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 553/665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 554/665 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 - Prescription Date To specify any or all of a date, a time, or a time period Usage notes Required when a drug is billed for this line and a prescription was written (or otherwise communicated by the prescriber if not written). If not required by this implementation guide, do not send. Example DTP471D8XX~ Variants (all may be used) DTP Date - Service Date DTP DATE - Certification Revision/Recertification Date DTP Date - Begin Therapy Date DTP Date - Initial Treatment Date DTP Date - Last Certification Date DTP Date - Last Seen Date DTP Date - Last X-ray Date DTP Date - Shipped Date DTP Date - Test 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 Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 555/665 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 - Certification Revision/Recertification Date To specify any or all of a date, a time, or a time period Usage notes Required when CR301 (DMERC Certification) = "R" or "S". If not required by this implementation guide, do not send. Example DTP607D8XX~ Variants (all may be used) DTP Date - Service Date DTP Date - Prescription Date DTP Date - Begin Therapy Date DTP Date - Initial Treatment Date DTP Date - Last Certification Date DTP Date - Last Seen Date DTP Date - Last X-ray Date DTP Date - Shipped Date DTP Date - Test 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 607 Certification Revision 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 Certification Revision or Recertification Date String (AN) Required Min 1 Max 35 Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 556/665 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 - Begin Therapy Date To specify any or all of a date, a time, or a time period Usage notes Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN) or DMERC Information Form (DIF), or Oxygen Therapy Certification is included on this service line. If not required by this implementation guide, do not send. Example DTP463D8XXXXXX~ Variants (all may be used) DTP Date - Service Date DTP Date - Prescription Date DTP DATE - Certification Revision/Recertification Date DTP Date - Initial Treatment Date DTP Date - Last Certification Date DTP Date - Last Seen Date DTP Date - Last X-ray Date DTP Date - Shipped Date DTP Date - Test 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 463 Begin Therapy 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 Begin Therapy 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 557/665 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 - 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, physcial therapy, occupational therapy, or speech language pathology and when different from what is reported at the claim level. If not required by this implementation guide, do not send. Example DTP454D8X~ Variants (all may be used) DTP Date - Service Date DTP Date - Prescription Date DTP DATE - Certification Revision/Recertification	X12 HIPAA 837 Health Care Claim_ Professional.pdf
Last Seen Date DTP Date - Last X-ray Date DTP Date - Shipped Date DTP Date - Test 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 607 Certification Revision 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 Certification Revision or Recertification Date String (AN) Required Min 1 Max 35 Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 556/665 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 - Begin Therapy Date To specify any or all of a date, a time, or a time period Usage notes Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN) or DMERC Information Form (DIF), or Oxygen Therapy Certification is included on this service line. If not required by this implementation guide, do not send. Example DTP463D8XXXXXX~ Variants (all may be used) DTP Date - Service Date DTP Date - Prescription Date DTP DATE - Certification Revision/Recertification Date DTP Date - Initial Treatment Date DTP Date - Last Certification Date DTP Date - Last Seen Date DTP Date - Last X-ray Date DTP Date - Shipped Date DTP Date - Test 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 463 Begin Therapy 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 Begin Therapy 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 557/665 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 - 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, physcial therapy, occupational therapy, or speech language pathology and when different from what is reported at the claim level. If not required by this implementation guide, do not send. Example DTP454D8X~ Variants (all may be used) DTP Date - Service Date DTP Date - Prescription Date DTP DATE - Certification Revision/Recertification Date DTP Date - Begin Therapy Date DTP Date - Last Certification Date DTP Date - Last Seen Date DTP Date - Last X-ray Date DTP Date - Shipped Date DTP Date - Test 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 558/665 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 - Last Certification Date To specify any or all of a date, a time, or a time period Usage notes Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN), DMERC Information Form (DIF), or Oxygen Therapy Certification is included on this service line. If not required by this implementation guide, do not send. This is the date the ordering physician signed the CMN or Oxygen Therapy Certification, or the date the supplier signed the DMERC Information Form (DIF). Example DTP461D8XXX~ Variants (all may be used) DTP Date - Service Date DTP Date - Prescription Date DTP DATE - Certification Revision/Recertification Date DTP Date - Begin Therapy Date DTP Date - Initial Treatment Date DTP Date - Last Seen Date DTP Date - Last X-ray Date DTP Date - Shipped Date DTP Date - Test 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 461 Last Certification 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 Certification 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 559/665 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 - Last Seen Date To specify any or all of a date, a time, or a time period Usage notes Required when a claim involves physician services for routine foot care; and is different than the date listed at the claim level and is known to impact the payer's adjudication process. If not required by this implementation guide, do not send.; Example DTP304D8XXXXX~ Variants (all may be used) DTP Date - Service Date DTP Date - Prescription Date DTP DATE - Certification Revision/Recertification Date DTP Date - Begin Therapy Date DTP Date - Initial Treatment Date DTP Date - Last Certification Date DTP Date - Last X-ray Date DTP Date - Shipped Date DTP Date - Test 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. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Treatment or Therapy 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 560/665 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 - 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 and is different than information at the claim level (Loop ID-2300). If not required by this implementation guide, do not send. Example DTP455D8X~ Variants (all may be used) DTP Date - Service Date DTP Date - Prescription Date DTP DATE - Certification Revision/Recertification Date DTP Date - Begin Therapy Date DTP Date - Initial Treatment Date DTP Date - Last Certification Date DTP Date - Last Seen Date DTP Date - Shipped Date DTP Date - Test 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 Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 561/665 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 - Shipped Date To specify any or all of a date, a time, or a time period Usage notes Required when billing or reporting shipped products. If not required by this implementation guide, do not send. Example DTP011D8XXXX~ Variants (all may be used) DTP Date - Service Date DTP Date - Prescription Date DTP DATE - Certification Revision/Recertification Date DTP Date - Begin Therapy Date DTP Date - Initial Treatment Date DTP Date - Last Certification Date DTP Date - Last Seen Date DTP Date - Last X-ray Date DTP Date - Test 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 011 Shipped 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 Shipped 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 562/665 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 - Test Date To specify any or all of a date, a time, or a time period Usage notes Required on initial EPO claims service lines for dialysis patients when test results are being billed or reported. If not required by this implementation guide, do not send. Example DTP739D8X~ Variants (all may be used) DTP Date - Service Date DTP Date - Prescription Date DTP DATE - Certification Revision/Recertification Date DTP Date - Begin Therapy Date DTP Date - Initial Treatment Date DTP Date - Last Certification Date DTP Date - Last Seen Date DTP Date - Last X-ray Date DTP Date - Shipped 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 738 Most Recent Hemoglobin or Hematocrit or Both 739 Most Recent Serum Creatine 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 Test Performed 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 563/665 QTY 4600 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > QTY Ambulance Patient Count To specify quantity information Usage notes Required when more than one patient is transported in the same vehicle for Ambulance or non-emergency transportation services. If not required by this implementation guide, do not send. The QTY02 is the only place to report the number of patients when there are multiple patients transported. Example QTYPT*0~ Variants (all may be	X12 HIPAA 837 Health Care Claim_ Professional.pdf
DTP Date - Service Date DTP Date - Prescription Date DTP DATE - Certification Revision/Recertification Date DTP Date - Begin Therapy Date DTP Date - Initial Treatment Date DTP Date - Last Certification Date DTP Date - Last Seen Date DTP Date - Last X-ray Date DTP Date - Test 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 011 Shipped 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 Shipped 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 562/665 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 - Test Date To specify any or all of a date, a time, or a time period Usage notes Required on initial EPO claims service lines for dialysis patients when test results are being billed or reported. If not required by this implementation guide, do not send. Example DTP739D8X~ Variants (all may be used) DTP Date - Service Date DTP Date - Prescription Date DTP DATE - Certification Revision/Recertification Date DTP Date - Begin Therapy Date DTP Date - Initial Treatment Date DTP Date - Last Certification Date DTP Date - Last Seen Date DTP Date - Last X-ray Date DTP Date - Shipped 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 738 Most Recent Hemoglobin or Hematocrit or Both 739 Most Recent Serum Creatine 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 Test Performed 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 563/665 QTY 4600 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > QTY Ambulance Patient Count To specify quantity information Usage notes Required when more than one patient is transported in the same vehicle for Ambulance or non-emergency transportation services. If not required by this implementation guide, do not send. The QTY02 is the only place to report the number of patients when there are multiple patients transported. Example QTYPT0~ Variants (all may be used) QTY Obstetric Anesthesia Additional Units Max use 1 Optional QTY-01 673 Quantity Qualifier Identifier (ID) Required Code specifying the type of quantity PT Patients QTY-02 380 Ambulance Patient Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 564/665 QTY 4600 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > QTY Obstetric Anesthesia Additional Units To specify quantity information Usage notes Required in conjunction with anesthesia for obstetric services when the anesthesia provider chooses to report additional complexity beyond the normal services reflected by the procedure base units and anesthesia time. If not required by this implementation guide, do not send. Example QTYFL0000000000~ Variants (all may be used) QTY Ambulance Patient Count Max use 1 Optional QTY-01 673 Quantity Qualifier Identifier (ID) Required Code specifying the type of quantity FL Units QTY-02 380 Obstetric Additional Units Min 1 Max 15 Decimal number (R) Required Numeric value of quantity Usage notes The number of additional units reported by an anesthesia provider to reflect additional complexity of services. 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 565/665 MEA 4620 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > MEA Test Result To specify physical measurements or counts, including dimensions, tolerances, variances, and weights (See Figures Appendix for example of use of C001) Usage notes Required on Dialysis related service lines for ESRD. Use R1, R2, R3, or R4 to qualify the Hemoglobin, Hematocrit, Epoetin Starting Dosage, and Creatinine test results. OR Required on DMERC service lines to report the Patient's Height from the Certificate of Medical Necessity (CMN). Use HT qualifier. If not required by this implementation guide, do not send. Example MEAOGR200000000~ Max use 5 Optional MEA-01 737 Measurement Reference Identification Code Identifier (ID) Required Code identifying the broad category to which a measurement applies OG Original Use OG to report Starting Dosage. TR Test Results MEA-02 738 Measurement Qualifier Identifier (ID) Required Code identifying a specific product or process characteristic to which a measurement applies HT Height R1 Hemoglobin R2 Hematocrit R3 Epoetin Starting Dosage R4 Creatinine MEA-03 739 Test Results Min 1 Max 15 Decimal number (R) Required The value of the measurement 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 566/665 CN1 4650 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number 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 CN10600000000000000XXX000000XX~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 567/665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 568/665 REF 4700 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number 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 and the number is different than the CLIA number reported at the claim level (Loop ID- 2300). If not required by this implementation guide, do not send.; Example REFX4XXXXX~ Variants (all may be used) REF Immunization Batch Number REF Line Item Control Number REF Mammography Certification Number REF Referral Number REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification REF Repriced Line Item Reference Number REF Adjusted Repriced Line Item Reference Number REF Prior Authorization 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 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 569/665 REF 4700 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF Immunization Batch Number To specify identifying information Usage notes Required when mandated by state or federal law or regulations to report an Immunization Batch Number. If not required by this implementation guide, do not send. Example REFBTXXXXX~ Variants (all may be used) REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Line Item Control Number REF Mammography Certification Number REF Referral Number REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification REF Repriced Line Item Reference Number REF Adjusted Repriced Line Item Reference Number REF Prior Authorization Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification BT Batch Number REF-02 127 Immunization Batch 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 570/665 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 REF6RXXXXXX~ Variants (all may be used) REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Immunization Batch Number REF Mammography Certification Number REF Referral Number REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification REF Repriced Line Item Reference Number REF Adjusted Repriced Line Item Reference Number REF Prior Authorization 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 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 571/665 receiving system is 30'. Characters beyond 30 are not required to be stored nor returned by any 837-receiving system. 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 572/665 REF 4700 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number	X12 HIPAA 837 Health Care Claim_ Professional.pdf
to report an Immunization Batch Number. If not required by this implementation guide, do not send. Example REFBTXXXXX~ Variants (all may be used) REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Line Item Control Number REF Mammography Certification Number REF Referral Number REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification REF Repriced Line Item Reference Number REF Adjusted Repriced Line Item Reference Number REF Prior Authorization Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification BT Batch Number REF-02 127 Immunization Batch 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 570/665 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 REF6RXXXXXX~ Variants (all may be used) REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Immunization Batch Number REF Mammography Certification Number REF Referral Number REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification REF Repriced Line Item Reference Number REF Adjusted Repriced Line Item Reference Number REF Prior Authorization 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 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 571/665 receiving system is 30'. Characters beyond 30 are not required to be stored nor returned by any 837-receiving system. 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 572/665 REF 4700 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF Mammography Certification Number To specify identifying information Usage notes Required when mammography services are rendered by a certified mammography provider and the mammography certification number is different than that sent in Loop ID-2300. If not required by this implementation guide, do not send. Example REFEWXXX~ Variants (all may be used) REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Immunization Batch Number REF Line Item Control Number REF Referral Number REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification REF Repriced Line Item Reference Number REF Adjusted Repriced Line Item Reference Number REF Prior Authorization 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 573/665 REF 4700 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF Referral Number To specify identifying information Usage notes Required when this service line involved a referral number that is different than the number reported at the claim level (Loop-ID 2300). If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Referral Numbers, the composite data element in REF04 is used to identify the payer which assigned this referral number. Example REF9FXXX*2U>XX~ Variants (all may be used) REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Immunization Batch Number REF Line Item Control Number REF Mammography Certification Number REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification REF Repriced Line Item Reference Number REF Adjusted Repriced Line Item Reference Number REF Prior Authorization Max use 5 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 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 Referral Number reported in REF02 of this segment is for a non- destination payer. Max use 1 Optional 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 574/665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 575/665 REF 4700 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification To specify identifying information Usage notes Required for claims for any laboratory that referred tests to another laboratory covered by the CLIA Act that is billed on this line. If not required by this implementation guide, do not send. Example REFF4XX~ Variants (all may be used) REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Immunization Batch Number REF Line Item Control Number REF Mammography Certification Number REF Referral Number REF Repriced Line Item Reference Number REF Adjusted Repriced Line Item Reference Number REF Prior Authorization Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification F4 Facility Certification Number REF-02 127 Referring CLIA 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 576/665 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 REF9BXXXXX~ Variants (all may be used) REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Immunization Batch Number REF Line Item Control Number REF Mammography Certification Number REF Referral Number REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification REF Adjusted Repriced Line Item Reference Number REF Prior Authorization 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 577/665 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 REF9DXXX~ Variants (all may be used) REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Immunization Batch Number REF Line Item Control Number REF Mammography Certification Number REF Referral Number REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification REF Repriced Line Item Reference Number REF Prior Authorization 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 578/665 REF 4700 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF Prior Authorization To specify identifying information Usage notes Required when service line involved a prior authorization number that is different than the number reported at the claim level (Loop ID-2300). If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Prior Authorization Numbers, the composite data element in REF04 is used to identify the payer which assigned this number. Example REFG1XXXX*2U>XXX~ Variants (all may be used) REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Immunization Batch Number REF Line Item Control Number REF Mammography Certification Number REF Referral Number REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification REF Repriced Line Item Reference Number REF Adjusted Repriced Line Item Reference Number Max use 5 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification G1 Prior Authorization Number REF-02 127 Prior Authorization or 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 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 Prior Authorization Number reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 579/665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 580/665 AMT 4750 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > AMT Sales Tax Amount To indicate the total monetary amount Usage notes Required when sales tax applies to the service line and the submitter is required to report that information to the receiver. If	X12 HIPAA 837 Health Care Claim_ Professional.pdf
Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification REF Repriced Line Item Reference Number REF Prior Authorization 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 578/665 REF 4700 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF Prior Authorization To specify identifying information Usage notes Required when service line involved a prior authorization number that is different than the number reported at the claim level (Loop ID-2300). If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Prior Authorization Numbers, the composite data element in REF04 is used to identify the payer which assigned this number. Example REFG1XXXX*2U>XXX~ Variants (all may be used) REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Immunization Batch Number REF Line Item Control Number REF Mammography Certification Number REF Referral Number REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification REF Repriced Line Item Reference Number REF Adjusted Repriced Line Item Reference Number Max use 5 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification G1 Prior Authorization Number REF-02 127 Prior Authorization or 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 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 Prior Authorization Number reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 579/665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 580/665 AMT 4750 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > AMT Sales Tax Amount To indicate the total monetary amount Usage notes Required when sales tax applies to the service line 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 Sales Tax Amount (AMT02), the amount reported in the Line Item Charge Amount (SV102) for this service line must include the amount reported in the Sales Tax Amount. Example AMTT00000~ Variants (all may be used) AMT Postage Claimed Amount Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount T Tax AMT-02 782 Sales Tax Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 581/665 AMT 4750 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > AMT Postage Claimed Amount To indicate the total monetary amount Usage notes Required when service line charge (SV102) includes postage amount claimed in this service line. If not required by this implementation guide, do not send. When reporting the Postage Claimed Amount (AMT02), the amount reported in the Line Item Charge Amount (SV102) for this service line must include the amount reported in the Postage Claimed Amount. Example AMTF4000~ Variants (all may be used) AMT Sales Tax Amount Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount F4 Postage Claimed AMT-02 782 Postage Claimed Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 582/665 K3 4800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number 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 K3XXXXX~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 583/665 NTE 4850 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > NTE Line 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. Use SV101-7 to describe non-specific procedure codes. Do not use this NTE Segment to describe a non-specific procedure code. If an NDC code is reported in Loop 2410, do not use this segment for a description of the procedure code. The NDC in loop 2410 will provide the description. Example NTEDCPXXXX~ Variants (all may be used) NTE Third Party Organization Notes 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 DCP Goals, Rehabilitation Potential, or Discharge Plans 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 584/665 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 NTETPOXXXXXX~ Variants (all may be used) NTE Line 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 585/665 PS1 4880 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > PS1 Purchased Service Information To specify the information about services that are purchased Usage notes Required on non-vision service lines when adjudication is known to be impacted by the charge amount for services purchased from another source. OR Required on vision service lines when adjudication is known to be impacted by the acquisition cost of lenses. If not required by this implementation guide, do not send. Example PS1X00000000000~ Max use 1 Optional PS1-01 127 Purchased Service 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 PS101 is provider identification number. Usage notes This must be the identifier from the Purchased Service Provider Loop (Loop ID-2420B). When the Secondary Identifier REF is used, that is the identifier to be reported. If not present, use the identifier in NM109. PS1-02 782 Purchased Service Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount PS102 is cost of the purchased service. 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 586/665 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 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. 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 HCP1300000000XXX0000XXX000000000000000E RXXXXXXMJ000000000000000T21*3~ 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 587/665 HCP02 is the allowed amount. HCP-03 782 Repriced Saving Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount HCP03	X12 HIPAA 837 Health Care Claim_ Professional.pdf
PS1 Purchased Service Information To specify the information about services that are purchased Usage notes Required on non-vision service lines when adjudication is known to be impacted by the charge amount for services purchased from another source. OR Required on vision service lines when adjudication is known to be impacted by the acquisition cost of lenses. If not required by this implementation guide, do not send. Example PS1X00000000000~ Max use 1 Optional PS1-01 127 Purchased Service 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 PS101 is provider identification number. Usage notes This must be the identifier from the Purchased Service Provider Loop (Loop ID-2420B). When the Secondary Identifier REF is used, that is the identifier to be reported. If not present, use the identifier in NM109. PS1-02 782 Purchased Service Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount PS102 is cost of the purchased service. 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 586/665 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 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. 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 HCP1300000000XXX0000XXX000000000000000E RXXXXXXMJ000000000000000T213~ 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 587/665 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. 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. 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. 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. 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. 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, 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 588/665 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. 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 Identifying number for a product or service HCP10 is the approved procedure code. 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 MJ Minutes 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 Note: When a decimal is needed to report units, include it in this element, for example, "15.6". 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 589/665 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. 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 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. 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 590/665 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 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. OR Required when an HHS approved pilot project specifies reporting of Universal Product Number (UPN) by parties registered in the pilot and their trading partners. OR Required when government regulation mandates that medical and surgical supplies are reported with UPN's. If not required by this implementation guide, do not send. Drugs and biologics reported in this segment are a further specification of service(s) described in the SV1 segment of this Service Line Loop ID-2400. Example LINN4XXXXXX~ 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. Usage notes At the time of this writing, UPN code sets designated by values EN, EO, HI, ON, UK, and UP have been approved by the Secretary of HHS as a pilot project allowed under HIPAA law. During the pilot, these code values may only be used by parties registered in the pilot project and their trading partners. Beyond the pilot, these codes may only be used if mandated by government regulation. EN EAN/UCC - 13 EO EAN/UCC - 8 HI HIBC (Health Care Industry Bar Code) Supplier Labeling Standard Primary Data Message N4 National Drug Code in 5-4-2 Format ON Customer Order Number UK GTIN 14-digit Data Structure UP UCC - 12 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 591/665 LIN-03 234 National Drug Code or Universal Product Number String (AN) Required Min 1 Max 48 Identifying number for a product or service 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 592/665 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***00000000ML~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 593/665 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 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. 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. 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 REFVYX~	X12 HIPAA 837 Health Care Claim_ Professional.pdf
U.P.C. No., ISBN No., Model No., or SKU. Usage notes At the time of this writing, UPN code sets designated by values EN, EO, HI, ON, UK, and UP have been approved by the Secretary of HHS as a pilot project allowed under HIPAA law. During the pilot, these code values may only be used by parties registered in the pilot project and their trading partners. Beyond the pilot, these codes may only be used if mandated by government regulation. EN EAN/UCC - 13 EO EAN/UCC - 8 HI HIBC (Health Care Industry Bar Code) Supplier Labeling Standard Primary Data Message N4 National Drug Code in 5-4-2 Format ON Customer Order Number UK GTIN 14-digit Data Structure UP UCC - 12 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 591/665 LIN-03 234 National Drug Code or Universal Product Number String (AN) Required Min 1 Max 48 Identifying number for a product or service 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 592/665 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***00000000ML~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 593/665 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 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. 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. 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 REFVYX~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 594/665 2420A Rendering Provider Name Loop Max 1 Optional Variants (all may be used) Purchased Service Provider Name Loop Service Facility Location Name Loop Supervising Provider Name Loop Ordering Provider Name Loop Referring Provider Name Loop Ambulance Pick-up Location Loop Ambulance Drop-off Location 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 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. Required when the Rendering Provider NM1 information is different than that carried in the Loop ID-2310B Rendering Provider. OR Required when Loop ID-2310B Rendering Provider is not used AND this particular line item has different Rendering Provider information than that which is carried in Loop ID- 2010AA Billing Provider. If not required by this implementation guide, do not send.; Example NM1822XXXXXXXXXXXXXXXXXXXXXX~ 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. 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 595/665 1 Person 2 Non-Person Entity NM1-03 1035 Rendering Provider Last or Organization Name String (AN) Required Min 1 Max 60 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 596/665 PRV 5050 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 > 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. Example PRVPEPXCXXX~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 597/665 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 REF1GX*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. 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 598/665 2420A 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 599/665 2420B Purchased Service Provider Name Loop Max 1 Optional Variants (all may be used) Rendering Provider Name Loop Service Facility Location Name Loop Supervising Provider Name Loop Ordering Provider Name Loop Referring Provider Name Loop Ambulance Pick-up Location Loop Ambulance Drop-off Location Loop NM1 5000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Purchased Service Provider Name Loop > NM1 Purchased Service Provider Name To supply the full name of an individual or organizational entity Usage notes Required when the service reported in this line item is a purchased service. If not required by this implementation guide, do not send. Purchased services are situations where, for example, a physician purchases a diagnostic exam from an outside entity. Purchased services do not include substitute (locum tenens) provider situations. Example NM1QB1****XXXXXXXXX~ If either Identification Code Qualifier (NM1-08) or Purchased Service 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 Usage notes The entity identifier in NM101 applies to all segments in this iteration of Loop ID-2420. QB Purchase Service 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 NM1-08 66 Identification Code Qualifier Identifier (ID) Optional 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 600/665 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 Purchased Service Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 601/665 REF 5250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Purchased Service Provider Name Loop > REF Purchased Service 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 REF0BXXXXXX**2U>XXXXXX~ Max	X12 HIPAA 837 Health Care Claim_ Professional.pdf
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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 599/665 2420B Purchased Service Provider Name Loop Max 1 Optional Variants (all may be used) Rendering Provider Name Loop Service Facility Location Name Loop Supervising Provider Name Loop Ordering Provider Name Loop Referring Provider Name Loop Ambulance Pick-up Location Loop Ambulance Drop-off Location Loop NM1 5000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Purchased Service Provider Name Loop > NM1 Purchased Service Provider Name To supply the full name of an individual or organizational entity Usage notes Required when the service reported in this line item is a purchased service. If not required by this implementation guide, do not send. Purchased services are situations where, for example, a physician purchases a diagnostic exam from an outside entity. Purchased services do not include substitute (locum tenens) provider situations. Example NM1QB1*****XXXXXXXXX~ If either Identification Code Qualifier (NM1-08) or Purchased Service 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 Usage notes The entity identifier in NM101 applies to all segments in this iteration of Loop ID-2420. QB Purchase Service 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 NM1-08 66 Identification Code Qualifier Identifier (ID) Optional 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 600/665 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 Purchased Service Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 601/665 REF 5250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Purchased Service Provider Name Loop > REF Purchased Service 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 REF0BXXXXXX*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. REF-02 127 Purchased Service 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 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 Max use 1 Optional 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 602/665 2420B Purchased Service Provider Name Loop end Required when the identifier reported in REF02 of this segment is for a non-destination payer. 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 603/665 2420C Service Facility Location Name Loop Max 1 Optional Variants (all may be used) Rendering Provider Name Loop Purchased Service Provider Name Loop Supervising Provider Name Loop Ordering Provider Name Loop Referring Provider Name Loop Ambulance Pick-up Location Loop Ambulance Drop-off Location Loop NM1 5000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Service Facility Location Name Loop > NM1 Service Facility Location Name To supply the full name of an individual or organizational entity Usage notes 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. Required when the location of health care service for this service line is different than that carried in Loop ID-2010AA Billing Provider or Loop ID-2310C Service Facility Location. If not required by this implementation guide, do not send. The purpose of this loop is to identify specifically where the service was rendered. When reporting ambulance services, do not use this loop. Use the pick-up (2420G) and drop-off location (2420H) loops elsewhere in this transaction.; Example NM1772XX****XXXXXXXXX~ 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. 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 604/665 2 Non-Person Entity 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 605/665 N3 5140 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number 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 N3XXX~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 606/665 N4 5200 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Service Facility Location Name Loop > N4 Service Facility Location City, State, ZIP Code To specify the geographic place of the named party Example N4XXXXXXXXXXXXXX~ 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 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 607/665 Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 608/665 REF 5250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Service Facility Location Name Loop > REF Service Facility Location Secondary Identification To specify identifying information Usage notes 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. 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 REFLUXXXXXX**2U>XXX~ Max use 3 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 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 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 C040-01 128 Reference Identification Qualifier Identifier (ID) Required 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 609/665 2420C Service Facility Location Name Loop end 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional	X12 HIPAA 837 Health Care Claim_ Professional.pdf
