EDI 837 X224A3 - Health Care Claim: Dental

Functional Group HC

X12N Insurance Subcommittee

This X12 Transaction Set contains the format and establishes the data contents of the Health Care Claim Transaction Set (837) for use within the context of an Electronic Data Interchange (EDI) environment. This transaction set can be used to submit health care claim billing information, encounter information, or both, from providers of health care services to payers, either directly or via intermediary billers and claims clearinghouses. It can also be used to transmit health care claims and billing payment information between payers with different payment responsibilities where coordination of benefits is required or between payers and regulatory agencies to monitor the rendering, billing, and/or payment of health care services within a specific health care/insurance industry segment. For purposes of this standard, providers of health care products or services may include entities such as physicians, hospitals and other medical facilities or suppliers, dentists, and pharmacies, and entities providing medical information to meet regulatory requirements. The payer refers to a third party entity that pays claims or administers the insurance product or benefit or both. For example, a payer may be an insurance company, health maintenance organization (HMO), preferred provider organization (PPO), government agency (Medicare, Medicaid, Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), etc.) or an entity such as a third party administrator (TPA) or third party organization (TPO) that may be contracted by one of those groups. A regulatory agency is an entity responsible, by law or rule, for administering and monitoring a statutory benefits program or a specific health care/insurance industry segment.

What is an EDI 837?

An EDI 837 Healthcare Claim communicates a patient's healthcare claim, sent from healthcare agencies to insurance providers. It contains information about the patient (SBR segment), the provider (PRV segment), services provided and the cost of the treatment (CLM segment). It must be HIPAA 5010 compliant.

How is an EDI 837 used?

For example, when Person A receives an x-ray, Hospital B will issue an EDI 837 Healthcare Claim to Medical Insurance Provider C. Insurance Provider C will respond to the EDI 837 Healthcare Claim an EDI 835 Health Care Claim Payment/Advice to provide payment or further details.

Heading

Position
Segment
Name
Max use
  1. To indicate the start of a transaction set and to assign a control number

  2. To define the business hierarchical structure of the transaction set and identify the business application purpose and reference data, i.e., number, date, and time

    The second example denotes the case where the entire transaction set contains ENCOUNTERS.
  3. 1000A Loop Mandatory
    Repeat 1
    1. To supply the full name of an individual or organizational entity

      The submitter is the entity responsible for the creation and formatting of this transaction.
    2. To identify a person or office to whom administrative communications should be directed

      When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number must always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as "1", in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as "ext" or "x-".
      The contact information in this segment identifies the person in the submitter organization who deals with data transmission issues. If data transmission problems arise, this is the person to contact in the submitter organization.
      There are 2 repetitions of the PER segment to allow for six possible combinations of communication numbers including extensions.
  4. 1000B Loop Mandatory
    Repeat 1
    1. To supply the full name of an individual or organizational entity

Detail

Position
Segment
Name
Max use
  1. 2000A Loop Mandatory
    Repeat >1
    1. To identify dependencies among and the content of hierarchically related groups of data segments

    2. To specify the identifying characteristics of a provider

      Required when the Billing Provider is also the Rendering Provider for at least one of the claims in this transaction. If not required by this implementation guide, do not send.
    3. To specify the currency (dollars, pounds, francs, etc.) used in a transaction

      Required when the amounts represented in this transaction are currencies other than the United States dollar. If not required by this implementation guide, do not send.
      It is REQUIRED that all amounts reported within the transaction are of the currency named in this segment. If this segment is not used, then it is required that all amounts in this transaction be expressed in US dollars.
    4. 2010AA Loop Mandatory
      Repeat 1
      1. To supply the full name of an individual or organizational entity

