Loop ID Reference Name Codes Notes/Comments Category claim adjudication. . 2300 PWK02 Attachment Transmission Code BM, FX The only values which may 6 be used in adjudication are and “BM” “FX”. 2300 CN1 CONTRACT INFORMATION Must not be present. 4 Submission of this segment will cause your claim to reject. 2300 REF MANDATORY MEDICARE Must not be present. 4 – Segment (SECTION 4081) CROSSOVER Submission of this segment Rule INDICATOR will cause your claim to reject. 2300 REF PAYER CLAIM CONTROL Must not be present. 4 – Segment NUMBER Submission of this segment Rule will cause your claim to reject. 2300 CR102 Patient Weight The maximum number of 2 characters to be submitted in the patient weight field is four characters to the left of the decimal and two characters to the right. Patient weight in excess of 9,999.99 pounds will be rejected. 2300 CR106 Transport Distance The maximum number of 2 characters to be submitted in the transport distance is four characters. Transport distance in excess of 9,999 miles will be rejected. 2300 HI Health Care Diagnosis Code All diagnosis codes 1 – Segment submitted on a claim must Rule be valid codes per the qualified code source. Claims that contain invalid diagnosis codes (pointed to or not) will be rejected. 2310A REF 4 REFERRING PROVIDER Must not be present (non- – Segment SECONDARY VA contractors). Rule IDENTIFICATION Submission of this segment will cause your claim to reject. 2310C REF SERVICE FACILITY Must not be present (non- 4 – Segment LOCATION SECONDARY VA contractors). Rule IDENTIFICATION Submission of this segment
Loop ID Reference Name Codes Notes/Comments Category claim adjudication. . 2300 PWK02 Attachment Transmission Code BM, FX The only values which may be used in adjudication are “BM” and “FX”. 6 2300 CN1 CONTRACT INFORMATION Must not be present. Submission of this segment will cause your claim to reject. 4 2300 REF – Segment Rule MANDATORY MEDICARE (SECTION 4081) CROSSOVER INDICATOR Must not be present. Submission of this segment will cause your claim to reject. 4 2300 REF – Segment Rule PAYER CLAIM CONTROL NUMBER Must not be present. Submission of this segment will cause your claim to reject. 4 2300 CR102 Patient Weight The maximum number of characters to be submitted in the patient weight field is four characters to the left of the decimal and two characters to the right. Patient weight in excess of 9,999.99 pounds will be rejected. 2 2300 CR106 Transport Distance The maximum number of characters to be submitted in the transport distance is four characters. Transport distance in excess of 9,999 miles will be rejected. 2 2300 HI – Segment Rule Health Care Diagnosis Code All diagnosis codes submitted on a claim must be valid codes per the qualified code source. Claims that contain invalid diagnosis codes (pointed to or not) will be rejected. 1 2310A REF – Segment Rule REFERRING PROVIDER SECONDARY IDENTIFICATION Must not be present (non- VA contractors). Submission of this segment will cause your claim to reject. 4 2310C REF – Segment Rule SERVICE FACILITY LOCATION SECONDARY IDENTIFICATION Must not be present (non- VA contractors). Submission of this segment 4
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