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 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 607/665 Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 608/665 REF 5250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Service Facility Location Name Loop > REF Service Facility Location Secondary Identification To specify identifying information Usage notes 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. 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 REFLUXXXXXX*2U>XXX~ Max use 3 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 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 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 C040-01 128 Reference Identification Qualifier Identifier (ID) Required 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 609/665 2420C Service Facility Location Name Loop end 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 610/665 2420D Supervising Provider Name Loop Max 1 Optional Variants (all may be used) Rendering Provider Name Loop Purchased Service Provider Name Loop Service Facility Location Name Loop Ordering Provider Name Loop Referring Provider Name Loop Ambulance Pick-up Location Loop Ambulance Drop-off Location Loop NM1 5000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number 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 and the supervising physician is different than that listed at the claim level for this service line. If not required by this implementation guide, do not send. Example NM1DQ1XXXXXXX*XXXXXXXXXXX~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 611/665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 612/665 REF 5250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number 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 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 REFG2XXX2U>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 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 613/665 2420D Supervising 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 614/665 2420E Ordering Provider Name Loop Max 1 Optional Variants (all may be used) Rendering Provider Name Loop Purchased Service Provider Name Loop Service Facility Location Name Loop Supervising Provider Name Loop Referring Provider Name Loop Ambulance Pick-up Location Loop Ambulance Drop-off Location Loop NM1 5000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ordering Provider Name Loop > NM1 Ordering Provider Name To supply the full name of an individual or organizational entity Usage notes Required when the service or supply was ordered by a provider who is different than the rendering provider for this service line. If not required by this implementation guide, do not send. Example NM1DK1XXXXXXXXXXXXXXXX*XXXXXXXXXXXX~ If either Identification Code Qualifier (NM1-08) or Ordering 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 Usage notes The entity identifier in NM101 applies to all segments in this iteration of Loop ID-2420. DK Ordering Physician NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Ordering Provider Last Name Min 1 Max 60 String (AN) Required 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 615/665 Individual last name or organizational name NM1-04 1036 Ordering Provider First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Ordering Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Ordering 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 Ordering Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 616/665 N3 5140 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ordering Provider Name Loop > N3 Ordering Provider Address To specify the location of the named party Usage notes Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN) or DMERC Information Form (DIF), or Oxygen Therapy Certification is included on this service line. If not required by this implementation guide, do not send. Example N3XXXXXXX~ Max use 1 Optional N3-01 166 Ordering Provider Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Ordering Provider Address Line Min 1 Max 55 String (AN) Optional Address information 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 617/665 N4 5200 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ordering Provider Name Loop > N4 Ordering Provider City, State, ZIP Code To specify the geographic place of the named party Usage notes Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN) or DMERC Information Form (DIF), or Oxygen Therapy Certification is included on this service line. If not required by this implementation guide, do not send. Example N4XXXXXXXXX*XXX~ Only one of Ordering 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 Optional N4-01 19 Ordering 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 Ordering 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 Ordering Provider 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	X12 HIPAA 837 Health Care Claim_ Professional.pdf
Provider First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Ordering Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Ordering 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 Ordering Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 616/665 N3 5140 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ordering Provider Name Loop > N3 Ordering Provider Address To specify the location of the named party Usage notes Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN) or DMERC Information Form (DIF), or Oxygen Therapy Certification is included on this service line. If not required by this implementation guide, do not send. Example N3XXXXXXX~ Max use 1 Optional N3-01 166 Ordering Provider Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Ordering Provider Address Line Min 1 Max 55 String (AN) Optional Address information 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 617/665 N4 5200 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ordering Provider Name Loop > N4 Ordering Provider City, State, ZIP Code To specify the geographic place of the named party Usage notes Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN) or DMERC Information Form (DIF), or Oxygen Therapy Certification is included on this service line. If not required by this implementation guide, do not send. Example N4XXXXXXXXXXXX~ Only one of Ordering 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 Optional N4-01 19 Ordering 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 Ordering 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 Ordering Provider 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 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 618/665 Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 619/665 REF 5250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ordering Provider Name Loop > REF Ordering 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 REFG2XXXXX*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 Ordering 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 620/665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 621/665 PER 5300 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ordering Provider Name Loop > PER Ordering Provider Contact Information To identify a person or office to whom administrative communications should be directed Usage notes Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN) or DMERC Information Form (DIF), or Oxygen Therapy Certification is included on this service line. 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 PERICXXFXXFXXXXTEXXXXX~ 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 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 Ordering 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 622/665 2420E Ordering 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 623/665 2420F Referring Provider Name Loop Max 2 Optional Variants (all may be used) Rendering Provider Name Loop Purchased Service Provider Name Loop Service Facility Location Name Loop Supervising Provider Name Loop Ordering Provider Name Loop Ambulance Pick-up Location Loop Ambulance Drop-off Location 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 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. Required when this service line involves a referral and the referring provider differs from that reported at the claim level (loop 2310A). If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Example NM1DN1XXXXXXX*XXXXX*XXXXXX~ 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. 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 624/665 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 625/665 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	X12 HIPAA 837 Health Care Claim_ Professional.pdf
> NM1 Referring Provider Name To supply the full name of an individual or organizational entity Usage notes 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. Required when this service line involves a referral and the referring provider differs from that reported at the claim level (loop 2310A). If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Example NM1DN1XXXXXXXXXXXXXXXXXX~ 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. 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 624/665 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 625/665 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 REF1GX2U>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. 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 626/665 2420F 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 627/665 2420G Ambulance Pick-up Location Loop Max 1 Optional Variants (all may be used) Rendering Provider Name Loop Purchased Service Provider Name Loop Service Facility Location Name Loop Supervising Provider Name Loop Ordering Provider Name Loop Referring Provider Name Loop Ambulance Drop-off Location Loop NM1 5000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number 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 the ambulance pick-up location for this service line is different than the ambulance pick-up location provided in Loop ID-2310E. If not required by this implementation guide, do not send.; Example NM1PW2~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 628/665 N3 5140 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number 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 N3XXXXXX~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 629/665 N4 5200 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number 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 N4XXXXXXXXXXXXXXXX~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 630/665 2420G Ambulance Pick-up Location Loop end Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 631/665 2420H Ambulance Drop-off Location Loop Max 1 Optional Variants (all may be used) Rendering Provider Name Loop Purchased Service Provider Name Loop Service Facility Location Name Loop Supervising Provider Name Loop Ordering Provider Name Loop Referring Provider Name Loop Ambulance Pick-up Location Loop NM1 5000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number 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 the ambulance drop-off location for this service line is different than the ambulance drop-off location provided in Loop ID-2310F. If not required by this implementation guide, do not send. Example NM1452XXXXX~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 632/665 N3 5140 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ambulance Drop-off Location Loop > N3 Ambulance Drop-off Location Address To specify the location of the named party Usage notes If the ambulance drop-off 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 N3XXXXXXX~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 633/665 N4 5200 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number 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 N4XXXXXXXXXX~ 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	X12 HIPAA 837 Health Care Claim_ Professional.pdf
Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number 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 the ambulance drop-off location for this service line is different than the ambulance drop-off location provided in Loop ID-2310F. If not required by this implementation guide, do not send. Example NM1452XXXXX~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 632/665 N3 5140 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Ambulance Drop-off Location Loop > N3 Ambulance Drop-off Location Address To specify the location of the named party Usage notes If the ambulance drop-off 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 N3XXXXXXX~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 633/665 N4 5200 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number 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 N4XXXXXXXXXX~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 634/665 2420H Ambulance Drop-off Location Loop end Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 635/665 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 SVDXXXXXX000HC>XXX>XX>XX>XX>XX>XX*00000000000 000~ 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. Max use 1 Required C003-01 235 Product or Service ID Qualifier Identifier (ID) Required 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 636/665 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. 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. 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 637/665 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 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-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 or Unbundled Line Number Min 1 Max 6 Numeric (N0) Optional Number assigned for differentiation within a transaction set 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 638/665 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 CASCOXXX00000000000000000000000XXXX00000000 000000000000XX00000000000000000XX0000000000 000000XXXXX000000000000XXXXX000000000000*00 0000~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 639/665 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	X12 HIPAA 837 Health Care Claim_ Professional.pdf
assigned for differentiation within a transaction set 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 638/665 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 CASCOXXX00000000000000000000000XXXX00000000 000000000000XX00000000000000000XX0000000000 000000XXXXX000000000000XXXXX00000000000000 0000~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 639/665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 640/665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 641/665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 642/665 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 DTP573D8XX~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 643/665 2430 Line Adjudication Information 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 AMTEAF000000~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 644/665 2440 Form Identification Code Loop Max >1 Optional LQ 5510 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Form Identification Code Loop > LQ Form Identification Code To identify standard industry codes Usage notes Required when adjudication is known to be impacted by one of the types of supporting documentation (standardized paper forms) listed in LQ01. If not required by this implementation guide, do not send. Loop ID-2440 is designed to allow providers to attach standardized supplemental information to the claim when required to do so by the payer. The LQ segment contains information to identify the form (LQ01) and the specific form number (LQ02). In the example given below, LQ01=UT which identifies the form as a Medicare DMERC CMN form. LQ02=01.02 identifies which DMERC CMN form is being used. An example application of this Form Identification Code Loop is for Medicare DMERC claims for which the DME provider is required to obtain a Certificate of Medical Necessity (DMERC CMN) or DMERC Information Form (DIF), or Oxygen Therapy Certification from the referring physician. Another example is payer documentation requirements for Home Health services. Example LQUTXX~ If Code List Qualifier Code (LQ-01) is present, then Form Identifier (LQ-02) is required Max use 1 Required LQ-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list AS Form Type Code Code value AS indicates that a Home Health form from External Code Source 656 is being identified in LQ02. UT Centers for Medicare and Medicaid Services (CMS) Durable Medical Equipment Regional Carrier (DMERC) Certificate of Medical Necessity (CMN) Forms LQ-02 1271 Form Identifier Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 645/665 FRM 5520 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Form Identification Code Loop > FRM Supporting Documentation To specify information in response to a codified questionnaire document Usage notes The LQ segment is used to identify the general (LQ01) and specific type (LQ02) for the form being reported in Loop ID-2440. The FRM segment is used to answer specific questions on the form identified in the LQ segment. FRM01 is used to indicate the question being answered. Answers can take one of 4 forms: FRM02 for Yes/No questions, FRM03 for text/uncodified answers, FRM04 for answers which use dates, and FRM05 for answers which are percents. For each FRM01 (question) use a remaining FRM element, choosing the element which has the most appropriate format. One FRM segment is used for each question/answer pair. The example below shows how the FRM can be used to answer all the pertinent questions on DMERC form 0802 (LQUT08.02~). Example FRMXXXXXWXXXX20250131*0~ At least one of Question Response (FRM-02), Question Response (FRM-03), Question Response (FRM-04) or Question Response (FRM-05) is required Max use 99 Required FRM-01 350 Question Number/Letter Min 1 Max 20 String (AN) Required Alphanumeric characters assigned for differentiation within a transaction set FRM01 is the question number on a questionnaire or codified form. FRM-02 1073 Question Response Identifier (ID) Optional Code indicating a Yes or No condition or response FRM02, FRM03, FRM04 and FRM05 are responses which only have meaning in reference to the question identified in FRM01. N No W Not Applicable Y Yes FRM-03 127 Question Response Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier FRM-04 373 Question Response CCYYMMDD format Date (DT) Optional 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE	X12 HIPAA 837 Health Care Claim_ Professional.pdf