        Beginning on the NPI compliance date: When the Billing Provider is an organization health care provider, the organization health care provider's NPI or its subpart's NPI is reported in NM109. When a health care provider organization has determined that it needs to enumerate its subparts, it will report the NPI of a subpart as the Billing Provider. The subpart reported as the Billing Provider MUST always represent the most detailed level of enumeration as determined by the organization health care provider and MUST be the same identifier sent to any trading partner. For additional explanation, see section 1.10.3 Organization Health Care Provider Subpart Presentation.
        Prior to the NPI compliance date, proprietary identifiers necessary for the receiver to identify the Billing Provider entity are to be reported in the REF segment of Loop ID-2010BB.
        The Taxpayer Identifying Number (TIN) of the Billing Provider to be used for 1099 purposes must be reported in the REF segment of this loop.
        The Billing Provider may be an individual only when the health care provider performing services is an independent, unincorporated entity. In these cases, the Billing Provider is the individual whose social security number is used for 1099 purposes. That individual's NPI is reported in NM109, and the individual's Tax Identification Number must be reported in the REF segment of this loop. The individual's NPI must be reported when the individual provider is eligible for an NPI. See section 1.10.1 (Providers who are Not Eligible for Enumeration).
        When the individual or the organization is not a health care provider and, thus, not eligible to receive an NPI (For example, personal care services, carpenters, etc), the Billing Provider should be the legal entity. However, willing trading partners may agree upon varying definitions. Proprietary identifiers necessary for the receiver to identify the entity are to be reported in the Loop ID-2010BB REF, Billing Provider Secondary Identification segment. The TIN to be used for 1099 purposes must be reported in the REF (Tax Identification Number) segment of this loop.
      2. To specify the location of the named party

        The Billing Provider Address must be a street address. Post Office Box or Lock Box addresses are to be sent in the Pay-To Address Loop (Loop ID-2010AB), if necessary.
      3. To specify the geographic place of the named party

      4. To specify identifying information

        This is the tax identification number (TIN) of the entity to be paid for the submitted services.
      5. To specify identifying information

        Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when a UPIN and/or license number is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI implementation date when NM109 of this loop is not used and a UPIN or license number is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send.
        Payer specific secondary identifiers are reported in the Loop ID-2010BB REF, Billing Provider Secondary Identification.
      6. To identify a person or office to whom administrative communications should be directed

        Required when this information is different than that contained in the Loop ID-1000A - Submitter PER segment. If not required by this implementation guide, do not send.;
        When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number must always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as "1", in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as "ext" or "x-".
        There are 2 repetitions of the PER segment to allow for six possible combinations of communication numbers including extensions.
    5. 2010AB Loop Optional
      Repeat 1
      1. To supply the full name of an individual or organizational entity

        Required when the address for payment is different than that of the Billing Provider. If not required by this implementation guide, do not send.;
        The purpose of Loop ID-2010AB has changed from previous versions. Loop ID-2010AB only contains address information when different from the Billing Provider Address. There are no applicable identifiers for Pay-To Address information.
      2. To specify the location of the named party

      3. To specify the geographic place of the named party

    6. 2010AC Loop Optional
      Repeat 1
      1. To supply the full name of an individual or organizational entity

        Required when willing trading partners agree to use this implementation for their subrogation payment requests.
        This loop may only be used when BHT06 = 31.
      2. To specify the location of the named party

      3. To specify the geographic place of the named party

      4. To specify identifying information

        Required prior to the mandated implementation date for the HIPAA National Plan Identifier when an additional identification number to that provided in the NM109 of this loop is necessary for the claim processor to identify the entity. If not required by this implementation guide, do not send.
      5. To specify identifying information

    7. 2000B Loop Mandatory
      Repeat >1
      1. To identify dependencies among and the content of hierarchically related groups of data segments

        If a patient can be uniquely identified to the destination payer in Loop ID-2010BB by a unique Member Identification Number, then the patient is the subscriber or is considered to be the subscriber and is identified at this level, and the patient HL in Loop ID-2000C is not used.
        If the patient is not the subscriber and cannot be identified to the destination payer by a unique Member Identification Number or it is not known to the sender if the Member Identification number is unique, both this HL and the patient HL in Loop ID- 2000C are required.
      2. To record information specific to the primary insured and the insurance carrier for that insured

      3. 2010BA Loop Mandatory
        Repeat 1
        1. To supply the full name of an individual or organizational entity

          In worker's compensation or other property and casualty claims, the "subscriber" may be a non-person entity (for example, the employer). However, this varies by state.
        2. To specify the location of the named party

          Required when the patient is the subscriber or considered to be the subscriber. If not required by this implementation guide, do not send.
        3. To specify the geographic place of the named party

          Required when the patient is the subscriber or considered to be the subscriber. If not required by this implementation guide, do not send.
        4. To supply demographic information

          Required when the patient is the subscriber or considered to be the subscriber. If not required by this implementation guide, do not send.
        5. To specify identifying information

          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.
        6. To specify identifying information

          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.
      4. 2010BB Loop Mandatory
        Repeat 1
        1. To supply the full name of an individual or organizational entity

          This is the destination payer.
          For the purposes of this implementation the term payer is synonymous with several other terms, such as, repricer and third party administrator.
        2. To specify the location of the named party

          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.
        3. To specify the geographic place of the named party

