EDI 837 X298A1 - Post-adjudicated Claims Data Reporting: Professional

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

1. 0050 · ST · Transaction Set Header · Max 1 · Mandatory

   To indicate the start of a transaction set and to assign a control number

2. 0100 · BHT · Beginning of Hierarchical Transaction · Max 1 · Mandatory

   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

3. 1000A Loop Mandatory Repeat 1

   1. 0200 · NM1 · Submitter Name · Max 1 · Mandatory

      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. 0450 · PER · Submitter EDI Contact Information · Max 2 · Mandatory

      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. 0200 · NM1 · Receiver Name · Max 1 · Mandatory

      To supply the full name of an individual or organizational entity

Detail

1. 2000A Loop Mandatory Repeat >1

   1. 0010 · HL · Billing Provider Hierarchical Level · Max 1 · Mandatory

      To identify dependencies among and the content of hierarchically related groups of data segments

   2. 0030 · PRV · Billing Provider Specialty Information · Max 1 · Optional

      To specify the identifying characteristics of a provider

      Required when available in the payer's system. If not required by this implementation guide, do not send.
      If, for whatever reason, the data is not stored within the payer's system, do not use.

   3. 0100 · CUR · Foreign Currency Information · Max 1 · Optional

      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. 0150 · NM1 · Billing Provider Name · Max 1 · Mandatory

         To supply the full name of an individual or organizational entity

         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.
         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 intent is to capture the information as stored in the payer's system.
         The information provided in this segment is intended to be representative of the information as known to the payer's system.

      2. 0250 · N3 · Billing Provider Address · Max 1 · Mandatory

         To specify the location of the named party

         The Billing Provider Address is to be the provider's address as known to the payer's enrollment files. When the provider address is not on file, report the address as received.

      3. 0300 · N4 · Billing Provider City, State, ZIP Code · Max 1 · Mandatory

         To specify the geographic place of the named party

         The Billing Provider Address is to be the provider's address as known to the payer's enrollment files. When the provider address is not on file, report the address as received.

      4. 0350 · REF · Billing Provider Tax Identification · Max 1 · Mandatory

         To specify identifying information

         This is the tax identification number (TIN) of the entity paid for the submitted services.

      5. 0350 · REF · Billing Provider License Information · Max 2 · Optional

         To specify identifying information

         Required when available in the payer's system. If not required by this implementation guide, do not send.
         If, for whatever reason, the data is not stored within the payer's system, do not use.

      6. 0350 · REF · Billing Provider Secondary Identification · Max 2 · Optional

         To specify identifying information

         If, for whatever reason, the data is not stored within the payer's system, do not use.
         Required when available in the payer's system. If not required by this implementation guide, do not send.

   5. 2000B Loop Mandatory Repeat >1

      1. 0010 · HL · Subscriber Hierarchical Level · Max 1 · Mandatory

         To identify dependencies among and the content of hierarchically related groups of data segments

         When submitting Medicare and/or Medicaid encounters, the patient is always the subscriber and the Patient HL in Loop 2000C is not used.

      2. 0050 · SBR · Subscriber Information · Max 1 · Mandatory

         To record information specific to the primary insured and the insurance carrier for that insured

      3. 2010BA Loop Mandatory Repeat 1

         1. 0150 · NM1 · Subscriber Name · Max 1 · Mandatory

            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.
            When submitting to an All Payer Claims Database or Health Benefit Exchange, this is the Subscriber as defined within the payers enrollment files. When submitting Medicare or Medicaid encounters, the patient is always the subscriber.

         2. 0250 · N3 · Subscriber Address · Max 1 · Mandatory

            To specify the location of the named party

            The information provided in this segment is intended to be representative of the information as known to the payer's system.

         3. 0300 · N4 · Subscriber City, State, ZIP Code · Max 1 · Mandatory

            To specify the geographic place of the named party

            The information provided in this segment is intended to be representative of the information as known to the payer's system.

         4. 0320 · DMG · Subscriber Demographic Information · Max 1 · Mandatory

            To supply demographic information

            The information provided in this segment is intended to be representative of the information as known to the payer's system.

         5. 0350 · REF · Subscriber Social Security Number · Max 1 · Optional

            To specify identifying information

            Required when: The entity identified as the data receiver in Loop ID 2010BB is an All Payer Claims Database or Health Insurance Exchange. AND The social security number is allowed to be used for this purpose under applicable law or regulation. AND The social security number is available in the payer's system. If not required by this implementation guide, do not send.
            Trading partners using this segment are encouraged to explicitly address necessary safeguards in the trading partner agreement.

         6. 0350 · REF · Property and Casualty Claim Number · Max 1 · Optional

            To specify identifying information

            Required when available in the payer's system. If not required by this implementation guide, do not send.
            If, for whatever reason, the data is not stored within the payer's system, do not use.