identifies the form as a Medicare DMERC CMN form. LQ02=01.02 identifies which DMERC CMN form is being used. An example application of this Form Identification Code Loop is for Medicare DMERC claims for which the DME provider is required to obtain a Certificate of Medical Necessity (DMERC CMN) or DMERC Information Form (DIF), or Oxygen Therapy Certification from the referring physician. Another example is payer documentation requirements for Home Health services. Example LQUTXX~ If Code List Qualifier Code (LQ-01) is present, then Form Identifier (LQ-02) is required Max use 1 Required LQ-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list AS Form Type Code Code value AS indicates that a Home Health form from External Code Source 656 is being identified in LQ02. UT Centers for Medicare and Medicaid Services (CMS) Durable Medical Equipment Regional Carrier (DMERC) Certificate of Medical Necessity (CMN) Forms LQ-02 1271 Form Identifier Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 645/665 FRM 5520 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Patient Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Form Identification Code Loop > FRM Supporting Documentation To specify information in response to a codified questionnaire document Usage notes The LQ segment is used to identify the general (LQ01) and specific type (LQ02) for the form being reported in Loop ID-2440. The FRM segment is used to answer specific questions on the form identified in the LQ segment. FRM01 is used to indicate the question being answered. Answers can take one of 4 forms: FRM02 for Yes/No questions, FRM03 for text/uncodified answers, FRM04 for answers which use dates, and FRM05 for answers which are percents. For each FRM01 (question) use a remaining FRM element, choosing the element which has the most appropriate format. One FRM segment is used for each question/answer pair. The example below shows how the FRM can be used to answer all the pertinent questions on DMERC form 0802 (LQUT08.02~). Example FRMXXXXXWXXXX202501310~ At least one of Question Response (FRM-02), Question Response (FRM-03), Question Response (FRM-04) or Question Response (FRM-05) is required Max use 99 Required FRM-01 350 Question Number/Letter Min 1 Max 20 String (AN) Required Alphanumeric characters assigned for differentiation within a transaction set FRM01 is the question number on a questionnaire or codified form. FRM-02 1073 Question Response Identifier (ID) Optional Code indicating a Yes or No condition or response FRM02, FRM03, FRM04 and FRM05 are responses which only have meaning in reference to the question identified in FRM01. N No W Not Applicable Y Yes FRM-03 127 Question Response Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier FRM-04 373 Question Response CCYYMMDD format Date (DT) Optional 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 646/665 2440 Form Identification Code 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 2000A Billing Provider Hierarchical Level Loop end Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year FRM-05 332 Question Response Min 1 Max 6 Decimal number (R) Optional Percent given in decimal format (e.g., 0.0 through 100.0 represents 0% through 100%) 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 SE0000001~ 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 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 647/665 Detail end 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 648/665 GE Functional Group Trailer To indicate the end of a functional group and to provide control information Example GE0000000000~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 649/665 IEA Interchange Control Trailer To define the end of an interchange of zero or more functional groups and interchange- related control segments Example IEA0000000000~ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 650/665 EDI Samples Example 1: Commercial Health Insurance ISA00* 00 ZZSENDER ZZRECEIVER 2311061408^005010000000010T>~ GSHCSENDERGSRECEIVERGS20231106140840000000001X005010X222A2~ ST8370021005010X222A2~ BHT001900244579200610151023CH~ NM1412PREMIER BILLING SERVICE****46TGJ23~ PERICJERRYTE3055552222EX231~ NM1402KEY INSURANCE COMPANY***4666783JJT~ HL1201~ PRVBIPXC203BF0100Y~ NM1852BEN KILDARE SERVICE****XX9876543210~ N3234 SEAWAY ST~ N4MIAMIFL33111~ REFEI587654321~ NM1872~ N32345 OCEAN BLVD~ N4MIAMIFL33111~ HL21221~ SBRP2222-SJ****CI~ NM1IL1SMITHJANE**MIJS00111223333~ DMGD819430501F~ NM1PR2KEY INSURANCE COMPANY****PI999996666~ REFG2KA6663~ HL32230~ PAT19~ NM1QC1SMITHTED~ N3236 N MAIN ST~ N4MIAMIFL33413~ DMGD819730501M~ CLM26463774100**11>B>1YAYI~ REFD917312345600006351~ HIBK>0340BF>V7389~ LX1~ SV1HC>9921340UN1**1~ DTP472D820061003~ LX2~ SV1HC>8707015UN1*1~ DTP472D820061003~ LX3~ SV1HC>9921435UN1*2~ DTP472D820061010~ LX4~ SV1HC>8666310UN1*2~ DTP472D820061010~ SE420021~ GE1000000001~ IEA1000000001~ 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 651/665 Example 10a: Drug administered in the Physician Office ISA00 00 ZZSENDER ZZRECEIVER 2311061411^005010000000010T>~ GSHCSENDERGSRECEIVERGS20231106141104000000001X005010X222A2~ ST8370711005010X222A2~ BHT0019000013200408011200CH~ NM1412Associates in Medicine****46587654321~ PERICBud HollyTE8017268899~ NM1402XYZ Receiver***46369852758~ HL1201~ NM1852Associates in Medicine***XX587654321~ N31313 Las Vegas Boulevard~ N4Las VegasNV89109~ REFEI587654321~ HL21220~ SBRP18GRP01020102****CI~ NM1IL1VaughnSteveR**MIMBRID12345~ N3236 Diamond ST~ N4Las VegasNV89109~ DMGD819430501M~ NM1PR2R&R Health Plan****XVPLANID12345~ CLMCLMNO12345103.37**11>B>1YAYY~ HIBK>03591~ NM1821HendrixJim***XX1122333341~ PRVPEPXC208D00000X~ LX1~ SV1HC>9078250UN1111~ DTP472D820040711~ LX2~ SV1HC>J155053.37UN111*1~ DTP472D820040711~ AMTT3.37~ LIN*N400026063512~ CTP***10ML~ SE310711~ GE1000000001~ IEA1000000001~ 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 652/665 Example 11: PPO Repriced Claim ISA00 00 ZZSENDER ZZRECEIVER 2311061415^005010000000010T>~ GSHCSENDERGSRECEIVERGS20231106141535000000001X005010X222A2~ ST8371002005010X222A2~ BHT00190010022005062009460000CH~ NM1412REGIONAL PPO NETWORK****46123456789~ PERICSUBMITTER CONTACT INFOTE8001231234~ NM1402EXTRA HEALTHY INSURANCE***46112244~ HL1201~ NM1852HAPPY DOCTORS GROUP PRACTICE***XX1234567890~ N3P O BOX 123~ N4FORT WAYNEIN462540000~ REFEI555512345~ PERICSUE BILLINGSWORTHTE8881231234~ HL21220~ SBRP18123XYZ****CI~ NM1IL1RINGDIAMONDD**MI00124A089~ N3123 EXAMPLE DRIVE~ N4INDIANAPOLISIN462290000~ DMGD819401229F~ NM1PR2EXTRA HEALTHY INSURANCE****PI12345~ CLMABC123-RI28.75**11>B>1YAYYP~ REF9A0902352342~ REFD9061505501749388~ HIBK>496BF>25000~ HCP0326.752908231234~ NM1DN1DOEJOHN***XX9988776655~ NM1821ANTHONYSUSANB*XX1122334455~ NM1772HAPPY DOCTORS GROUP~ N3123 FEEL GOOD ROAD~ N4WASHINGTONIN475010000~ LX1~ SV1HC>E0570>RR25UN1**1>2~ DTP472D820050514~ HCP0323.751.25908231234~ LX2~ SV1HC>A7003>NU3.75UN1*1~ DTP472D820050514~ HCP033.75908231234~ SE371002~ GE1000000001~ IEA1000000001~ 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 653/665 Example 12: Out of Network Repriced Claim ISA00 00 ZZSENDER ZZRECEIVER 2311061416^005010000000010T>~ GSHCSENDERGSRECEIVERGS20231106141631000000001X005010X222A2~ ST8371024005010X222A2~ BHT0019001024200507111335CH~ NM1412REGIONAL PPO NETWORK****46123456789~ PERICSUBMITTER CONTACT INFOTE8001231234~ NM1402CONSERVATIVE INSURANCE***46000110002~ HL1201~ NM1852EMERGENCY PHYSICIANS GROUP***XX1122334455~ N37423 SUPER STREET~ N4BILLINGSMO919910000~ REFEI111002222~ HL21221~ SBRP232AA****CI~ NM1IL1SMITHMATTHEWR**MI57976235C~ N35698 SOUTH STREET~ N4BILLINGSMO919910000~ DMGD819561015M~ NM1PR2CONSERVATIVE INSURANCE****PI00123~ HL32230~ PAT19~ NM1QC1SMITHTOME~ N35698 SOUTH STREET~ N4BILLINGSMO919910000~ DMGD819960807M~ CLMTS234H3252.71*23>B>1YAYYP~ REF9A0902345406~ REFD9687534234346~ HIBK>9951~ HCP000333001234*******T1~ NM1821BLUEJACKIED**XX1112223336~ SBRS1856567***CI~ OIY*Y~ NM1IL1SMITHTOME**MI23424570~ N35698 SOUTH STREET~ N4BILLINGSMO919910000~ NM1PR2SECONDARY INSURANCE COMPANY***PI95645~ LX1~ SV1HC>99284252.71UN1*1~ DTP472D820050506~ SE391024~ GE1000000001~ IEA1000000001~ 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 654/665 Example 2: Encounter ISA00 00 ZZSENDER ZZRECEIVER 2311061418^005010000000010T>~ GSHCSENDERGSRECEIVERGS20231106141815000000001X005010X222A2~ ST8370021005010X222A2~ BHT0019000123200610151023RP~ NM1412PREMIER BILLING SERVICE****46TGJ23~ PERICJERRYTE3055552222EX231~ NM1402AHLIC***4666783JJT~ HL1201~ PRVBIPXC203BF0100Y~ NM1852BEN KILDARE SERVICE****XX9876543210~ N3234 SEAWAY ST~ N4MIAMIFL33111~ REFEI587654321~ NM1872~ N32345 OCEAN BLVD~ N4MIAMIFL33111~ HL21220~ SBRP1812312-A****HM~ NM1IL1SMITHTED**MI000221111~ N3236 N MAIN ST~ N4MIAMIFL33413~ DMGD819430501M~ NM1PR2ALLIANCE HEALTH AND LIFE INSURANCE****PI741234~ CLM26462967100**11>B>1YAYI~ DTP431D819981003~ REFD917312345600006351~ HIBK>0340BF>V7389~ NM1772KILDARE ASSOCIATES***XX5812345679~ N32345 OCEAN BLVD~ N4MIAMIFL33111~ LX1~ SV1HC>9921340UN1*1~ DTP472D820061003~ LX2~ SV1HC>8707215UN1*1~ DTP472D820061003~ LX3~ SV1HC>9921435UN1*2~ DTP472D820061010~ LX4~ SV1HC>8666310UN1*2~ DTP472D820061010~ SE410021~ GE1000000001~ IEA1000000001~ 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 655/665 Example 3a: Claim from Billing Provider to Payer A ISA00 00 ZZSENDER ZZRECEIVER 2311061420^005010000000010T>~ GSHCSENDERGSRECEIVERGS20231106142058000000001X005010X222A2~ ST8370021005010X222A2~ BHT0019000123200510151023CH~ NM1412PREMIER BILLING SERVICE****46TGJ23~ PERICJERRYTE3055552222~ NM1402XYZ REPRICER***4666783JJT~ HL1201~ NM1851KILDAREBEN***XX1999996666~ N3234 SEAWAY ST~ N4MIAMIFL33111~ REFEI123456789~ PERICCONNIETE3055551234~ NM1872~ N32345 OCEAN BLVD~ N4MIAMIFL33111~ HL21221~ SBRP******CI~ NM1IL1SMITHJANE**MI111223333~ DMGD819430501F~ NM1PR2KEY INSURANCE COMPANY****PI999996666~ N33333 OCEAN ST~ N4SOUTH MIAMIFL33000~ REFG2PBS3334~ HL32230~ PAT19~ NM1QC1SMITHTED~ N3236 N MAIN ST~ N4MIAMIFL33413~ DMGD819730501M~ CLM2640778979.04**11>B>1YAYIP~ HIBK>4779BF>2724BF>2780BF>53081~ NM1821KILDAREBEN***XX1999996666~ PRVPEPXC204C00000X~ REFG2KA6663~ NM1772KILDARE ASSOCIATES****XX1581234567~ N32345 OCEAN BLVD~ N4MIAMIFL33111~ SBRS01*****CI~ OIYP*Y~ NM1IL1SMITHJACK**MIT55TY666~ N3236 N MAIN ST~ N4MIAMIFL33111~ NM1PR2KEY INSURANCE COMPANY***PI999996666~ LX1~ SV1HC>9921343UN1*1>2>3>4~ DTP472D820051003~ LX2~ SV1HC>9078215UN1*1>2~ DTP472D820051003~ LX3~ SV1HC>J330121.04UN1*1>2~ DTP472D820051003~ 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 656/665 SE520021~ GE1000000001~ IEA1000000001~ 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 657/665 Example 4: Medicare Secondary Payer (COB) ISA00 00 ZZSENDER ZZRECEIVER 2311061421^005010000000010T>~ GSHCSENDERGSRECEIVERGS20231106142142000000001X005010X222A2~ ST8370002005010X222A2~ BHT00190000000114220050214115101CH~ NM1412SPECIALISTS****461111111~ PERICSUETE8005558888~ NM1402MEDICARE PENNSYLVANIA***4610234~ HL1201~ NM1852SPECIALISTS***XX0100000090~ N35 MAP COURT~ N4MAYNEPA17111~ REFEI890123456~ REF1G110101~ HL21220~ SBRS18MEDICARE12****MB~ NM1IL1MEDYUMWAYNEM**MI102200221B1~ N31010 THOUSAND OAK LANE~ N4MAYNPA17089~ DMGD819560110M~ NM1PR2MEDICARE PENNSYLVANIA****PI10234~ N35232 MAYNE AVENUE~ N4LYGHTPA17009~ CLM101KEN6055120**11>B>1YAYYP~ HIBK>71516BF>71906~ NM1DN1BRYHTLEET~ REF1GB01010~ NM1821HENZESJACK**XX9090909090~ PRVPEPXC207X00000X~ REFG2110102CCC~ SBRP01COMMERCE***CI~ AMTD80~ AMTA815~ OI*YP*Y~ NM1IL1MEDYUMCAROL**MICOM188-404777~ N3PO BOX 45~ N4MAYNPA17089~ NM1PR2COMMERCE***PI59999~ LX1~ SV1HC>99203>25120UN1*1>2~ DTP472D820050119~ SVD5999980HC>99203>251~ CASCO4225~ CASPR215~ DTP573D820050128~ SE430002~ GE1000000001~ IEA1000000001~ 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 658/665 Example 5: Ambulance ISA00 00 ZZSENDER ZZRECEIVER 2311061422^005010000000010T>~ GSHCSENDERGSRECEIVERGS20231106142212000000001X005010X222A2~ ST837000017712005010X222A2~ BHT001900000017712200502081112CH~ NM1412AAA AMBULANCE SERVICE****46376985369~ PERICLISA SMITHTE3037752536~ NM1402MEDICARE B***46123245~ HL1201~ PRVBIPXC3416L0300X~ NM1852AAA AMBULANCE SERVICE****XX2366554859~ N312202 AIRPORT WAY~ N4BROOMFIELDCO800210021~ REFEI376985369~ HL21220~ SBRP18******MB~ NM1IL1JONESSARAHA**MI012345678A~ N31129 REINDEER ROAD~ N4CARRCO80612~ DMGD819630729F~ NM1PR2MEDICARE PART B****PI123245~ N3PO BOX 3543~ N4BALTIMOREMD666013543~ CLM051068766.50**41>B>1YAYYPOA~ DTP439D820050208~ CR1LB275*ADH21**PATIENT IMOBILIZED~ CRC07Y040609~ CRC07N050708~ HIBK>8628BF>E8888BF>9592BF>8540~ NM1PW2~ N31129 REINDEER ROAD~ N4CARRCO80612~ NM1452~ N310005 BANNOCK ST~ N4CHEYENNEWY82009~ LX1~ SV1HC>A0427>RH700UN1*1>2>3>4Y~ DTP472D820050208~ QTYPT2~ REF6R1001~ NTEADDCARDIAC EMERGENCY~ LX2~ SV1HC>A0425>RH8.20UN21*1>2>3>4Y~ DTP472D820050208~ QTYPT2~ REF6R1002~ LX3~ SV1HC>A0422>RH46UN1*1>2>3>4Y~ DTP472D820050208~ REF6R1003~ LX4~ SV1HC>A0382>RH12.30UN1*1>2>3>4Y~ DTP472D820050208~ REF6R1004~ 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 659/665 SE52000017712~ GE1000000001~ IEA1000000001~ 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 660/665 Example 6: Chiropractic ISA00* 00 ZZSENDER ZZRECEIVER 2311061422^005010000000010T>~ GSHCSENDERGSRECEIVERGS20231106142242000000001X005010X222A2~ ST8373701005010X222A2~ BHT00190000722720050215075420CH~ NM1412DAVID GREEN****46S01057~ PERICKATHY SMITHTE4105558888~ NM1402MEDICARE PART B MARYLAND***4612345~ HL1201~ NM1851GREENEDAVIDM*XX1234567890~ N31264 OAKWOOD AVE~ N4BALTIMOREMD21236~ REFEI987654321~ PERICDRTE4105551212~ HL21220~ SBRP18******MB~ NM1IL1WILLIAMSONMATTHEWJ**MI123456789A~ N3128 BROADCREEK~ N4BALTIMOREMD21234~ DMGD819250110M~ NM1PR2MEDICARE PART B MARYLAND****PIC12345~ CLM125WILL145.5**11>B>1YAYY~ DTP454D820050115~ DTP453D820050110~ DTP455D820050113~ CR2******ACHRONIC PAIN AND DISCOMFORT~ HIBK>7215~ LX1~ SV1HC>98940145.5UN1**1~ DTP472D820050215~ REF6R01~ SE293701~ GE1000000001~ IEA1000000001~ 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 661/665 Example 7: Oxygen ISA00 00 ZZSENDER ZZRECEIVER 2311061423^005010000000010T>~ GSHCSENDERGSRECEIVERGS20231106142340000000001X005010X222A2~ ST8370001005010X222A2~ BHT00190016200503261036CH~ NM1412OXYGEN SUPPLY COMPANY****46ABC11111~ PERICBONNIETE8125551111EM[email protected]~ NM1402DMERC CARRIER***4699999~ HL1201~ NM1852OXYGEN SUPPLY COMPANY***XX9992233334~ N31800 EAST RIDGE DRIVE~ N4RICHMONDIN46224~ REFEI389999999~ HL21220~ SBRP18******MB~ NM1IL1SMITHTERRY**MI111222333A~ N3121 SOUTH ST~ N4RICHMONDIN46236~ DMGD819380105F~ NM1PR2DMERC CARRIER****PI99999~ CLMR03996273 #01520.24**11>B>1YAYY~ HIBK>496BF>51881BF>2859~ LX1~ SV1HC>E1390>RR461.1UN1*1>2~ PWKCTAD~ CR3RMO99~ DTP472RD820050321-20050321~ DTP607D820050321~ DTP463D820040321~ DTP461D820050321~ NM1DK1WILSONLARRY***XX5555511111~ N31212 NORTH MERIDIAN~ N4RICHMONDIN46223~ REF1GX99999~ PERICLEETE5554446666~ LQUT04.03~ FRM1A056~ FRM1C*20050228~ FRM2*1~ FRM3*1~ FRM4Y~ FRM5*2~ FRM7Y~ FRM8N~ FRM9Y~ LX2~ SV1HC>E0431>RR59.14UN1**1>2~ PWKCTAD~ CR3RMO99~ DTP472RD820050321-20050321~ DTP607D820050321~ DTP463D820040321~ DTP461D820050321~ NM1DK1WILSONLARRY***XX5555511111~ 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 662/665 N31212 NORTH MERIDIAN~ N4RICHMONDIN46223~ REF1GX99999~ PERICLEETE5554446666~ LQUT04.03~ FRM1A056~ FRM1C*20050228~ FRM2*1~ FRM3*1~ FRM4Y~ FRM5*2~ FRM7Y~ FRM8N~ FRM9Y~ SE660001~ GE1000000001~ IEA1000000001~ 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 663/665 Example 8: Wheelchair ISA00* 00 ZZSENDER ZZRECEIVER 2311061424^005010000000010T>~ GSHCSENDERGSRECEIVERGS20231106142406000000001X005010X222A2~ ST837112233005010X222A2~ BHT00190016200503261036CH~ NM1412XYZ WHEELCHAIRS INC****46ABC55~ PERICJANETE2225551111~ NM1402DMERC CARRIER***4699999~ HL1201~ NM1852XYZ WHEELCHAIR INC***XX7778889999~ N31440 NORTH STREET~ N4LAFAYETTEIN47904~ REFEI123567989~ REF1G0426960001~ HL21220~ SBRP18*****MB~ PAT****01155~ NM1IL1SMITHJAMES***MI987654321A~ N312 MAIN ST~ N4FRANKFORTIN46209~ DMGD819201023M~ NM1PR2DMERC CARRIER****PI99999~ CLMSMI12375**12>B>1YAYY~ HIBK>436BF>3449~ LX1~ SV1HC>K0001>RR>KH>BR75UN1**1>2~ PWKCTAD~ CR3IMO99~ DTP472RD820050321-20050321~ DTP463D820040321~ DTP461D820050321~ MEATRHT70~ NM1DK1WILSONRANDALL***XX1111155555~ N31226 WEST RAILROAD STREET~ N4LAFAYETTEIN47905~ REF1GM12345~ PERICLEETE7659259999~ LQUT02.03B~ FRM1Y~ FRM2N~ FRM3N~ FRM4N~ FRM58~ FRM8N~ FRM9Y~ SE43112233~ GE1000000001~ IEA1*000000001~ 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 664/665 Stedi is a registered trademark of Stedi, Inc. 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PENNSYLVANIA****PI10234~ N35232 MAYNE AVENUE~ N4LYGHTPA17009~ CLM101KEN6055120**11>B>1YAYYP~ HIBK>71516BF>71906~ NM1DN1BRYHTLEET~ REF1GB01010~ NM1821HENZESJACK**XX9090909090~ PRVPEPXC207X00000X~ REFG2110102CCC~ SBRP01COMMERCE***CI~ AMTD80~ AMTA815~ OI*YP*Y~ NM1IL1MEDYUMCAROL**MICOM188-404777~ N3PO BOX 45~ N4MAYNPA17089~ NM1PR2COMMERCE***PI59999~ LX1~ SV1HC>99203>25120UN1*1>2~ DTP472D820050119~ SVD5999980HC>99203>251~ CASCO4225~ CASPR215~ DTP573D820050128~ SE430002~ GE1000000001~ IEA1000000001~ 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 658/665 Example 5: Ambulance ISA00 00 ZZSENDER ZZRECEIVER 2311061422^005010000000010T>~ GSHCSENDERGSRECEIVERGS20231106142212000000001X005010X222A2~ ST837000017712005010X222A2~ BHT001900000017712200502081112CH~ NM1412AAA AMBULANCE SERVICE****46376985369~ PERICLISA SMITHTE3037752536~ NM1402MEDICARE B***46123245~ HL1201~ PRVBIPXC3416L0300X~ NM1852AAA AMBULANCE SERVICE****XX2366554859~ N312202 AIRPORT WAY~ N4BROOMFIELDCO800210021~ REFEI376985369~ HL21220~ SBRP18******MB~ NM1IL1JONESSARAHA**MI012345678A~ N31129 REINDEER ROAD~ N4CARRCO80612~ DMGD819630729F~ NM1PR2MEDICARE PART B****PI123245~ N3PO BOX 3543~ N4BALTIMOREMD666013543~ CLM051068766.50**41>B>1YAYYPOA~ DTP439D820050208~ CR1LB275*ADH21**PATIENT IMOBILIZED~ CRC07Y040609~ CRC07N050708~ HIBK>8628BF>E8888BF>9592BF>8540~ NM1PW2~ N31129 REINDEER ROAD~ N4CARRCO80612~ NM1452~ N310005 BANNOCK ST~ N4CHEYENNEWY82009~ LX1~ SV1HC>A0427>RH700UN1*1>2>3>4Y~ DTP472D820050208~ QTYPT2~ REF6R1001~ NTEADDCARDIAC EMERGENCY~ LX2~ SV1HC>A0425>RH8.20UN21*1>2>3>4Y~ DTP472D820050208~ QTYPT2~ REF6R1002~ LX3~ SV1HC>A0422>RH46UN1*1>2>3>4Y~ DTP472D820050208~ REF6R1003~ LX4~ SV1HC>A0382>RH12.30UN1*1>2>3>4Y~ DTP472D820050208~ REF6R1004~ 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 659/665 SE52000017712~ GE1000000001~ IEA1000000001~ 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 660/665 Example 6: Chiropractic ISA00* 00 ZZSENDER ZZRECEIVER 2311061422^005010000000010T>~ GSHCSENDERGSRECEIVERGS20231106142242000000001X005010X222A2~ ST8373701005010X222A2~ BHT00190000722720050215075420CH~ NM1412DAVID GREEN****46S01057~ PERICKATHY SMITHTE4105558888~ NM1402MEDICARE PART B MARYLAND***4612345~ HL1201~ NM1851GREENEDAVIDM*XX1234567890~ N31264 OAKWOOD AVE~ N4BALTIMOREMD21236~ REFEI987654321~ PERICDRTE4105551212~ HL21220~ SBRP18******MB~ NM1IL1WILLIAMSONMATTHEWJ**MI123456789A~ N3128 BROADCREEK~ N4BALTIMOREMD21234~ DMGD819250110M~ NM1PR2MEDICARE PART B MARYLAND****PIC12345~ CLM125WILL145.5**11>B>1YAYY~ DTP454D820050115~ DTP453D820050110~ DTP455D820050113~ CR2******ACHRONIC PAIN AND DISCOMFORT~ HIBK>7215~ LX1~ SV1HC>98940145.5UN1**1~ DTP472D820050215~ REF6R01~ SE293701~ GE1000000001~ IEA1000000001~ 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 661/665 Example 7: Oxygen ISA00 00 ZZSENDER ZZRECEIVER 2311061423^005010000000010T>~ GSHCSENDERGSRECEIVERGS20231106142340000000001X005010X222A2~ ST8370001005010X222A2~ BHT00190016200503261036CH~ NM1412OXYGEN SUPPLY COMPANY****46ABC11111~ PERICBONNIETE8125551111EM[email protected]~ NM1402DMERC CARRIER***4699999~ HL1201~ NM1852OXYGEN SUPPLY COMPANY***XX9992233334~ N31800 EAST RIDGE DRIVE~ N4RICHMONDIN46224~ REFEI389999999~ HL21220~ SBRP18******MB~ NM1IL1SMITHTERRY**MI111222333A~ N3121 SOUTH ST~ N4RICHMONDIN46236~ DMGD819380105F~ NM1PR2DMERC CARRIER****PI99999~ CLMR03996273 #01520.24**11>B>1YAYY~ HIBK>496BF>51881BF>2859~ LX1~ SV1HC>E1390>RR461.1UN1*1>2~ PWKCTAD~ CR3RMO99~ DTP472RD820050321-20050321~ DTP607D820050321~ DTP463D820040321~ DTP461D820050321~ NM1DK1WILSONLARRY***XX5555511111~ N31212 NORTH MERIDIAN~ N4RICHMONDIN46223~ REF1GX99999~ PERICLEETE5554446666~ LQUT04.03~ FRM1A056~ FRM1C*20050228~ FRM2*1~ FRM3*1~ FRM4Y~ FRM5*2~ FRM7Y~ FRM8N~ FRM9Y~ LX2~ SV1HC>E0431>RR59.14UN1**1>2~ PWKCTAD~ CR3RMO99~ DTP472RD820050321-20050321~ DTP607D820050321~ DTP463D820040321~ DTP461D820050321~ NM1DK1WILSONLARRY***XX5555511111~ 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 662/665 N31212 NORTH MERIDIAN~ N4RICHMONDIN46223~ REF1GX99999~ PERICLEETE5554446666~ LQUT04.03~ FRM1A056~ FRM1C*20050228~ FRM2*1~ FRM3*1~ FRM4Y~ FRM5*2~ FRM7Y~ FRM8N~ FRM9Y~ SE660001~ GE1000000001~ IEA1000000001~ 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 663/665 Example 8: Wheelchair ISA00* 00 ZZSENDER ZZRECEIVER 2311061424^005010000000010T>~ GSHCSENDERGSRECEIVERGS20231106142406000000001X005010X222A2~ ST837112233005010X222A2~ BHT00190016200503261036CH~ NM1412XYZ WHEELCHAIRS INC****46ABC55~ PERICJANETE2225551111~ NM1402DMERC CARRIER***4699999~ HL1201~ NM1852XYZ WHEELCHAIR INC***XX7778889999~ N31440 NORTH STREET~ N4LAFAYETTEIN47904~ REFEI123567989~ REF1G0426960001~ HL21220~ SBRP18*****MB~ PAT****01155~ NM1IL1SMITHJAMES***MI987654321A~ N312 MAIN ST~ N4FRANKFORTIN46209~ DMGD819201023M~ NM1PR2DMERC CARRIER****PI99999~ CLMSMI12375**12>B>1YAYY~ HIBK>436BF>3449~ LX1~ SV1HC>K0001>RR>KH>BR75UN1**1>2~ PWKCTAD~ CR3IMO99~ DTP472RD820050321-20050321~ DTP463D820040321~ DTP461D820050321~ MEATRHT70~ NM1DK1WILSONRANDALL***XX1111155555~ N31226 WEST RAILROAD STREET~ N4LAFAYETTEIN47905~ REF1GM12345~ PERICLEETE7659259999~ LQUT02.03B~ FRM1Y~ FRM2N~ FRM3N~ FRM4N~ FRM58~ FRM8N~ FRM9Y~ SE43112233~ GE1000000001~ IEA1000000001~ 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 664/665 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. Example 9: Anesthesia ISA00* 00 ZZSENDER ZZRECEIVER 2311061424^005010000000010T>~ GSHCSENDERGSRECEIVERGS20231106142432000000001X005010X222A2~ ST8370001005010X222A2~ BHT0019000123200501171023CH~ NM1412PROVIDER MEDICAL GROUP****46N305~ PERICNINATE6155551212EX911~ NM1402ABC PAYER***4605440~ HL1201~ NM1852PROVIDER MEDICAL GROUP***XX2366554859~ N31234 WEST END AVE~ N4NASHVILLETN37232~ REFEI756473826~ HL21220~ SBRP18******MB~ NM1IL1JONESMARGARET**MI123456789A~ N3123 RAINBOW ROAD~ N4NASHVILLETN37232~ DMGD819740303F~ NM1PR2ABC PAYER****PI05440~ CLM153829140827**22>B>1YAYY~ HIBK>36616~ NM1821TOWNSENDJACOBE*XX5678912345~ PRVPEPXC207L00000X~ REFG29741234~ NM1772PROVIDER OP HOSP****XX432198765~ N3345 MAIN DRIVE~ N4NASHVILLETN37232~ LX1~ SV1HC>00142>QK>QS>P1827MJ61*1~ DTP472D820050112~ SE290001~ GE1000000001~ IEA1000000001~ 1/30/25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-professional-x222a2/01GRYB6EJ999Y6MZ53ZBAHYBHE 665/665	X12 HIPAA 837 Health Care Claim_ Professional.pdf