          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.
        4. To specify identifying information

          Required prior to the mandated implementation date for the HIPAA National Plan Identifier when an additional identification number to that provided in the NM109 of this loop is necessary for the claim processor to identify the entity. If not required by this implementation guide, do not send.
        5. To specify identifying information

          Required prior to the mandated NPI Implementation Date when an additional identification number is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in Loop 2010AA is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send.
      5. 2300 Loop Optional
        Repeat 100
        1. To specify basic data about the claim

          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.
        2. To specify any or all of a date, a time, or a time period

          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.
        3. To specify any or all of a date, a time, or a time period

          Required when reporting the date orthodontic appliances were placed. 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.
        4. To specify any or all of a date, a time, or a time period

          Required when all of the services for this claim were performed. Not used when the claim is being submitted as a Predetermination of Benefits. 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.
        5. To specify any or all of a date, a time, or a time period

          Required when a repricer is passing the claim onto the payer. If not required by this implementation guide, do not send.
        6. To supply orthodontic information

          Required when the claim contains services related to treatment for orthodontic purposes. If not required by this implementation guide, do not send.
          When reporting this segment, at least one of DN101, DN102 or DN104 must be present.
        7. To specify the status of individual teeth

          Required when the submitter is reporting a missing tooth or a tooth to be extracted in the future. If not required by this implementation guide, do not send.
        8. To identify the type or transmission or both of paperwork or supporting information

          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.
        9. To specify basic data about the contract or contract line item

          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.
        10. To indicate the total monetary amount

          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).
        11. To specify identifying information

          Required when sending the Predetermination of Benefits Identification Number for services that have been previously predetermined and are now being submitted for payment. If not required by this implementation guide, do not send.
          Reference numbers at this position apply to the entire claim.
        12. To specify identifying information

          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.
        13. To specify identifying information

          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.
        14. To specify identifying information

          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.
          This segment must not be used to report the Predetermination of Benefits Identification Number.
        15. To specify identifying information

          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.
          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.
          This segment must not be used to report the Predetermination of Benefits Identification Number.
          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.
        16. To specify identifying information

          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.
        17. To specify identifying information

          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.
        18. To specify identifying information

          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.
        19. To transmit a fixed-format record or matrix contents

          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).
        20. To transmit information in a free-form format, if necessary, for comment or special instruction

          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.
          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.;
        21. To supply information related to the delivery of health care

          Do not transmit the decimal point for ICD codes. The decimal point is implied.
          Required when the diagnosis may have an impact on the adjudication of the claim in cases where specific dental procedures may minimize the risks associated with the connection between the patient's oral and systemic health conditions. If not required by this implementation guide, do not send.
        22. To specify pricing or repricing information about a health care claim or line item

          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.
        23. 2310A Loop Optional
          Repeat 2
          1. To supply the full name of an individual or organizational entity

            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 the 2310A loop at the claim 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.
          2. To specify the identifying characteristics of a provider

            Required when adjudication is known to be impacted by the provider taxonomy code. If not required by this implementation guide, do not send.
          3. To specify identifying information

            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.
        24. 2310B Loop Optional
          Repeat 1
          1. To supply the full name of an individual or organizational entity

            Required when the Rendering Provider NM1 information is different than that carried in the Billing Provider loop (Loop ID-2010AA) and the Assistant Surgeon loop (Loop ID-2310D) is not used. 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.
          2. To specify the identifying characteristics of a provider

            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.
          3. To specify identifying information

            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.
        25. 2310C Loop Optional
          Repeat 1
          1. To supply the full name of an individual or organizational entity

            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.
            When the service(s) was rendered in the patient's home (the address reported as the patient address in the Subscriber or Patient loop), do not use the Service Facility Location loop. In that case, the place of service code in CLM05-1 indicates that the service occurred in the patient's home.
            The purpose of this loop is to identify specifically where the service was rendered.
            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.
          2. To specify the location of the named party

            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".)
          3. To specify the geographic place of the named party

          4. To specify identifying information

            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.
        26. 2310D Loop Optional
          Repeat 1
          1. To supply the full name of an individual or organizational entity

            Required when the Rendering Provider provided these services in the role of the Assisting Surgeon. 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.
          2. To specify the identifying characteristics of a provider

            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.
          3. To specify identifying information

            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.
        27. 2310E Loop Optional
          Repeat 1
          1. To supply the full name of an individual or organizational entity

            Required when the rendering provider is supervised by a physician or dentist. 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.
          2. To specify identifying information

