Loop ID Reference Name Codes Notes/Comments Category 2420B REF PURCHASED SERVICE Must not be present (non- 4 – Segment PROVIDER SECONDARY VA contractors). Rule IDENTIFICATION Submission of this segment will cause your claim to reject. 2420C REF 4 SERVICE FACILITY Must not be present (non- – Segment LOCATION SECONDARY VA contractors). Rule IDENTIFICATION Submission of this segment will cause your claim to reject. 2420D REF 4 SUPERVISING PROVIDER Must not be present (non- – Segment SECONDARY VA contractors). Rule IDENTIFICATION Submission of this segment will cause your claim to reject. 2420E REF ORDERING PROVIDER Must not be present (non- 4 – Segment SECONDARY VA contractors). Rule IDENTIFICATION Submission of this segment will cause your claim to reject. 2420F LQ REFERRING PROVIDER Must not be present. 4 – Segment SECONDARY Submission of this Rule IDENTIFICATION segment for Part B will cause your claim to reject. 2440 LQ 4 FORM If 2400 PWK01 = CT and – Segment IDENTIFICATION CODE PWK02= AD, the LQ Rule segment must be submitted. 2440 LQ01 FORM UT Must be 1 “UT”. IDENTIFICATION CODE Submission of any other value will cause your claim to reject. 2440 FRM SUPPORTING Must not be present. 6 – Segment DOCUMENTATION Submission of this Rule segment for Part B will cause your claim to reject.
Loop ID Reference Name Codes Notes/Comments Category 2420B REF – Segment Rule PURCHASED SERVICE PROVIDER SECONDARY IDENTIFICATION Must not be present (non- VA contractors). Submission of this segment will cause your claim to reject. 4 2420C REF – Segment Rule SERVICE FACILITY LOCATION SECONDARY IDENTIFICATION Must not be present (non- VA contractors). Submission of this segment will cause your claim to reject. 4 2420D REF – Segment Rule SUPERVISING PROVIDER SECONDARY IDENTIFICATION Must not be present (non- VA contractors). Submission of this segment will cause your claim to reject. 4 2420E REF – Segment Rule ORDERING PROVIDER SECONDARY IDENTIFICATION Must not be present (non- VA contractors). Submission of this segment will cause your claim to reject. 4 2420F LQ – Segment Rule REFERRING PROVIDER SECONDARY IDENTIFICATION Must not be present. Submission of this segment for Part B will cause your claim to reject. 4 2440 LQ – Segment Rule FORM IDENTIFICATION CODE If 2400 PWK01 = CT and PWK02= AD, the LQ segment must be submitted. 4 2440 LQ01 FORM IDENTIFICATION CODE UT Must be “UT”. Submission of any other value will cause your claim to reject. 1 2440 FRM – Segment Rule SUPPORTING DOCUMENTATION Must not be present. Submission of this segment for Part B will cause your claim to reject. 6
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