CarePartners of Connecticut 837 COMPANION GUIDE HIPAA Transaction Standard Companion Guide Refers to the Implementation Guides Based on ASC X12 version 005010 Instructions Related to 837 Healthcare Institutional & Professional Claims Transactions Based on ASC X12 Implementation Guides, Version 005010 October 2018 CarePartnersCT Standard 837 Companion Guide Disclosure Statement The information in this document is subject to change. Changes will be posted via the CarePartners of Connecticut website located at: www.carepartnersct.com/ This template is Copyright © 2010 by The Workgroup for Electronic Data Interchange (WEDI) and the Data Interchange Standards Association (DISA), on behalf of the Accredited Standards Committee (ASC) X12. All rights reserved. It may be freely redistributed in its entirety provided that this copyright notice is not removed. It may not be sold for profit or used in commercial documents without the written permission of the copyright holder. This document is provided “as is” without any express or implied warranty. Note that the copyright on the underlying ASC X12 Standards is held by DISA on behalf of ASC X12 Preface CarePartners of Connecticut is accepting X12 837 Institutional (837I) & X12 837 Professional (837P) Health Care Claims, as mandated by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The X12 837I and 837P versions of the 5010 Standards for Electronic Data Interchange Technical Report Type 3 and Errata (also referred to as Implementation Guides) for the Health Care Institutional and Professional Claims has been established as the standard for Health Care claims transaction compliance. This document has been prepared to serve as a CarePartners of Connecticut specific companion guide to the 837I and 837P Transaction Sets. This document supplements but does not contradict any requirements in the 837 I&P Technical Report, Type 3. The primary focus of the document is to clarify specific segments and data elements that should be submitted to CarePartners of Connecticut on the 837 Institutional & Professional Claim Transactions. This document will be subject to revisions as new versions of the 837 Institutional & Professional Health Care Claim Transaction Set Technical Reports are released. This document has been designed to aid both the technical and business areas. It contains CarePartners of Connecticut specifications for the transactions as well as contact information and key points CarePartnersCT Standard 837 Companion Guide Table Of Contents 1 INTRODUCTION .................................................................................................................................................................... 4 SCOPE ............................................................................................................................................................................................... 4 OVERVIEW ........................................................................................................................................................................................ 4 REFERENCES ..................................................................................................................................................................................... 4 2 GETTING STARTED ................................................................................................................................................................ 5 WORKING WITH CAREPARTNERS OF CONNECTICUT ........................................................................................................................ 5 TRADING PARTNER REGISTRATION .................................................................................................................................................. 5 3 TESTING WITH THE PAYER ..................................................................................................................................................... 6 4 CONNECTIVITY WITH THE PAYER/COMMUNICATIONS ........................................................................................................... 6 TRANSMISSION ADMINISTRATIVE PROCEDURES ............................................................................................................................. 6 Direct Submitters ......................................................................................................................................................................... 6 RE-TRANSMISSION PROCEDURE .................................................................................................................................................. 6 COMMUNICATION PROTOCOL SPECIFICATIONS .............................................................................................................................. 7 PASSWORDS ..................................................................................................................................................................................... 9 MAINTENANCE SCHEDULE ............................................................................................................................................................. 10 RULES OF BEHAVIOR ...................................................................................................................................................................... 10 5 CONTACT INFORMATION ................................................................................................................................................... 10 6 CONTROL SEGMENTS/ENVELOPES ....................................................................................................................................... 10 SETUP FOR 837 INBOUND TRANSACTIONS ............................................................................................................................................. 11 ISA-IEA ....................................................................................................................................................................................... 11 IEA - Interchange Control Trailer Segment ................................................................................................................................. 12 GS-GE - Functional Group Header Segment ................................................................................................................................ 12 Group Trailer .............................................................................................................................................................................. 13 7 PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS........................................................................................................... 12 BUSINESS SCENARIOS ........................................................................................................................................................................... 12 FREQUENTLY ASKED QUESTIONS ............................................................................................................................................................ 14 GENERAL CLAIM QUESTIONS ................................................................................................................................................................. 14 CAREPARTNERS OF CONNECTICUT PRODUCT TYPE QUESTIONS ..................................................................................................................... 15 DIRECT 837 CLAIMS QUESTIONS............................................................................................................................................................ 15 ELECTRONIC FUNDS TRANSFER .............................................................................................................................................................. 15 8 ACKNOWLEDGEMENTS AND/OR REPORTS ..................................................................................................................... 15 ACKNOWLEDGEMENTS ......................................................................................................................................................................... 15 9 TRADING PARTNER AGREEMENTS .................................................................................................................................. 18 TRADING PARTNERS ....................................................................................................................................................................... 18 10 TRANSACTION SPECIFIC INFORMATION ......................................................................................................................... 18 005010X223A2 HEALTH CARE CLAIM: INSTITUTIONAL ............................................................................................................................. 19 005010X222A1 HEALTH CARE CLAIM: PROFESSIONAL ............................................................................................................................. 21 APPENDICES .......................................................................................................................................................................... 30 A - EDI SET UP FORM ......................................................................................................................................................................... 30 B - TRANSACTION EXAMPLES ................................................................................................................................................................. 31 837 Institutional Claim Sample: ................................................................................................................................................. 31 837 Professional Claim Sample: ................................................................................................................................................. 32 C - CHANGE SUMMARY ......................................................................................................................................................................... 32 CarePartnersCT Standard 837 Companion Guide 1 INTRODUCTION In order to submit a valid transaction, please refer to the National Electronic Data Interchange Transaction Set Technical Report & Errata for the Health Care Claim: Institutional ASC X12N 837 (005010X223, 005010X223A1 & 005010X223A2) and The Health Care Claim: Professional ASC X12N 837 (005010X222 & 005010X222A1). The Technical Reports can be ordered from the Washington Publishing Company’s website at www.wpc-edi.com. For questions relating to the CarePartners of Connecticut 837 Institutional Claim Transaction, and the 837 Professional Claim Transaction, or testing, please contact the EDI Operations Department at 888-631-7002, Ext. 52994 or email your questions to [email protected]. CarePartners of Connecticut billing guidelines are not included in this document. Please refer to our website at http://www.carepartnersct.com/ for these guidelines, or contact Provider Services at 888-341-1508. Please note, CarePartners of Connecticut is not responsible for any software utilized by the submitter for the creation of an ASC X12 837I or ASC X12 837P transactions. SCOPE The transaction instruction component of this companion guide must be used in conjunction with an associated ASC X12 Implementation Guide. The instructions in this companion guide are not intended to be stand-alone requirements documents. This companion guide conforms to all the requirements of any associated ASC X12 Implementation Guides and is in conformance with ASC X12’s Fair Use and Copyright statements. OVERVIEW The Health Insurance Portability and Accountability Act–Administration Simplification (HIPAA-AS) requires CarePartners of Connecticut and all other covered entities to comply with the electronic data interchange standards for health care as established by the Secretary of Health and Human Services. This guide is designed to help those responsible for testing and setting up electronic claim submission transactions. Specifically, it documents and clarifies when situational data elements and segments must be used for reporting and identifies codes and data elements that do not apply to CarePartners of Connecticut. This guide supplements (but does not contradict) requirements in the ASC X12 837 (version 005010X223 and 005010X223A1/A2) or the ASC X12 837 (005010X222 & 005010X222A1) implementation. This information should be given to the provider’s business area to ensure that healthcare claim status responses are interpreted correctly. REFERENCES The ASC X12 837 (version 005010X222A1 and 005010X223A2) Implementation Guide for HealthCare Claim Transaction has been established as the standard for claim submission transactions and is available at http://www.wpc-edi.com. CarePartners of Connecticut Web site containing documentation on transactions for providers is located at www.carepartnersct.com. CarePartners of Connecticut Web site containing documentation on e-transactions for providers is located at https://www.carepartnersct.com/for-providers/provider-resource-center CarePartnersCT Standard 837 Companion Guide 2 GETTING STARTED WORKING WITH CAREPARTNERS OF CONNECTICUT This section describes how to interact with CarePartners of Connecticut EDI Department. For questions relating to the CarePartners of Connecticut 837 Health Care Transactions or testing, contact the EDI Operations Department at 888-631-7002, Ext. 52994 or e-mail your questions to: [email protected] TRADING PARTNER REGISTRATION This section describes how to register as a trading partner with CarePartners of Connecticut. By contacting the EDI Operations group, the Trading partner will be sent a File Exchange Request Form to fill out and return to EDI Operations. EDI Operations will then assign a Submitter ID to use in your transactions. The trading partner will then be set up in CarePartners of Connecticut testing environment and the information is sent back to the trading partner so they may begin testing. CarePartnersCT Standard 837 Companion Guide 3 TESTING WITH THE PAYER EDI Operations will work with the new submitter to setup a username and password. After establishing a username and password, the submitter can begin sending claim transactions to the test environment. 1. During the testing process, EDI Operations examines submitted test transactions for required elements. EDI Operations also ensures that the submitter gets a response during the testing mode. Submitters are encouraged to review their 999s and 277CA reports for errors. 2. EDI Operations notifies the submitter upon the successful completion of testing. 3. When the submitter is ready to send an 837 transaction to the production mailbox, they are notified by EDI Operations, and given a GO LIVE date to move to the production environment. 4. The submitter's username remains the same when moving from test to production. 5. CarePartners of Connecticut recommends each test file includes no more than 100 claims. 4 CONNECTIVITY WITH THE PAYER/COMMUNICATIONS TRANSMISSION ADMINISTRATIVE PROCEDURES Direct Submitters  Providers interested in submitting electronic claim transactions should contact EDI Operations at CarePartners of Connecticut via email or telephone to request setup. Please refer to section 5 for contact details. A direct submitter EDI setup form can be found in Appendix A- EDI Set-up Form section.  EDI Operations will coordinate the appropriate process to set up the electronic data interchange. This includes completing enveloping requirements as indicated in the Communications/Connection, section 4.  Upon setup completion, EDI Operations notifies the submitter and reviews the testing procedures. After this review, test claim files can be sent to CarePartners of Connecticut.  Upon successful testing between CarePartners of Connecticut and the new submitter, the submitter migrates to a production status. RE-TRANSMISSION PROCEDURE CarePartners of Connecticut currently supports re-transmission of transactions, once any errors have been corrected. Please refer to your 999 and 277CA acknowledgement reports for details. CarePartnersCT Standard 837 Companion Guide COMMUNICATION PROTOCOL SPECIFICATIONS This section describes CarePartners of Connecticut communication protocol(s). The following is a list of technical standards and versions for the HTTP MIME Multipart envelope and eligibility payload:  HTTP Version 1.1  SOAP Version 1.2  TLS v1.2  Health Care Institutional & Professional Claims Transactions - Version 005010X223A2 - 005010X222A1  CAQH MIME – CarePartners of Connecticut supports the use of HTTP MIME Multipart existing envelope standards and has implemented the HTTP MIME Multipart envelope standards as identified in CAQH CORE Phase IV Connectivity standards. Please refer to: (https://www.caqh.org/sites/default/files/470_Connectivity_Rule_0_0.pdf).  The following is a list of technical standards and versions for the HTTP MIME Multipart envelope and eligibility payload:  HTTP Version 1.1  TLS v1.2  MIME Version 1.0  Health Care Institutional & Professional Claims Transactions - Version 005010X223A2 - 005010X222A1 CAQH SOAP – CarePartners of Connecticut supports the use of HTTP SOAP + WSDL envelope standards as identified in CAQH CORE Phase IV Connectivity standards. Please refer to: (https://www.caqh.org/sites/default/files/470_Connectivity_Rule_0_0.pdf). CarePartners of Connecticut provides certificates to use in place of a user ID and password for SOAP upon completion of enrollment process. CarePartnersCT Standard 837 Companion Guide Message specifications for SOAP Batch Transactions Batch Submit Transaction Envelope Element Specification PayloadType X12_837_Request_005010X223A2 X12_837_Request_005010X222A1 ProcessingMode Batch PayloadID Unique UUID PayloadLength Required CheckSum Checksum for MIME Attached Payload Payload cid of base64 encoded MIME Attachment SenderID ISA06 value as assigned by CarePartners of Connecticut ReceiverID 16307 CORERuleVersion 4.0.0 Certificate Version X.509 Batch Submit AckRetrieval Transaction Envelope Element Specification PayloadType X12_999_RetrievalRequest_005010X231A1 ProcessingMode Batch PayloadID Unique UUID of Inbound 837 SenderID ISA06 value = 16307 ReceiverID ISA08 value as assigned by CarePartners of Connecticut CORERuleVersion 4.0.0 Certificate Version X.509 CarePartnersCT Standard 837 Companion Guide Batch Results Retrieval Transaction Envelope Element Specification PayloadType X12_277CA_Request_005010X214 ProcessingMode Batch PayloadID Unique UUID of Inbound 837 SenderID ISA06 value = 16307 ReceiverID ISA08 value as assigned by CarePartnersCT CORERuleVersion 4.0.0 Certificate Version X.509 Batch Results AckSubmit Transaction (Optional) Envelope Element Specification PayloadType X12_999_SubmissionRequest_005010X231A1 ProcessingMode Batch PayloadID Unique UUID of Inbound 837 SenderID ISA06 value as assigned by CarePartners of Connecticut ReceiverID 16307 CORERuleVersion 4.0.0 Certificate Version X.509 Note: Changes to CAQH that occur after the writing of this document will override this document. PASSWORDS Password assignment and resets are done by the EDI Operations group, (See Contact Information below in section 5.) CarePartnersCT Standard 837 Companion Guide MAINTENANCE SCHEDULE The systems used for 837 transactions have a standard maintenance schedule of Sunday 8PM to 12AM EST. The systems are unavailable during this time. Email notifications will be sent notifying submitters of unscheduled system outages. RULES OF BEHAVIOR Rules of Behavior for programs that connect to this site: - Unauthorized use of certificates is not permitted - Must not deliberately submit batch files that contain Viruses. 5 CONTACT INFORMATION The following sections provide contact information for any questions regarding HIPAA, 837 transactions, EDI, documentation, or training. For 837 Transaction Questions The following table provides specific contact information by department and responsibility. For Questions Regarding… Contact Phone Number Email Address EDI Claims Submission (i.e., file submissions, claim rejections) CarePartners of Connecticut EDI Operations 888-631-7002, Ext. 52994 EDI_CT_Operations @carepartnersct.com Claim Information (i.e., claim denials, payment policies) CarePartners of Connecticut Provider Services 888-341-1508 NPI registration and credentialing CarePartners of Connecticut Provider Information 888-880-8699 Ext. 43153 Applicable Websites/E-MAIL This section contains detailed information about useful web sites and email addresses. http://www.wpc-edi.com/ for corrected examples http://www.carepartnersct.com/providers 6 CONTROL SEGMENTS/ENVELOPES Envelope Identifiers  CarePartners of	837-claims-transactions-guide.pdf