            Required when the HIPAA National Provider Identifier (NPI) is not reported in NM109 of this loop; OR Required for Health Care Providers prior to the mandated NPI implementation date when an NPI is reported in NM109 of this loop and an additional identification number is required by the receiver to identify the provider; OR Required for providers who are not Health Care Providers when an NPI is reported in NM109 of this loop and an additional identification number is required by the receiver to identify the provider. If not required by this implementation guide, do not send.
        28. 2320 Loop Optional
          Repeat 10
          1. To record information specific to the primary insured and the insurance carrier for that insured

            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.
          2. To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid

            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).
          3. To indicate the total monetary amount

            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.;
          4. To indicate the total monetary amount

            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.
          5. To indicate the total monetary amount

            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.
          6. To specify information associated with other health insurance coverage

            All information contained in the OI segment applies only to the payer identified in Loop ID-2330B in this iteration of Loop ID-2320.
          7. To convey claim-level data related to the adjudication of Medicare claims not related to an inpatient setting

            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.
          8. 2330A Loop Mandatory
            Repeat 1
            1. To supply the full name of an individual or organizational entity

              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.
            2. To specify the location of the named party

              Required when the information is available. If not required by this implementation guide, do not send.
            3. To specify the geographic place of the named party

              Required when the information is available. If not required by this implementation guide, do not send.
            4. To specify identifying information

              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.
          9. 2330B Loop Mandatory
            Repeat 1
            1. To supply the full name of an individual or organizational entity

              See Crosswalking COB Data Elements section for more information on handling COB in the 837.
            2. To specify the location of the named party

              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.
            3. To specify the geographic place of the named party

              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.
            4. To specify any or all of a date, a time, or a time period

              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.;
            5. To specify identifying information

              Required prior to the mandated implementation date for the HIPAA National Plan Identifier when an additional identification number to that provided in the NM109 of this loop is necessary for the claim processor to identify the entity. If not required by this implementation guide, do not send.
            6. To specify identifying information

              This segment must not be used to report the Predetermination of Benefits Identification Number.
              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.
            7. To specify identifying information

              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.
            8. To specify identifying information

              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.
            9. To specify identifying information

              Required when the payer identified in this loop has assigned a predetermination identification number to this claim. If not required by this implementation guide, do not send.
            10. To specify identifying information

              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.
          10. 2330C Loop Optional
            Repeat 2
            1. To supply the full name of an individual or organizational entity

              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.
            2. To specify identifying information

              See Crosswalking COB Data Elements section for more information on handling COB in the 837.
          11. 2330D Loop Optional
            Repeat 1
            1. To supply the full name of an individual or organizational entity

              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.
            2. To specify identifying information

              See Crosswalking COB Data Elements section for more information on handling COB in the 837.
          12. 2330E Loop Optional
            Repeat 1
            1. To supply the full name of an individual or organizational entity

              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.
            2. To specify identifying information

              See Crosswalking COB Data Elements section for more information on handling COB in the 837.
          13. 2330F Loop Optional
            Repeat 1
            1. To supply the full name of an individual or organizational entity

              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.
            2. To specify identifying information

              See Crosswalking COB Data Elements section for more information on handling COB in the 837.
          14. 2330G Loop Optional
            Repeat 1
            1. To supply the full name of an individual or organizational entity

              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.
            2. To specify identifying information

          15. 2330H Loop Optional
            Repeat 1
            1. To supply the full name of an individual or organizational entity

              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.
            2. To specify identifying information

              See Crosswalking COB Data Elements section for more information on handling COB in the 837.
        29. 2400 Loop Mandatory
          Repeat 50
          1. To reference a line number in a transaction set

            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.
          2. To specify the service line item detail for dental work

          3. To identify a tooth by number and, if applicable, one or more tooth surfaces

            Required when reporting tooth information related to this service line. If not required by this implementation guide, do not send.
            Multiple iterations of the TOO segment are allowed only when the quantity reported in Loop ID-2400 SV306 is equal to one.
          4. To specify any or all of a date, a time, or a time period

            Required when the service was performed and the service date is different than the date reported in the Service Date segment in the 2300 loop. If not required by this implementation guide, do not send.
            Do not use this DTP segment when submitting a Predetermination of Dental Benefits.
            Do not use this DTP segment when submitting a Treatment Start Date, Treatment Completion Date or both.
          5. To specify any or all of a date, a time, or a time period

            Required when the value of SV305 for this iteration of the 2400 loop is R - Replacement. If not required by this implementation guide, do not send.
          6. To specify any or all of a date, a time, or a time period

            Required when the orthodontic appliance placement date is different than the orthodontic appliance placement date in the DTP segment in the Loop ID-2300 loop. If not required by this implementation guide, do not send.;
          7. To specify any or all of a date, a time, or a time period

            Required when reporting the date that an orthodontic appliance was replaced. If not required by this implementation guide, do not send.
          8. To specify any or all of a date, a time, or a time period

            Required when reporting initial impression or preparation for a crown or denture. OR Required when reporting initial endodontic treatment. OR Required when reporting the implant fixture placement. If not required by this implementation guide, do not send.
            When the Treatment Start Date is used, the Date of Service must not be used.
          9. To specify any or all of a date, a time, or a time period

            Required when reporting the date that a course of treatment was completed. If not required by this implementation guide, do not send.
            When the Treatment Completion Date is used, the Date of Service must not be used.
          10. To specify basic data about the contract or contract line item

            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.
          11. To specify identifying information

            Required when sending the Predetermination of Benefits Identification Number for the line item that has been previously predetermined and is now being submitted for payment. If not required by this implementation guide, do not send.
            Reference numbers at this position apply to the current line item only.
            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.
          12. To specify identifying information

            This segment must not be used to report the Predetermination of Benefits Identification Number.
            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.
          13. To specify identifying information

            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.
          14. To specify identifying information

            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.
          15. To specify identifying information

            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.
          16. To specify identifying information

            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.
          17. To indicate the total monetary amount

            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 (SV302) for this service line must include the amount reported in the Sales Tax Amount.
          18. To transmit a fixed-format record or matrix contents

            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).
          19. To specify pricing or repricing information about a health care claim or line item

            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.
          20. 2420A Loop Optional
            Repeat 1
            1. To supply the full name of an individual or organizational entity

              Required when the Rendering Provider NM1 information is different than that carried in the Loop ID-2310B Rendering Provider and the Assistant Surgeon (Loop ID-2420C) loop is not present OR Required when each of the following conditions apply: - the Rendering Provider information is carried at the Billing Provider level (Loop ID-2010AA) - this particular line item has different Rendering Provider information than that which is carried in the Loop ID-2010AA Billing Provider - the Assistant Surgeon loop (Loop ID-2420C) is not used. 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.
            2. To specify the identifying characteristics of a provider

            3. To specify identifying information

              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.
          21. 2420B Loop Optional
            Repeat 1
            1. To supply the full name of an individual or organizational entity

              Required when the Rendering Provider provided these services in the role of the Assistant Surgeon and the Assistant Surgeon information in this loop is different from the Assistant Surgeon information sent in Loop ID-2310D. If not required by this implementation guide, do not send.;
            2. To specify the identifying characteristics of a provider

              Required when the Assistant Surgeon specialty information is needed to facilitate reimbursement of the claim. If not required by this implementation guide, do not send.;
            3. To specify identifying information

              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 send provider identifiers that are not payer-specific (e.g. UPIN, State License Number), those identifiers must be sent in the corresponding 2310 loop.
              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.
          22. 2420C Loop Optional
            Repeat 1
            1. To supply the full name of an individual or organizational entity

              Required when the rendering provider is supervised by a physician or dentist and the supervising physician or dentist is different than that listed at the claim level for this service line. If not required by this implementation guide, do not send.
            2. To specify identifying information

              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 this segment is used, the identifier(s) to be provided are limited to those necessary for the claim processor to identify the entity.
              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.
          23. 2420D Loop Optional
            Repeat 1
            1. To supply the full name of an individual or organizational entity

              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.
            2. To specify the location of the named party

              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".)
            3. To specify the geographic place of the named party

            4. To specify identifying information

              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.
          24. 2430 Loop Optional
            Repeat 15
            1. To convey service line adjudication information for coordination of benefits between the initial payers of a health care claim and all subsequent payers

              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.
            2. To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid

              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).
            3. To specify any or all of a date, a time, or a time period

            4. To indicate the total monetary amount

              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.
              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 not used if the claim level (Loop ID-2320) Remaining Patient Liability AMT segment is used for this Other Payer.
              This segment is only used in provider submitted claims. It is not used in Payer-to-Payer Coordination of Benefits (COB).
      6. 2000C Loop Optional
        Repeat >1
        1. To identify dependencies among and the content of hierarchically related groups of data segments