the use of HTTP MIME Multipart existing envelope standards and has implemented the HTTP MIME Multipart envelope standards as identified in CAQH CORE Phase IV Connectivity standards. Please refer to: (https://www.caqh.org/sites/default/files/470_Connectivity_Rule_0_0.pdf).  The following is a list of technical standards and versions for the HTTP MIME Multipart envelope and eligibility payload:  HTTP Version 1.1  TLS v1.2  MIME Version 1.0  Health Care Institutional & Professional Claims Transactions - Version 005010X223A2 - 005010X222A1 CAQH SOAP – CarePartners of Connecticut supports the use of HTTP SOAP + WSDL envelope standards as identified in CAQH CORE Phase IV Connectivity standards. Please refer to: (https://www.caqh.org/sites/default/files/470_Connectivity_Rule_0_0.pdf). CarePartners of Connecticut provides certificates to use in place of a user ID and password for SOAP upon completion of enrollment process. CarePartnersCT Standard 837 Companion Guide Message specifications for SOAP Batch Transactions Batch Submit Transaction Envelope Element Specification PayloadType X12_837_Request_005010X223A2 X12_837_Request_005010X222A1 ProcessingMode Batch PayloadID Unique UUID PayloadLength Required CheckSum Checksum for MIME Attached Payload Payload cid of base64 encoded MIME Attachment SenderID ISA06 value as assigned by CarePartners of Connecticut ReceiverID 16307 CORERuleVersion 4.0.0 Certificate Version X.509 Batch Submit AckRetrieval Transaction Envelope Element Specification PayloadType X12_999_RetrievalRequest_005010X231A1 ProcessingMode Batch PayloadID Unique UUID of Inbound 837 SenderID ISA06 value = 16307 ReceiverID ISA08 value as assigned by CarePartners of Connecticut CORERuleVersion 4.0.0 Certificate Version X.509 CarePartnersCT Standard 837 Companion Guide Batch Results Retrieval Transaction Envelope Element Specification PayloadType X12_277CA_Request_005010X214 ProcessingMode Batch PayloadID Unique UUID of Inbound 837 SenderID ISA06 value = 16307 ReceiverID ISA08 value as assigned by CarePartnersCT CORERuleVersion 4.0.0 Certificate Version X.509 Batch Results AckSubmit Transaction (Optional) Envelope Element Specification PayloadType X12_999_SubmissionRequest_005010X231A1 ProcessingMode Batch PayloadID Unique UUID of Inbound 837 SenderID ISA06 value as assigned by CarePartners of Connecticut ReceiverID 16307 CORERuleVersion 4.0.0 Certificate Version X.509 Note: Changes to CAQH that occur after the writing of this document will override this document. PASSWORDS Password assignment and resets are done by the EDI Operations group, (See Contact Information below in section 5.) CarePartnersCT Standard 837 Companion Guide MAINTENANCE SCHEDULE The systems used for 837 transactions have a standard maintenance schedule of Sunday 8PM to 12AM EST. The systems are unavailable during this time. Email notifications will be sent notifying submitters of unscheduled system outages. RULES OF BEHAVIOR Rules of Behavior for programs that connect to this site: - Unauthorized use of certificates is not permitted - Must not deliberately submit batch files that contain Viruses. 5 CONTACT INFORMATION The following sections provide contact information for any questions regarding HIPAA, 837 transactions, EDI, documentation, or training. For 837 Transaction Questions The following table provides specific contact information by department and responsibility. For Questions Regarding… Contact Phone Number Email Address EDI Claims Submission (i.e., file submissions, claim rejections) CarePartners of Connecticut EDI Operations 888-631-7002, Ext. 52994 EDI_CT_Operations @carepartnersct.com Claim Information (i.e., claim denials, payment policies) CarePartners of Connecticut Provider Services 888-341-1508 NPI registration and credentialing CarePartners of Connecticut Provider Information 888-880-8699 Ext. 43153 Applicable Websites/E-MAIL This section contains detailed information about useful web sites and email addresses. http://www.wpc-edi.com/ for corrected examples http://www.carepartnersct.com/providers 6 CONTROL SEGMENTS/ENVELOPES Envelope Identifiers  CarePartners of Connecticut supplies each submitting provider with the Submitter and Sender Identifiers for the envelope elements as a part of the setup process. The Interchange Receiver and Application Receiver IDs depend upon which e-Channel is used.  For other e-Channels: The Interchange Receiver ID (ISA08) is 16307 and the Application Receiver ID (GS03) is 16307 CarePartnersCT Standard 837 Companion Guide Setup for 837 INBOUND Transactions ISA-IEA This section describes CarePartners of Connecticut use of the interchange control segments. It includes a description of expected sender and receiver codes, authorization information, and delimiters ISA - Interchange Control Header Segment Segment Name Seg. ID Req / Opt # of Char Value Remarks Authorization Information Qualifier ISA01 R 2 00 00 - No Authorization Information Present Authorization Information ISA02 R 10 <spaces> * No Authorization Information Present Security Information Qualifier ISA03 R 2 00 00 - No Security Information Present Security Information/ Password ISA04 R 10 <spaces>* No Security Information Present Interchange ID Qualifier/Qualifier for Trading Partner ID ISA05 R 2 ZZ Sender Qualifier - Mutually Agreed. Interchange Sender ID/Trading Partner ID ISA06 R 15 <SENDER ID>* Sender’s Identification Number Interchange ID Qualifier/Qualifier for CarePartners of Connecticut ID ISA07 R 2 33 National Association of Insurance Commissioner’s Company Code is being used. Interchange Receiver ID/ CarePartners of Connecticut ID ISA08 R 15 16307 CarePartners of Connecticut - NAIC number: 16307 Interchange Date ISA09 R 6 <YYMMDD> Date of the interchange in YYMMDD format Interchange Time ISA10 R 4 <HHMM> Time of the interchange in HHMM format Repetition Separator ISA11 R 1 ^ (is a typical separator received) 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 Interchange Control Version Number ISA12 R 5 00501 Version number Interchange Control Number/Last Control Number ISA13 R 9 <Auto- generated> Assigned by the interchange sender, must be associated with IEA02 segment Acknowledgement Request ISA14 R 1 0 0 - No Acknowledgement Requested Usage Indicator ISA15 R 1 <T or P> T-test data; P-production data Separator ISA16 R 1 <Any> ASCII Value. Component element separator CarePartnersCT Standard 837 Companion Guide IEA - Interchange Control Trailer Segment This segment defines the end of an interchange of zero or more functional groups and interchange-related control segments. The Input Data column below contains text entered in [bracketed italics] indicates special input data dependent on sender, time, date, etc. Elements Size Name Input Data Remarks IEA01 1/5 Number of Included Functional Groups [Submitter-specific ID number] A count of the number of functional groups included in an interchange. IEA02 9 Interchange Control Number [Submitter-specific ID number] A control number assigned by the interchange sender. GS-GE - Functional Group Header Segment This section describes CarePartners of Connecticut use of the functional group control segments. It includes a description of expected application sender and receiver codes. Also included in this section is a description concerning how CarePartners of Connecticut expects functional groups to be sent and how CarePartners of Connecticut will send functional groups. These discussions will describe how similar transaction sets will be packaged and CarePartners of Connecticut use of functional group control numbers. Segment Name Seg. ID Req / Opt # of Char Value Remarks Functional Identifier Code GS01 R 2 HC Health Care Claim. Application Sender’s Code GS02 R 2/15 [CarePartners of Connecticut Submitter ID] Code identifying party sending transmission Application Receiver’s Code GS03 R 2/15 16307 Code identifying party receiving transmission. National Association of Insurance Commissioner’s Company Code is being used. Date GS04 R 8 <CCYYMMDD> Functional Group creation date in CCYYMMDD format Time GS05 R 4/8 <HHMM> Functional Group creation time in HHMM format. Time expressed in 24-hour clock. For example, 3:23 PM is entered as 1523. Group Control Number GS06 R 1/9 <#> Assigned and maintained by the sender, must be associated with GE02 segment GS06 Responsible Agency Code GS07 R 1/2 X Accredited Standards Committee X12 Version/Release/Industry Identifier Code GS08 R 1/12 005010X223A2 or 005010X222A1 Health Care Claim for Institutional Health Care Claim for Professional. CarePartnersCT Standard 837 Companion Guide Group Trailer Segment Name Seg. ID Req / Opt # of Char Value Remarks Number of Transaction Sets Included GE01 R 1/6 1 Total number of transactional sets included in the functional group or interchange Group Control Number GE02 R 1/9 <#> Assigned number originated and maintained by the sender CarePartnersCT Standard 837 Companion Guide 7 PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS Business Scenarios Please refer to the business scenarios presented in the Implementation Guides or visit http://www.wpc-edi.com/837 for additional or corrected examples. Category 1: General Instructions  All NPIs on claims submitted to CarePartners of Connecticut must be registered with the Provider Information Department prior to transmission. Please call 888-880-8699 Ext. 43153 to verify or register the NPIs of your organization.  CarePartners of Connecticut will require a valid NPI when NM109 is used in any provider loop and will not accept Provider Secondary Identification as the primary identifier of that provider.  New submitters must go through the appropriate set-up/authorization process in order to transmit electronic claims with CarePartners of Connecticut. Please refer to the Communications/Connectivity Component of this document for details.  CarePartners of Connecticut will accept 837 Institutional and 837 Professional Claim Transactions for all business products, however the 837 Institutional and 837 Professional claim files must be sent separately. They cannot be sent on the same file.  As stated in the technical reports, a maximum of 5000 CLM segments will be accepted by CarePartners of Connecticut.  CarePartners of Connecticut is adhering to structural specifications for required and situational fields as stated in the technical reports. If the incoming 837I or 837P has a single ST/SE and the structure does not comply, the entire file will fail in the validation process. If the incoming 837I or 837P has multiple ST/SEs, only the failed ST/SEs in the file will fail in the validation process. The submitter receives a 999 acknowledgement for notification of the ST/SEs that failed.  CarePartners of Connecticut will capture payee information from the Billing Provider Name loop (Loop 2010AA).  The Pay-To Address Name loop (Loop 2010AB) in 5010 has been changed to enter a separate billing provider address where payments should be sent. Please note that CarePartners of Connecticut will continue making payments to the address on record in our backend system database instead of the addresses submitted in loop 2010AB.  CarePartners of Connecticut cannot currently support billing for atypical provider type submissions.  For Frequency Types 5, 7, and 8, (Element CLM05-3), CarePartners of Connecticut’s original claim number (Original Reference Number – Element REF02) must be submitted as stated in the technical report. We also strongly recommend sending the Original Reference Number with Frequency Types 2, 3, and 4. CarePartnersCT Standard 837 Companion Guide  When contacting CarePartners of Connecticut with questions for claims with Frequency Types 2, 3, 4, 5, 7, and 8, (Element CLM05-3), please use the original claim number even though a new claim number for that submission may be assigned.  The CarePartners of Connecticut implementation of Coordination of Benefits (COB) Information utilizes claim header information in the COB Header Other Subscriber Information (Loop 2320), Other Subscriber Name (Loop 2330A), and Other Payer Name (Loop 2330B) as well as line level information in the Line Adjudication Information Details (Loop 2430) within the 837 transactions. We strongly recommend closely reviewing these loops in the technical reports before submitting COB information. Many data segments have been changed or deleted.  Although the HIPAA Transaction Set technical report allows the repeating of Billing Provider Name loop (2010AA Loop) for each claim, the size of transmission files can be reduced by up to 20% by using only one repeat of Billing Provider Name loop followed by all subscriber and claim information for that Provider. Transmission files can be further reduced by grouping the claims of each subscriber together.  CarePartners of Connecticut only accepts ICD-10 Codes.  For compliance purposes, CarePartners of Connecticut will only accept qualifier MJ for minutes when billing anesthesia procedure codes. UN is a valid qualifier for procedures other than anesthesia.  Due to system limitations, CarePartners of Connecticut is unable to accept claims submitted electronically where charges total one million dollars or more.  Each CarePartners of Connecticut member is uniquely identified by his or her member ID. All members should be considered as subscribers, and providers should submit member ID in Element NM109 of Loop 2010BA. CarePartners of Connecticut will not accept any data in the Patient Loop (2000C) and will REJECT accordingly. CarePartnersCT Standard 837 Companion Guide Frequently Asked Questions General Claim Questions Q. Who do I contact for setup issues? A. Contact EDI Operations, [email protected], for all setup issues. Q. Is there an EDI setup form? A. Yes, you can find the EDI setup form on the CarePartners of Connecticut Web site (www.carepartnersct.com) or in this guide, (see appendix A-EDI Set-up Form). Q. What is CarePartners of Connecticut’s Payer ID#? A. Contact EDI Operations by sending email to: [email protected] to obtain CarePartners	837-claims-transactions-guide.pdf
that failed.  CarePartners of Connecticut will capture payee information from the Billing Provider Name loop (Loop 2010AA).  The Pay-To Address Name loop (Loop 2010AB) in 5010 has been changed to enter a separate billing provider address where payments should be sent. Please note that CarePartners of Connecticut will continue making payments to the address on record in our backend system database instead of the addresses submitted in loop 2010AB.  CarePartners of Connecticut cannot currently support billing for atypical provider type submissions.  For Frequency Types 5, 7, and 8, (Element CLM05-3), CarePartners of Connecticut’s original claim number (Original Reference Number – Element REF02) must be submitted as stated in the technical report. We also strongly recommend sending the Original Reference Number with Frequency Types 2, 3, and 4. CarePartnersCT Standard 837 Companion Guide  When contacting CarePartners of Connecticut with questions for claims with Frequency Types 2, 3, 4, 5, 7, and 8, (Element CLM05-3), please use the original claim number even though a new claim number for that submission may be assigned.  The CarePartners of Connecticut implementation of Coordination of Benefits (COB) Information utilizes claim header information in the COB Header Other Subscriber Information (Loop 2320), Other Subscriber Name (Loop 2330A), and Other Payer Name (Loop 2330B) as well as line level information in the Line Adjudication Information Details (Loop 2430) within the 837 transactions. We strongly recommend closely reviewing these loops in the technical reports before submitting COB information. Many data segments have been changed or deleted.  Although the HIPAA Transaction Set technical report allows the repeating of Billing Provider Name loop (2010AA Loop) for each claim, the size of transmission files can be reduced by up to 20% by using only one repeat of Billing Provider Name loop followed by all subscriber and claim information for that Provider. Transmission files can be further reduced by grouping the claims of each subscriber together.  CarePartners of Connecticut only accepts ICD-10 Codes.  For compliance purposes, CarePartners of Connecticut will only accept qualifier MJ for minutes when billing anesthesia procedure codes. UN is a valid qualifier for procedures other than anesthesia.  Due to system limitations, CarePartners of Connecticut is unable to accept claims submitted electronically where charges total one million dollars or more.  Each CarePartners of Connecticut member is uniquely identified by his or her member ID. All members should be considered as subscribers, and providers should submit member ID in Element NM109 of Loop 2010BA. CarePartners of Connecticut will not accept any data in the Patient Loop (2000C) and will REJECT accordingly. CarePartnersCT Standard 837 Companion Guide Frequently Asked Questions General Claim Questions Q. Who do I contact for setup issues? A. Contact EDI Operations, [email protected], for all setup issues. Q. Is there an EDI setup form? A. Yes, you can find the EDI setup form on the CarePartners of Connecticut Web site (www.carepartnersct.com) or in this guide, (see appendix A-EDI Set-up Form). Q. What is CarePartners of Connecticut’s Payer ID#? A. Contact EDI Operations by sending email to: [email protected] to obtain CarePartners of Connecticut Payer ID number. It is important to make sure your NPI is on file at CarePartners of Connecticut and that you are set up to submit claims via a clearinghouse. Q. Is My NPI on file at CarePartners of Connecticut? A. To determine if your NPI is on file, contact our Provider Information Department, 888- 880-8699 Ext.43153. Q. Is there an NPI registration form? A. Yes, you can find the NPI registration form on the CarePartners of Connecticut Web site. It is located at: https://www.carepartnersct.com/for-providers/provider-resource-center Q. What should I do if I change Clearinghouses? A. If you change your clearinghouse, please inform EDI Operations by sending email to: [email protected]. Q. How do I add or delete payees? A. Contact EDI Operations by sending an email to [email protected] to add or delete payees. Q. Can I send paper claims? A. Yes. However CarePartners of Connecticut strongly recommends electronic claims submission; when sending paper claims, you must clearly print paper claims on original CMS 1500 or UB04 RED forms. Q. Will CarePartners of Connecticut accept a P.O. Box or Lock Box in Loop 2010AA? A. No, P.O. Boxes or Lock Boxes are not allowed in loop 2010AA per the Implementation Guides and claims that contain them will be rejected. As specified in the Implementation Guides, P.O. Box or Lock Box information can be sent in loop 2010AB, Pay-To Address Name, if necessary. However, CarePartners of Connecticut uses the address of record that we have on file. Q. Will CarePartners of Connecticut accept a 5-digit zip code in loop 2010AA? A. No, per the Implementation Guides, only 9-digit zip codes can be accepted. If the claim contains a 5-digit zip code, the claim will be rejected. CarePartnersCT Standard 837 Companion Guide CarePartners of Connecticut Product Type Questions Q. Can I send all CarePartners of Connecticut product types in one electronic file? B. Yes, all products can be submitted in one file. However, the 837 Institutional and 837 Professional claim files must be sent separately. They cannot be sent on the same file. Direct 837 Claims Questions Q. Is testing required to send 837 claims to CarePartners of Connecticut? A.Yes. Please refer to section 3 in this Companion Guide for testing process details. Q. For how long are 277CA Acknowledgement reports available? A. The 277CA Acknowledgement reports are retained in your mailbox for one week. Electronic Funds Transfer Q. Does CarePartners of Connecticut offer electronic funds transfer (EFT)? A. CarePartners of Connecticut offers EFT through our partnership with PaySpan Health. Go to the PaySpan Health website at www.payspanhealth.com. A step-by-step registration guide is available online.  If you need additional assistance or have questions concerning EFT, please contact PaySpan. Send an email to [email protected] or call the Provider Support Team at 877.331.7154, option 1. Provider Support Specialists are available to assist Monday through Friday from 8am to 8pm, Eastern Time.  Registration with PaySpan is available after the first claim a provider has submitted is adjudicated and paid by CarePartners of Connecticut. The first payment will be in the form of a paper check that will contain the registration instructions 8 ACKNOWLEDGEMENTS AND/OR REPORTS Acknowledgements  CarePartners of Connecticut will send an acknowledgement for each 837 transaction sent with the 277CA Health Care Claim Acknowledgment (See 277CA Companion Guide).  