          There are no HLs subordinate to the Patient HL.
          If a patient is a dependent of a subscriber and can be uniquely identified to the payer by a unique Identification Number, then the patient is considered the subscriber and is to be identified in the Subscriber Level.
          Required when the patient is a dependent of the subscriber identified in Loop ID-2000B and cannot be uniquely identified to the payer using the subscriber's identifier in the Subscriber Level. If not required by this implementation guide, do not send.
        2. To supply patient information

        3. 2010CA Loop Mandatory
          Repeat 1
          1. To supply the full name of an individual or organizational entity

          2. To specify the location of the named party

          3. To specify the geographic place of the named party

          4. To supply demographic information

          5. To specify identifying information

            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.
          6. To specify identifying information

            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.
        4. 2300 Loop Mandatory
          Repeat 100
          1. To specify basic data about the claim

            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.
          2. To specify any or all of a date, a time, or a time period

            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.
          3. To specify any or all of a date, a time, or a time period

            Required when reporting the date orthodontic appliances were placed. 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.
          4. To specify any or all of a date, a time, or a time period

            Required when all of the services for this claim were performed. Not used when the claim is being submitted as a Predetermination of Benefits. 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.
          5. To specify any or all of a date, a time, or a time period

            Required when a repricer is passing the claim onto the payer. If not required by this implementation guide, do not send.
          6. To supply orthodontic information

            Required when the claim contains services related to treatment for orthodontic purposes. If not required by this implementation guide, do not send.
            When reporting this segment, at least one of DN101, DN102 or DN104 must be present.
          7. To specify the status of individual teeth

            Required when the submitter is reporting a missing tooth or a tooth to be extracted in the future. If not required by this implementation guide, do not send.
          8. To identify the type or transmission or both of paperwork or supporting information

            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.
          9. To specify basic data about the contract or contract line item

            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.
          10. To indicate the total monetary amount

            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).
          11. To specify identifying information

            Required when sending the Predetermination of Benefits Identification Number for services that have been previously predetermined and are now being submitted for payment. If not required by this implementation guide, do not send.
            Reference numbers at this position apply to the entire claim.
          12. To specify identifying information

            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.
          13. To specify identifying information

            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.
          14. To specify identifying information

            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.
            This segment must not be used to report the Predetermination of Benefits Identification Number.
          15. To specify identifying information

            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.
            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.
            This segment must not be used to report the Predetermination of Benefits Identification Number.
            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.
          16. To specify identifying information

            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.
          17. To specify identifying information

            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.
          18. To specify identifying information

            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.
          19. To transmit a fixed-format record or matrix contents

            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).
          20. To transmit information in a free-form format, if necessary, for comment or special instruction

            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.
            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.;
          21. To supply information related to the delivery of health care

            Do not transmit the decimal point for ICD codes. The decimal point is implied.
            Required when the diagnosis may have an impact on the adjudication of the claim in cases where specific dental procedures may minimize the risks associated with the connection between the patient's oral and systemic health conditions. If not required by this implementation guide, do not send.
          22. To specify pricing or repricing information about a health care claim or line item

            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.
          23. 2310A Loop Optional
            Repeat 2
            1. To supply the full name of an individual or organizational entity

              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 the 2310A loop at the claim 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.
            2. To specify the identifying characteristics of a provider

              Required when adjudication is known to be impacted by the provider taxonomy code. If not required by this implementation guide, do not send.
            3. To specify identifying information

              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.
          24. 2310B Loop Optional
            Repeat 1
            1. To supply the full name of an individual or organizational entity

              Required when the Rendering Provider NM1 information is different than that carried in the Billing Provider loop (Loop ID-2010AA) and the Assistant Surgeon loop (Loop ID-2310D) is not used. 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.
            2. To specify the identifying characteristics of a provider

              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.
            3. To specify identifying information

              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.
          25. 2310C Loop Optional
            Repeat 1
            1. To supply the full name of an individual or organizational entity

              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.
              When the service(s) was rendered in the patient's home (the address reported as the patient address in the Subscriber or Patient loop), do not use the Service Facility Location loop. In that case, the place of service code in CLM05-1 indicates that the service occurred in the patient's home.
              The purpose of this loop is to identify specifically where the service was rendered.
              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.
            2. To specify the location of the named party

              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".)
            3. To specify the geographic place of the named party

            4. To specify identifying information

              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.
          26. 2310D Loop Optional
            Repeat 1
            1. To supply the full name of an individual or organizational entity

              Required when the Rendering Provider provided these services in the role of the Assisting Surgeon. 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.
            2. To specify the identifying characteristics of a provider

              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.
            3. To specify identifying information

              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.
          27. 2310E Loop Optional
            Repeat 1
            1. To supply the full name of an individual or organizational entity

              Required when the rendering provider is supervised by a physician or dentist. 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.
            2. To specify identifying information

              Required when the HIPAA National Provider Identifier (NPI) is not reported in NM109 of this loop; OR Required for Health Care Providers prior to the mandated NPI implementation date when an NPI is reported in NM109 of this loop and an additional identification number is required by the receiver to identify the provider; OR Required for providers who are not Health Care Providers when an NPI is reported in NM109 of this loop and an additional identification number is required by the receiver to identify the provider. If not required by this implementation guide, do not send.
          28. 2320 Loop Optional
            Repeat 10
            1. To record information specific to the primary insured and the insurance carrier for that insured

              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.
            2. To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid

              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).
            3. To indicate the total monetary amount

              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.;
            4. To indicate the total monetary amount

              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.
            5. To indicate the total monetary amount

              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.
            6. To specify information associated with other health insurance coverage

              All information contained in the OI segment applies only to the payer identified in Loop ID-2330B in this iteration of Loop ID-2320.
            7. To convey claim-level data related to the adjudication of Medicare claims not related to an inpatient setting

              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.
            8. 2330A Loop Mandatory
              Repeat 1
              1. To supply the full name of an individual or organizational entity

                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.
              2. To specify the location of the named party

                Required when the information is available. If not required by this implementation guide, do not send.
              3. To specify the geographic place of the named party

                Required when the information is available. If not required by this implementation guide, do not send.
              4. To specify identifying information

                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.
            9. 2330B Loop Mandatory
              Repeat 1
              1. To supply the full name of an individual or organizational entity

                See Crosswalking COB Data Elements section for more information on handling COB in the 837.
              2. To specify the location of the named party

                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.
              3. To specify the geographic place of the named party

                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.
              4. To specify any or all of a date, a time, or a time period

                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.;
              5. To specify identifying information

                Required prior to the mandated implementation date for the HIPAA National Plan Identifier when an additional identification number to that provided in the NM109 of this loop is necessary for the claim processor to identify the entity. If not required by this implementation guide, do not send.
              6. To specify identifying information

                This segment must not be used to report the Predetermination of Benefits Identification Number.
                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.
              7. To specify identifying information

                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.
              8. To specify identifying information

                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.
              9. To specify identifying information

                Required when the payer identified in this loop has assigned a predetermination identification number to this claim. If not required by this implementation guide, do not send.
              10. To specify identifying information

                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.
            10. 2330C Loop Optional
              Repeat 2
              1. To supply the full name of an individual or organizational entity

                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.
              2. To specify identifying information

                See Crosswalking COB Data Elements section for more information on handling COB in the 837.
            11. 2330D Loop Optional
              Repeat 1
              1. To supply the full name of an individual or organizational entity

                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.
              2. To specify identifying information

                See Crosswalking COB Data Elements section for more information on handling COB in the 837.
            12. 2330E Loop Optional
              Repeat 1
              1. To supply the full name of an individual or organizational entity

                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.
              2. To specify identifying information

                See Crosswalking COB Data Elements section for more information on handling COB in the 837.
            13. 2330F Loop Optional
              Repeat 1
              1. To supply the full name of an individual or organizational entity

                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.
              2. To specify identifying information

                See Crosswalking COB Data Elements section for more information on handling COB in the 837.
            14. 2330G Loop Optional
              Repeat 1
              1. To supply the full name of an individual or organizational entity

                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.
              2. To specify identifying information

            15. 2330H Loop Optional
              Repeat 1
              1. To supply the full name of an individual or organizational entity

                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.
              2. To specify identifying information

                See Crosswalking COB Data Elements section for more information on handling COB in the 837.
          29. 2400 Loop Mandatory
            Repeat 50
            1. To reference a line number in a transaction set

              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.
            2. To specify the service line item detail for dental work

            3. To identify a tooth by number and, if applicable, one or more tooth surfaces

              Required when reporting tooth information related to this service line. If not required by this implementation guide, do not send.
              Multiple iterations of the TOO segment are allowed only when the quantity reported in Loop ID-2400 SV306 is equal to one.
            4. To specify any or all of a date, a time, or a time period

              Required when the service was performed and the service date is different than the date reported in the Service Date segment in the 2300 loop. If not required by this implementation guide, do not send.
              Do not use this DTP segment when submitting a Predetermination of Dental Benefits.
              Do not use this DTP segment when submitting a Treatment Start Date, Treatment Completion Date or both.
            5. To specify any or all of a date, a time, or a time period