CarePartners of Connecticut will return the 999 IMPLEMENTATION ACKNOWLEDGMENT FOR HEALTH CARE INSURANCE as per the Technical Report, Type 3. The standard format is below. ST Transaction Set Header AK1 Functional Group Response Header LOOP ID - 2000 - AK2 TRANSACTION SET RESPONSE HEADER AK2 Transaction Set Response Header LOOP ID - 2100 - AK2/IK3 ERROR IDENTIFICATION IK3 Error Identification CTX Segment Context CarePartnersCT Standard 837 Companion Guide CTX Business Unit Identifier LOOP ID - 2110 - AK2/IK3/IK4 IMPLEMENTATION DATA ELEMENT NOTE IK4 Implementation Data Element Note CTX Element Context IK5 Transaction Set Response Trailer AK9 Functional Group Response Trailer SE Transaction Set Trailer Present On Admission (POA) Indicators Provider Types Affected  Hospitals who submit claims to fiscal intermediaries (FI) or Medicare Part A/B Administrative Contractors (A/B MACs) for Medicare beneficiary inpatient services.  CarePartners of Connecticut recommends that your billing staff is aware of this requirement, and that your physicians and other practitioners and coders are collaborating to ensure complete and accurate documentation, code assignment and reporting of diagnoses and procedures. CarePartnersCT Standard 837 Companion Guide Reporting Options and Definitions N (No) Not present at the time of inpatient admission U (Unknown) Documentation is insufficient to determine if condition is present at time of inpatient admission W Not Applicable Y (Yes) Present at the time of inpatient admission  The POA data element on your electronic claims has been moved from the K3 segment (version 4010A1) to the HI - PRINCIPAL DIAGNOSIS and HI - OTHER DIAGNOSIS INFORMATION segments. NOTE: The value of “1” has been removed in 5010. Example: Below is an example of acceptable coding on an electronic claim: HIBF:4821:::::::NHI*BF:25000:::::::Y CarePartnersCT Standard 837 Companion Guide 9 TRADING PARTNER AGREEMENTS TRADING PARTNERS An EDI Trading Partner is defined as any CarePartners of Connecticut customer (provider, billing service, software vendor, employer group, financial institution, etc.) that transmits to, or receives electronic data from CarePartners of Connecticut. CarePartners of Connecticut utilizes the File Exchange Request Form to establish the Trading Partners agreement/set-up forms to process electronic transactions. 10 TRANSACTION SPECIFIC INFORMATION This section describes how ASC X12 Implementation Guides (IGs) adopted under HIPAA will be detailed with the use of a table. The tables contain a row for each segment that CarePartners of Connecticut has something additional, over and above, the information in the IGs. That information can: 1. Limit the repeat of loops, or segments 2. Limit the length of a simple data element 3. Specify a sub-set of the IGs internal code listings 4. Clarify the use of loops, segments, composite and simple data elements 5. Any other information tied directly to a loop, segment, composite or simple data element pertinent to trading electronically with CarePartners of Connecticut In addition to the row for each segment, one or more additional rows are used to describe CarePartners of Connecticut usage for composite and simple data elements and for any other information. The following table specifies the columns and suggested use of the rows for the detailed description of the transaction set companion guides. CarePartnersCT Standard 837 Companion Guide These tables contain one or more rows for each segment for which a supplemental instruction is needed. Legend BOLDED and SHADED rows represent “loops” or “segments” in the X12N implementation guides. NON-SHADED rows represent “data elements” in the X12N implementation guides. 005010X223A2 Health Care Claim: Institutional Page # Loop ID Reference Name Codes Length Notes/Comments 1000A NM1 Information Source Name 72 1000A NM109 Submitter Identification Code 2/80 The existing trading partners will continue using the six-digit submitter code. CarePartners of Connecticut will work with new trading partners prior to implementation to determine the six-digit submitter code. (Exceptions to the six digit IDs may apply) 94 2010AB NM1 Pay-To Address Name N/A This loop has been changed to indicate a separate address for payments to the Billing Provider. Please note that CarePartners of Connecticut will continue making payments to the address in our backend system database instead of the address submitted in 2010AB. 109 2000B SBR Subscriber Hierarchical Level 109 2000B SBR01 Payer Responsibility Sequence Number Code 1/1 This data element is NOT a payer counter. It is a code that indicates the order of responsibility for payment. 112 2010BA NM1 Subscriber Name N/A 135 2010CA NM1 Patient Name N/A As stated in Section 7: Each CarePartners of Connecticut member is uniquely identified by his or her member ID. All members should be considered as subscribers, and providers should submit member ID in Element NM109 of Loop 2010BA. CarePartners of Connecticut will not accept any data in the Patient Loop (2000C) and will REJECT accordingly. 166 2300 REF Payer Claim Control Number 166 2300 REF02 Reference Identification 1/50 For frequency types 5, 7, and 8, Original Reference Number (Claim Number) must be submitted as stated in the technical report. CarePartners of Connecticut also strongly recommends sending the Original Reference Number with frequency types 2, 3, and 4. CarePartnersCT Standard 837 Companion Guide Page # Loop ID Reference Name Codes Length Notes/Comments 271 2300 HI01-2 Occurrence Code 1/30 If a claim is accident or employment related, CarePartners of Connecticut requires the appropriate occurrence code. We will only process one iteration of HI01. 272 2300 HI01-4 Date Time Period 1/35 If a claim is accident or employment related, CarePartners of Connecticut requires the appropriate occurrence date. We will only process one iteration of HI01 341 2310E NM1 Service Facility Location Name N/A CarePartners of Connecticut REQUIRES that Service Facility Information always matches Billing Provider Information given that the payee should always equal the provider on institutional claims. 354 2320 Other Subscriber Information N/A 354 2320 SBR Other Subscriber Information N/A Required by CarePartners of Connecticut to understand the payer responsibility sequence. 354 2320 AMT COB Payor Amount Paid N/A CarePartners of Connecticut requires the total amount paid at the claim level 377 2330A NM1 Other Subscriber Name N/A CarePartners of Connecticut requires this segment for COB claims. 384 2330B NM1 Other	837-claims-transactions-guide.pdf
data elements and for any other information. The following table specifies the columns and suggested use of the rows for the detailed description of the transaction set companion guides. CarePartnersCT Standard 837 Companion Guide These tables contain one or more rows for each segment for which a supplemental instruction is needed. Legend BOLDED and SHADED rows represent “loops” or “segments” in the X12N implementation guides. NON-SHADED rows represent “data elements” in the X12N implementation guides. 005010X223A2 Health Care Claim: Institutional Page # Loop ID Reference Name Codes Length Notes/Comments 1000A NM1 Information Source Name 72 1000A NM109 Submitter Identification Code 2/80 The existing trading partners will continue using the six-digit submitter code. CarePartners of Connecticut will work with new trading partners prior to implementation to determine the six-digit submitter code. (Exceptions to the six digit IDs may apply) 94 2010AB NM1 Pay-To Address Name N/A This loop has been changed to indicate a separate address for payments to the Billing Provider. Please note that CarePartners of Connecticut will continue making payments to the address in our backend system database instead of the address submitted in 2010AB. 109 2000B SBR Subscriber Hierarchical Level 109 2000B SBR01 Payer Responsibility Sequence Number Code 1/1 This data element is NOT a payer counter. It is a code that indicates the order of responsibility for payment. 112 2010BA NM1 Subscriber Name N/A 135 2010CA NM1 Patient Name N/A As stated in Section 7: Each CarePartners of Connecticut member is uniquely identified by his or her member ID. All members should be considered as subscribers, and providers should submit member ID in Element NM109 of Loop 2010BA. CarePartners of Connecticut will not accept any data in the Patient Loop (2000C) and will REJECT accordingly. 166 2300 REF Payer Claim Control Number 166 2300 REF02 Reference Identification 1/50 For frequency types 5, 7, and 8, Original Reference Number (Claim Number) must be submitted as stated in the technical report. CarePartners of Connecticut also strongly recommends sending the Original Reference Number with frequency types 2, 3, and 4. CarePartnersCT Standard 837 Companion Guide Page # Loop ID Reference Name Codes Length Notes/Comments 271 2300 HI01-2 Occurrence Code 1/30 If a claim is accident or employment related, CarePartners of Connecticut requires the appropriate occurrence code. We will only process one iteration of HI01. 272 2300 HI01-4 Date Time Period 1/35 If a claim is accident or employment related, CarePartners of Connecticut requires the appropriate occurrence date. We will only process one iteration of HI01 341 2310E NM1 Service Facility Location Name N/A CarePartners of Connecticut REQUIRES that Service Facility Information always matches Billing Provider Information given that the payee should always equal the provider on institutional claims. 354 2320 Other Subscriber Information N/A 354 2320 SBR Other Subscriber Information N/A Required by CarePartners of Connecticut to understand the payer responsibility sequence. 354 2320 AMT COB Payor Amount Paid N/A CarePartners of Connecticut requires the total amount paid at the claim level 377 2330A NM1 Other Subscriber Name N/A CarePartners of Connecticut requires this segment for COB claims. 384 2330B NM1 Other Payer Name N/A CarePartners of Connecticut requires this segment for COB claims. 476 2430 SVD Line Adjudication Information N/A 477 2430 SVD02 Monetary Amount 1/18 CarePartners of Connecticut requires the amount paid by the payer in 2330B for this line. 481 2430 CAS01 Claim Adjustment Group Code CO – Contractual Obligations 1/2 Used to validate total amount billed in SV1 segment. 481 2430 CAS01 Claim Adjustment Group Code PR – Patient Responsibility 1/2 Also used to validate total amount billed in SV1 segment. (if applicable) CarePartnersCT Standard 837 Companion Guide 005010X222A1 Health Care Claim: Professional Page # Loop ID Reference Name Codes Length Notes/Comments 75 1000A NM1 Submitter Name 75 1000A NM109 Submitter Identifier 2/80 The existing trading partners will continue using the six-digit submitter code. CarePartners of Connecticut will work with new trading partners prior to implementation to determine the six-digit submitter code. (Exceptions to the six digit IDs may apply) 83 2000A PRV Billing Provider Specialty Information N/A CarePartners of Connecticut recommends providers include the appropriate taxonomy code for the services rendered. 83 2000A PRV01 Provider Code BI 1/3 Code identifying the type of provider 83 2000A PRV02 Code qualifying the Reference Identification PXC 2/3 Health Care Provider Taxonomy Code 83 2000A PRV03 Reference Identification 1/50 Provider Taxonomy Code 101 2010AB Pay-To Address Name N/A This loop has been changed to indicate a separate address for payment to the Billing Provider. Please note that CarePartners of Connecticut will continue making payments to the address in our backend system database instead of the address submitted in 2010AB. 116 2000B SBR Subscriber Hierarchical Level 116 2000B SBR01 Payer Responsibility Sequence Number Code 1/1 This data element is NOT a payer counter. It is a code that indicates the order of responsibility for payment. 121 2010BA NM1 Subscriber Name N/A 123 2010BA NM109 Identification Code 2/80 Each CarePartners of Connecticut member is uniquely identified by his or her member ID. Thus we require treating all members as subscribers, and submitting member ID in NM109 of loop 2010BA. 147 2010CA NM1 Patient Name N/A As stated in section 7: Each CarePartners of Connecticut member is uniquely identified by his or her member ID. All members should be considered as subscribers, and providers should be submitting member ID in Element NM109 of Loop 2010BA. Thus CarePartners of Connecticut will not accept any data in the Patient Loop (2000C) and will REJECT accordingly. CarePartnersCT Standard 837 Companion Guide Page # Loop ID Reference Name Codes Length Notes/Comments 196 2300 REF Payer Claim Control Number N/A 196 2300 REF02 Reference Identification 1/50 For frequency types 5, 7, and 8, Original Reference Number (Claim Number) must be submitted as stated in the technical report. CarePartners of Connecticut also strongly recommends sending Original Reference Number with frequency types 2, 3, and 4. 265 2310B PRV Rendering Provider Specialty Information CarePartners of Connecticut recommends providers include the appropriate taxonomy code for the services rendered. 265 2310B PRV01 Provider Code PE 1/3 Code identifying the type of provider 265 2310B PRV02 Code qualifying the Reference Identification PXC 2/3 Health Care Provider Taxonomy Code 265 2310B PRV03 Reference Identification 1/50 Provider Taxonomy Code 320 2330B NM1 Other Payer Name N/A CarePartners of Connecticut requires this segment for COB claims. 480 2430 SVD Line Adjudication Information N/A 481 2430 SVD02 Monetary Amount 1/18 CarePartners of Connecticut requires the amount paid by the payer in 2330B for this line. 485 2430 CAS01 Claim Adjustment Group Code CO – Contractual Obligation 1/2 Used to validate total amount billed in SV1 segment. 485 2430 CAS01 Claim Adjustment Group Code PR – Patient Responsibility 1/2 Also used to validate total amount billed in SV1 segment. (if applicable) CarePartnersCT Standard 837 Companion Guide APPENDICES A - EDI Set Up Form CarePartnersCT Standard 837 Companion Guide This form is also available on the CarePartners of Connecticut Public Provider website: https://www.carepartnersct.com/cpct-pdoc-edi-set-up-form B - Transaction Examples 837 Institutional Claim Sample: ISA00 00 ZZSender ID 3316307 1704240814^005010061108291P: GSHC Sender ID163072017042408146110829X005010X223A2 ST8370001005010X223A2 BHT0019006110829N120170424081458CH NM1412ABC SYSTEMS INC****46 Sender ID PERICCLAIMS CLEARINGHOUSEEMABC [email protected] NM1402CAREPARTNERS OF CONNECTICUT***4616307 HL1201 PRVBIPXC282N00000X NM1852MEDICAL CENTER****XX1234567890 N33801 SPRING STREET N4RACINEWI534051667 REFEI123456789 PERICPATIENT ACCOUNTSTE8885551212 NM1872 N3PO BOX 860004 N4MINNEAPOLISMN554866000 HL21220 SBRP18CAREPARTNERS OF CONNECTICUT**CI NM1IL1DOEJANE**MI12345678901 N33400 10 AVE N4RACINEWI53402 DMGD819880227F NM1PR2CAREPARTNERS OF CONNECTICUT****PI16307 CLM9876543211109.2*13:A:1AYY DTP434RD820170418-20170418 CL11101 REFD96110829N1 REFEAE2675423 HIABK:S8391XA HIAPR:M25561 HIABN:V484XXA HIBH:11:D8:20170418 NM1711SMITHMAMTAMALIK*XX1234567899 PRVATPXC207P00000X NM1721SMITHMAMTAMALIK**XX1234567899 LX1 SV20250*1.2UN1 DTP472D820170418 REF6R34289381 LX2 SV20320HC:73564:RT343UN1 DTP472D820170418 REF6R34289382 LX3 SV20450HC:99283765UN1 DTP472D820170418 REF6R34289383 SE470001 GE16110829 IEA1006110829 CarePartnersCT Standard 837 Companion Guide 837 Professional Claim Sample: ISA00 00 ZZSENDERID 3316307 1704240253^005010061108241P: GSHC SENDERID163072017042402536110824X005010X222A1 ST8370001005010X222A1 BHT0019006110824N120170424025343CH NM1412NEBO SYSTEMS INC****46 SENDERID PERICCLAIMS CLEARINGHOUSEEM ABC [email protected] NM1402CAREPARTNERS OF CONNECTICUT***4616307 HL1201 NM1852* ABC HEALTH VENTURE****XX1234567896 N33471 EAGLE WAY N4CHICAGOIL606781034 REFEI123456789 HL21220 SBRP184886800****CI NM1IL1DOEJANE**MI98765432101 N3542 S KATHLEEN DR N4ROMEOVILLEIL60446 DMGD820040827F NM1PR2CAREPARTNERS OF CONNECTICUT****PI16307 CLM123456789321369**21:B:1YAYY DTP431D820170407 DTP435D820170407 DTP096D820170409 REFD96110824N1 REFEAGE12447281 HIABK:T383X2AABF:F322ABF:T1491 NM1DN1JONESJOE**XX1234567890 NM1821DOESHYAMSUNDER***XX1234567891 PRVPEPXC2084P0800X NM1772GOOD HOSPITAL IP****XX1234567893 N3801 S WASHINGTON ST N4NAPERVILLEIL605407430 LX1 SV1HC:99253369UN1*1:2:3 DTP472D820170408 REF6R454902631 SE350001 GE16110824 IEA1006110824 C - Change Summary This section describes the differences between the current Companion Guide and previous guide(s). Revision Revision Date Comments 1 10/2018 Version 5010	837-claims-transactions-guide.pdf
Page 1 of 13 Standard Companion Guide Refers to the Implementation Guide Based on X12 Version 005010X221A1 Health Care Claim Payment/Advice (835) Companion Guide Version Number: 3.0 May 2024 Page 2 of 13 CHANGE LOG Version Release date Changes 1.0 08/08/2013 Initial External Release Draft 1.2 09/17/2014 PLB segment Notes 1.3 12/15/2016 Removed REF1W other claim related identification for Member ID reporting 2.0 1/19/2018 Reformatted entire document and updated various sections with current information, including hyperlinks and contacts. 2.1 7/31/2018 Updated phone number for EDI Support and hyperlink to EDI Transaction Support form 3.0 5/22/2024 Updated logo and PLB segment Notes, Claim Filing Indicator codes, and Payment Method Codes. Page 3 of 13 PREFACE This Companion Guide to the ASC X12N/005010X221A1 Health Care Claim Payment Advice (835) Implementation Guide, also known as Technical Report Type 3 (TR3), clarifies and specifies the data content when exchanging electronically with UnitedHealth care. Transmissions based on this companion guide, used in tandem with the specified ASC X12/005010X221A1 835 Implementation Guides, are compliant with both X12 syntax and those guides. This Companion Guide is intended to convey information that is within the framework of the ASC X12N/005010X221A1 835 implementation Guide adopted for use under HIPAA (Health Insurance Portability and Accountability Act). The Companion Guide is not intended to convey information that exceeds the requirements or usages of data expressed in the Implementation Guides. Page 4 of 13 Table of Contents CHANGE LOG...........................................................................................................................2 PREFACE .................................................................................................................................3 1. INTRODUCTION..............................................................................................................5 1.1. SCOPE ...........................................................................................................................6 1.2. OVERVIEW ....................................................................................................................6 1.3. REFERENCE ....................................................................................................................7 1.4. ADDITIONAL INFORMATION ............................................................................................7 2. GETTING STARTED ..........................................................................................................7 2.1 EXCHANGING TRANSACTIONS WITH UNITEDHEALTHCARE ..................................................7 2.2 CLEARINGHOUSE CONNECTION........................................................................................7 3. CONNECTIVITY WITH THE PAYER / COMMUNICATIONS ......................................................7 3.1. PROCESS FLOW ..............................................................................................................7 3.2. RE-TRANSMISSION PROCEDURE .......................................................................................8 5.1. ISA-IEA ..........................................................................................................................8 5.2. GS-GE ...........................................................................................................................9 5.3. ST-SE ............................................................................................................................9 6. PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS ..........................................................9 6.1. 835 ENROLLMENTS.........................................................................................................9 7. ACKNOWLEDGEMENTS AND OR REPORTS .........................................................................9 7.1. REPORT INVENTORY .......................................................................................................9 8. TRADING PARTNER AGREEMENTS ....................................................................................9 8.1. TRADING PARTNERS .......................................................................................................9 9. TRANSACTION SPECIFIC INFORMATION .......................................................................... 10 10. APPENDECIES ........................................................................................................ 12 10.1. IMPLEMENTATION CHECKLIST................................................................................. 12 10.2. FREQUENTLY ASKED QUESTIONS ............................................................................. 12 10.3. UNITEDHEALTHCARE COMMUNITY PLAN PAYER IDs .................................................. 13 Page 5 of 13 1. INTRODUCTION This section describes how Technical Report Type 3 (TR3), also called Health Care Claim: Professional (835) ASC X12N/005010X222A1, adopted under HIPAA, will be detailed with the use of a table. The tables contain a row for each segment that UnitedHealth Group has something additional, over, and above, the information in the TR3. That information can: 1. Limit the repeat of loops, or segments 2. Limit the length of a simple data element 3. Specify a sub-set of the TR3’s internal code listings 4. Clarify the use of loops, segments, composite, and simple data elements 5. Any other information tied directly to a loop, segment, and composite or simple data element pertinent to trading electronically with UnitedHealthcare In addition to the row for each segment, one or more additional rows are used to describe UnitedHealthcare usage for composite and simple data elements and for any other information. Notes and comments should be placed at the deepest level of detail. For example, a note about a code value should be placed on a row specifically for that code value, not in a general note about the segment. The table below specifies the columns and suggested use of the rows for the detailed description of the transaction set companion guides. The table contains a row for each segment that UnitedHealthcare has included, in addition to the information contained in the TR3s. The following table specifies the columns and suggested use of the rows for the detailed description of the transaction set companion guides: IG Page # Loop Reference Name Codes Length Comments 71 1000A NM1 Submitter Name This type of row exists to indicate that a new segment has begun. It is always shaded at 10% and notes or comment about the segment itself goes in this cell 114 2100C NM109 Subscriber Primary Identifier 15 This type of row exists to limit the length of the specified data element Page 6 of 13 114 2100C NM108 Identification Code Qualifier MI This type of row exists when a note for a particular code value is required. For example, this note may say that value MI is the only valid value. Not populating the first 3 columns makes it clear that the code value belongs to the row immediately above it. 184 2300 HI Principal Diagnosis Code 2300 HI01-2 Code List Qualifier Code This row illustrates how to indicate a component data element in the Reference column and how to specify that only one code value is applicable 1.1. SCOPE This guide is to be used by the Trading Partner for the development of the ASC X12/005010X221A1 835 transaction for the purpose of reporting claim payment information from UnitedHealthcare. 1.2. OVERVIEW This UnitedHealthcare Community Plan Health Care Claim Payment/Advice Companion Guide has been written to assist you in designing and implementing Claim Payment Advice transactions to meet UnitedHealthcare's processing standards. This Companion Guide must be used in conjunction with the Health Care Claim Payment/Advice (835) instructions as set forth by the ASC X12 Standards for Electronic Data Interchange (Version 005010X221), April 2006, and the Errata (Version 005010X221A1), June 2010. The UnitedHealthcare Companion Guide identifies key data elements from the transaction set that will be provided in the transaction. The recommendations made are to enable you to more effectively complete EDI transactions with UnitedHealthcare. Updates to this companion guide occur periodically and are available online. CG documents are posted in the Electronic Data Interchange (EDI) section of our Resource Library on the Companion Guides page: https://www.uhcprovider.com/en/resource-library/edi/edi-companion-guides.html In addition, trading partners can sign up for the Network Bulletin and other online news: https://uhg.csharmony.epsilon.com/Account/Register. Page 7 of 13 1.3. REFERENCE For more information regarding the ASC Standards for Electronic Data Interchange (X12/005010X221A1) Health Care Claim Payment/Advice (835) and to purchase copies of the TR3 documents, consult the Washington Publishing Company website: http://www.wpc-edi.com 1.4. ADDITIONAL INFORMATION The American National Standards Institute (ANSI) is the coordinator for information on national and international standards. In 1979 ANSI chartered the Accredited Standards Committee (ASC) X12 to develop uniform standards for electronic interchange of business transactions and eliminate the problem of non-standard electronic data communication. The objective of the ASC X12 Committee is to develop standards to facilitate electronic interchange relating to all types of business transactions. The ANSI X12 standards is recognized by the United States as the standard for North America. EDI adoption has been proved to reduce the administrative burden on providers. Please note that this is UnitedHealthcare’s approach to 837 Professional claim transactions. After careful review of the existing IG for Version 005010X222A1, we have compiled the UnitedHealthcare specific CG. We are not responsible for any changes and updates made to the IG. 2. GETTING STARTED 2.1 EXCHANGING TRANSACTIONS WITH UNITEDHEALTHCARE UnitedHealthcare exchanges transactions with clearinghouses and direct submitters, also referred to as Trading Partners. Most transactions go through the Optum clearinghouse, Optum360, the managed gateway for UnitedHealthcare EDI transactions. 2.2 CLEARINGHOUSE CONNECTION Physicians, facilities, and health care professionals should contact their current clearinghouse vendor to discuss their ability to support the ASC X12N/005010X221A1 Health Care Claim Payment/Advice transaction (835), as well as associated timeframes, costs, etc. This includes protocols for testing the exchange of transactions with UnitedHealthcare through your clearinghouse. To receive Electronic Funds Transfer, you should enroll in Electronic Payments and Statements online. If questions, contact EDI Support by: • Using our EDI Transaction Support Form • Sending an email to [email protected] • Calling 800-210-8315 3. CONNECTIVITY WITH THE PAYER / COMMUNICATIONS 3.1. PROCESS FLOW Page 8 of 13 835 Connection File Delivery Flows Clearinghouse Connectivity 3.2. RE-TRANSMISSION PROCEDURE Trading Partners can request re-transmission of the entire 835 file by contacting EDI Support using our EDI Transaction Support Form, sending an email to [email protected] or calling 800-842- 1109. The 835 files will be routed through the Trading Partner’s regular connectivity path. Please note the re-transmission is the entire 835 file, not a specified 835 contained within a file. Physicians and health care professionals that do not have a direct connection with UnitedHealthcare will need to contact the entity they are receiving the 835 files from to discuss how to receive a re-transmission. 4. CONTACT INFORMATION 4.1. EDI SUPPORT Most questions can be answered by referring to the EDI section of our resource library on UHCprovider.com. View the EDI 835: Electronic Remittance Advice (ERA) page for information specific to 835 health claim payment transactions. Enroll in Electronic Payments and Statements to receive your 835 files. For assistance with understanding your 835 or for more information on our direct connection, please contact EDI Support by using our EDI Transaction Support Form, sending an email to [email protected] or calling 800-210-8315. If you have questions related to submitting transactions through a clearinghouse, please contact your clearinghouse or software vendor directly. 5. CONTROL SEGMENTS/ENVELOPES 5.1. ISA-IEA Transactions transmitted during a session or as a batch are identified by an interchange header segment (ISA) and trailer segment (IEA) which form the envelope enclosing the transmission. Each ISA marks the beginning of the transmission (batch) and provides sender and receiver identification. UnitedHealthcare uses the following delimiters on your 835 files: UnitedHealthcare uses the following delimiters on your 835 files: Community Plan 835 Optum360 Connectivity Solutions Provider is Trading Partner? Clearinghouse, VAN, etc. YES Page 9 of 13 1. Data Element: The first element separator following the ISA will define what Data Element Delimiter is used throughout the entire transaction. The Data Element Delimiter is an asterisk (). 2. Segment: The last position in the ISA will define what Segment Element Delimiter is used throughout the entire transaction. The Segment Delimiter is a tilde (~). 3. Component-Element: Element ISA16 will define what Component-Element Delimiter is used throughout the entire transaction. The Component-Element Delimiter is a colon (:). 5.2. GS-GE EDI transactions of a similar nature and destined for one trading partner may be gathered into a functional group, identified by a functional group header segment (GS) and a functional group trailer segment (GE). Each GS segment marks the beginning of a functional group. There can be many functional groups within an interchange envelope. 5.3. ST-SE The beginning of each individual transaction is identified using a transaction set header segment (ST). The end of every transaction is marked by a transaction set trailer segment (SE). 6. PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS 6.1. 835 ENROLLMENTS The 835 transaction enrollment registration will be done at the Federal Tax Identification Number level. Registrations for 835 at levels lower than the Federal Tax Identification Number do not currently exist. 7. ACKNOWLEDGEMENTS AND OR REPORTS Currently UnitedHealthcare does not provide acknowledgments or reporting on the 835 transactions. 7.1. REPORT INVENTORY No 835 reporting inventory is available currently. 8. TRADING PARTNER AGREEMENTS 8.1. TRADING PARTNERS An EDI Trading Partner is defined as any UnitedHealthcare customer (provider, billing service, software vendor, employer group, financial institution, etc.) that transmits to, or receives Page 10 of 13 electronic data directly from UnitedHealthcare. Payers have EDI Trading Partner Agreements that accompany the standard implementation guide to ensure the integrity of the electronic transaction process. The Trading Partner Agreement is related to the electronic exchange of information, whether the agreement is an entity or a part of a larger agreement, between each party to the agreement. The agreement is related to the electronic exchange of information. The agreement is an entity or a part of a larger agreement, between each party to the agreement. The Trading Partner Agreement may specify among other things, the roles, and responsibilities of each party to the agreement in conducting standard transactions. Since your clearinghouse is considered the EDI Trading Partner, you are covered under a larger agreement and there is no need to execute an EDI Trading Partner Agreement with UnitedHealthcare Community Plan. 9. TRANSACTION SPECIFIC INFORMATION UnitedHealthcare has put together the following grid to assist you in designing and programming the information we would provide in 835 transactions. This Companion Guide is meant to illustrate the data provided by UnitedHealthcare for successful posting of Health Care Claim Payment/Advice transactions. The table contains a row for each segment that UnitedHealthcare has something additional, over and above, the information in the IG. That information can: 1. Limit the repeat of loops or segments	EDI-835-Companion-Guide-UHCCP-005010X221A1.pdf
delimiters on your 835 files: Community Plan 835 Optum360 Connectivity Solutions Provider is Trading Partner? Clearinghouse, VAN, etc. YES Page 9 of 13 1. Data Element: The first element separator following the ISA will define what Data Element Delimiter is used throughout the entire transaction. The Data Element Delimiter is an asterisk (*). 2. Segment: The last position in the ISA will define what Segment Element Delimiter is used throughout the entire transaction. The Segment Delimiter is a tilde (~). 3. Component-Element: Element ISA16 will define what Component-Element Delimiter is used throughout the entire transaction. The Component-Element Delimiter is a colon (:). 5.2. GS-GE EDI transactions of a similar nature and destined for one trading partner may be gathered into a functional group, identified by a functional group header segment (GS) and a functional group trailer segment (GE). Each GS segment marks the beginning of a functional group. There can be many functional groups within an interchange envelope. 5.3. ST-SE The beginning of each individual transaction is identified using a transaction set header segment (ST). The end of every transaction is marked by a transaction set trailer segment (SE). 6. PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS 6.1. 835 ENROLLMENTS The 835 transaction enrollment registration will be done at the Federal Tax Identification Number level. Registrations for 835 at levels lower than the Federal Tax Identification Number do not currently exist. 7. ACKNOWLEDGEMENTS AND OR REPORTS Currently UnitedHealthcare does not provide acknowledgments or reporting on the 835 transactions. 7.1. REPORT INVENTORY No 835 reporting inventory is available currently. 8. TRADING PARTNER AGREEMENTS 8.1. TRADING PARTNERS An EDI Trading Partner is defined as any UnitedHealthcare customer (provider, billing service, software vendor, employer group, financial institution, etc.) that transmits to, or receives Page 10 of 13 electronic data directly from UnitedHealthcare. Payers have EDI Trading Partner Agreements that accompany the standard implementation guide to ensure the integrity of the electronic transaction process. The Trading Partner Agreement is related to the electronic exchange of information, whether the agreement is an entity or a part of a larger agreement, between each party to the agreement. The agreement is related to the electronic exchange of information. The agreement is an entity or a part of a larger agreement, between each party to the agreement. The Trading Partner Agreement may specify among other things, the roles, and responsibilities of each party to the agreement in conducting standard transactions. Since your clearinghouse is considered the EDI Trading Partner, you are covered under a larger agreement and there is no need to execute an EDI Trading Partner Agreement with UnitedHealthcare Community Plan. 9. TRANSACTION SPECIFIC INFORMATION UnitedHealthcare has put together the following grid to assist you in designing and programming the information we would provide in 835 transactions. This Companion Guide is meant to illustrate the data provided by UnitedHealthcare for successful posting of Health Care Claim Payment/Advice transactions. The table contains a row for each segment that UnitedHealthcare has something additional, over and above, the information in the IG. That information can: 1. Limit the repeat of loops or segments 2. Limit the length of a simple data element 3. Specify a subset of the IG internal code listings 4. Clarify the use of loops, segments, composite, and simple data elements 5. Provide any other information tied directly to a loop, segment and composite or simple data element pertinent to trading electronically with UnitedHealthcare All segments, data elements, and codes supported in the ASC X12N/005010X221A1 835 Implementation Guide are acceptable; however, all data may not be used in the processing of this transaction by UnitedHealthcare for an 835 transaction. The following table describes UnitedHealthcare Services Company of the River Valley, Inc. (UnitedHealthcare) selections within the context of the HIPAA Implementation Guides and Addenda. Page 11 of 13 LEGEND: Shaded rows represent “segments” in the X12N Implementation Guide. NON-SHADED rows represent “data elements” in the X12N Implementation Guide. IG Page # Loop Reference Name Codes Length Comments 69 BPR Financial Information 70-71 BPR01 Transaction Handling Code C, I UHC will use C (Payment Accompanies Remit) or I (remittance Info Only). 71 BPR03 Credit/Debit Flag Code C UHC will use C (Credit). 72 BPR04 Payment Method Code ACH, CHK, NON, UHC will use ACH (Automated Clearinghouse), CHK (Check), BOP, or NON (Non-Payment Data). 72 BPR05 Payment Format Code CTX UHC will use CCP (Corporate Trade Exchange) 112 2000 TS3 Provider Summary Information 113 2000 TS301 Reference Identification The Provider tax ID plus a two- character identification number assigned by UHC under which the claims was judged. 123 2100 CLP Claim Payment Information Claim Payment Information 124 2100 CLP02 Claim Status Code 1, 2, 19, 22 UHC will use the following values for the claim status codes: 1- Processed as Primary, 2- Processed as Secondary, 19-Processed as Primary, forwarded to additional payers, 22- Reversal of Previous Payment 126- 127 2100 CLP06 Claim Filing Indicator Code HM, MC 12, or 13 UHC will return the appropriate qualifier that aligns with the insurance plan adjudicated 140 2100 NM1 Patient Name 142 2100 NM108 Identification Code Qualifier MI Member Identification Qualifier 142 2100 NM109 Identification Code Qualifier Member Identification code as submitted on the inbound claim 146 2100 NM1 Service Provider Name 148 2100 NM108 Identification Code Qualifier XX UHC (UnitedHealthcare) will use XX (National Provider Identifier) Page 12 of 13 149 2100 NM109 Identification Code UHC Unique Provider ID The provider tax ID plus a two- character identification number assigned by UHC under which the claim was adjudicated. 182 2100 AMT Claim Supplemental Information 182- 183 2100 AMT01 Amount Qualifier Code AU UHC will use AU (Coverage Amt) to report the total net allowed amount for the claim 186 2110 SVC Service Payment Information UHC will report service lines for professional, dental, and outpatient institutional services. Service line detail for inpatient institutional claims is not provided. 206 2110 REF Line-Item Control Number 206 2110 REF01 Reference Identification Qualifier 6R UHC will return the Patient Control Number from the inbound 837 2400 loop REF02 if supplied 211 2110 AMT Service Supplemental Amount 211- 212 2110 AMT01 Amount Qualifier Code B6 UHC will report B6 (Allowed - Actual Amount) to indicate the total net amount allowed for service lines. 217 PLB Provider Adjustment 219- 222 PLB03-1 Adjustment Reason Code FB, L3, L6 and WO UHC will use: FB qualifier for the Forward Balance (negative amount) that will be recovered from a provider's future remits. The Reference ID will includes Patient Acct number, Claim number, and remit number, WO qualifier for the overpayment recovery, along with the members account number. 10. APPENDECIES 10.1.IMPLEMENTATION CHECKLIST 1. Contact your Clearinghouse to enroll in Electronic Funds Transfer (EFT) 2. Enroll in Electronic Payments and Statements (EPS) with UnitedHealthcare/Optum 10.2.FREQUENTLY ASKED QUESTIONS 1. Does this companion guide apply to all UnitedHealthcare Payers? No. This companion guide will apply to UnitedHealthcare Community and State Plans. 2. Why are the claim adjustment reason codes different than the adjustment codes on the EOB? Page 13 of 13 The adjustment codes reported in the 835 transactions are from the National Claim Adjustment Reason Code list. In most instances the UnitedHealthcare proprietary adjustment codes are reported on the EOB. 3. If a claim is submitted to UnitedHealthcare on paper and not in an 837 will the claim payment data be reported in the 835? Yes, the source of claim submission does not impact the 835 reporting. 4. If a claim is closed for additional information will the closed claim be reported in the 835? No. UnitedHealthcare only reports claims that are paid or denied are reported in the 835. 5. Does enrollment to receive the 835 transaction impact the payment cycle? No, the generation of the 835 transaction will mirror the current payment cycle for the physician or health care professional. 10.3.UNITEDHEALTHCARE COMMUNITY PLAN PAYER IDs For a complete listing of claims and electronic remittance advice (ERA) Payer IDs for UnitedHealthcare Community Plan payers, refer to our Claims payer list and ERA payer List, both posted online at UHCprovider.com/EDI.	EDI-835-Companion-Guide-UHCCP-005010X221A1.pdf

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