              Required when the value of SV305 for this iteration of the 2400 loop is R - Replacement. If not required by this implementation guide, do not send.
            6. To specify any or all of a date, a time, or a time period

              Required when the orthodontic appliance placement date is different than the orthodontic appliance placement date in the DTP segment in the Loop ID-2300 loop. If not required by this implementation guide, do not send.;
            7. To specify any or all of a date, a time, or a time period

              Required when reporting the date that an orthodontic appliance was replaced. If not required by this implementation guide, do not send.
            8. To specify any or all of a date, a time, or a time period

              Required when reporting initial impression or preparation for a crown or denture. OR Required when reporting initial endodontic treatment. OR Required when reporting the implant fixture placement. If not required by this implementation guide, do not send.
              When the Treatment Start Date is used, the Date of Service must not be used.
            9. To specify any or all of a date, a time, or a time period

              Required when reporting the date that a course of treatment was completed. If not required by this implementation guide, do not send.
              When the Treatment Completion Date is used, the Date of Service must not be used.
            10. To specify basic data about the contract or contract line item

              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.
            11. To specify identifying information

              Required when sending the Predetermination of Benefits Identification Number for the line item that has been previously predetermined and is now being submitted for payment. If not required by this implementation guide, do not send.
              Reference numbers at this position apply to the current line item only.
              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.
            12. To specify identifying information

              This segment must not be used to report the Predetermination of Benefits Identification Number.
              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.
            13. To specify identifying information

              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.
            14. To specify identifying information

              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.
            15. To specify identifying information

              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.
            16. To specify identifying information

              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.
            17. To indicate the total monetary amount

              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 (SV302) for this service line must include the amount reported in the Sales Tax Amount.
            18. To transmit a fixed-format record or matrix contents

              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).
            19. To specify pricing or repricing information about a health care claim or line item

              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.
            20. 2420A Loop Optional
              Repeat 1
              1. To supply the full name of an individual or organizational entity

                Required when the Rendering Provider NM1 information is different than that carried in the Loop ID-2310B Rendering Provider and the Assistant Surgeon (Loop ID-2420C) loop is not present OR Required when each of the following conditions apply: - the Rendering Provider information is carried at the Billing Provider level (Loop ID-2010AA) - this particular line item has different Rendering Provider information than that which is carried in the Loop ID-2010AA Billing Provider - the Assistant Surgeon loop (Loop ID-2420C) is not used. 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.
              2. To specify the identifying characteristics of a provider

              3. To specify identifying information

                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.
            21. 2420B Loop Optional
              Repeat 1
              1. To supply the full name of an individual or organizational entity

                Required when the Rendering Provider provided these services in the role of the Assistant Surgeon and the Assistant Surgeon information in this loop is different from the Assistant Surgeon information sent in Loop ID-2310D. If not required by this implementation guide, do not send.;
              2. To specify the identifying characteristics of a provider

                Required when the Assistant Surgeon specialty information is needed to facilitate reimbursement of the claim. If not required by this implementation guide, do not send.;
              3. To specify identifying information

                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 send provider identifiers that are not payer-specific (e.g. UPIN, State License Number), those identifiers must be sent in the corresponding 2310 loop.
                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.
            22. 2420C Loop Optional
              Repeat 1
              1. To supply the full name of an individual or organizational entity

                Required when the rendering provider is supervised by a physician or dentist and the supervising physician or dentist is different than that listed at the claim level for this service line. If not required by this implementation guide, do not send.
              2. To specify identifying information

                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 this segment is used, the identifier(s) to be provided are limited to those necessary for the claim processor to identify the entity.
                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.
            23. 2420D Loop Optional
              Repeat 1
              1. To supply the full name of an individual or organizational entity

                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.
              2. To specify the location of the named party

                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".)
              3. To specify the geographic place of the named party

              4. To specify identifying information

                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.
            24. 2430 Loop Optional
              Repeat 15
              1. To convey service line adjudication information for coordination of benefits between the initial payers of a health care claim and all subsequent payers

                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.
              2. To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid

                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).
              3. To specify any or all of a date, a time, or a time period

              4. To indicate the total monetary amount

                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.
                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 not used if the claim level (Loop ID-2320) Remaining Patient Liability AMT segment is used for this Other Payer.
                This segment is only used in provider submitted claims. It is not used in Payer-to-Payer Coordination of Benefits (COB).
  2. To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments)

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