      4. 2010BB Loop Mandatory Repeat 1

         1. 0150 · NM1 · Data Receiver · Max 1 · Mandatory

            To supply the full name of an individual or organizational entity

      5. 2000C Loop Optional Repeat >1

         1. 0010 · HL · Patient Hierarchical Level · Max 1 · Mandatory

            To identify dependencies among and the content of hierarchically related groups of data segments

            Required when the data receiver is a reporting entity, such as an APCD or Health Insurance Exchange, AND the patient is not the subscriber.
            The information reported in this loop describes the patient as known by the payer's system.
            When submitting Medicare and/or Medicaid encounters, the patient is always the subscriber and the Patient HL in Loop 2000C is not used.
            There are no HLs subordinate to the Patient HL.
            This loop is not used for Medicare and Medicaid encounters.

         2. 0070 · PAT · Patient Information · Max 1 · Mandatory

            To supply patient information

            The information provided in this segment is intended to be representative of the information as known to the payer's system.

         3. 2010CA Loop Mandatory Repeat 1

            1. 0150 · NM1 · Patient Name · Max 1 · Mandatory

               To supply the full name of an individual or organizational entity

               The information provided in this segment is intended to be representative of the information as known to the payer's system.

            2. 0250 · N3 · Patient Address · Max 1 · Mandatory

               To specify the location of the named party

               The information provided in this segment is intended to be representative of the information as known to the payer's system.

            3. 0300 · N4 · Patient City, State, ZIP Code · Max 1 · Mandatory

               To specify the geographic place of the named party

               The information provided in this segment is intended to be representative of the information as known to the payer's system.

            4. 0320 · DMG · Patient Demographic Information · Max 1 · Mandatory

               To supply demographic information

               The information provided in this segment is intended to be representative of the information as known to the payer's system.

            5. 0350 · REF · Patient Social Security Number · Max 1 · Optional

               To specify identifying information

               Required when: The entity identified as the data receiver in Loop ID 2010BB is an All Payer Claims Database or Health Insurance Exchange. AND The social security number is allowed to be used for this purpose under applicable law or regulation. AND The social security number is available in the payer's system. If not required by this implementation guide, do not send.
               Trading partners using this segment are encouraged to explicitly address necessary safeguards in the trading partner agreement.

            6. 0350 · REF · Property and Casualty Claim Number · Max 1 · Optional

               To specify identifying information

               Required when available in the payer's system. If not required by this implementation guide, do not send.
               If, for whatever reason, the data is not stored within the payer's system, do not use.

         4. 2300 Loop Mandatory Repeat 100

            1. 1300 · CLM · Claim Information · Max 1 · Mandatory

               To specify basic data about the claim

               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 patient 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 patient. 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, Loop ID-2000C and Loop ID-2010CA are not sent.

            2. 1350 · DTP · Date - Onset of Current Illness or Symptom · Max 1 · Optional

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

               This date is the onset of acute symptoms for the current illness or condition.
               Required when available in the payer's system. If not required by this implementation guide, do not send.
               If, for whatever reason, the data is not stored within the payer's system, do not use.

            3. 1350 · DTP · Date - Initial Treatment Date · Max 1 · Optional

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

               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.
               Required when available in the payer's system. If not required by this implementation guide, do not send.
               If, for whatever reason, the data is not stored within the payer's system, do not use.

            4. 1350 · DTP · Date - Last Seen Date · Max 1 · Optional

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

               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.
               This is the date that the patient was seen by the attending or supervising physician for the qualifying medical condition related to the services performed.
               Required when available in the payer's system. If not required by this implementation guide, do not send.
               If, for whatever reason, the data is not stored within the payer's system, do not use.

            5. 1350 · DTP · Date - Acute Manifestation · Max 1 · Optional

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

               Required when available in the payer's system. If not required by this implementation guide, do not send.
               If, for whatever reason, the data is not stored within the payer's system, do not use.

            6. 1350 · DTP · Date - Accident · Max 1 · Optional

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

               Required when available in the payer's system. If not required by this implementation guide, do not send.
               If, for whatever reason, the data is not stored within the payer's system, do not use.

            7. 1350 · DTP · Date - Last Menstrual Period · Max 1 · Optional

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

               Required when available in the payer's system. If not required by this implementation guide, do not send.
               If, for whatever reason, the data is not stored within the payer's system, do not use.

            8. 1350 · DTP · Date - Last X-ray Date · Max 1 · Optional

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

               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.
               Required when available in the payer's system. If not required by this implementation guide, do not send.
               If, for whatever reason, the data is not stored within the payer's system, do not use.

            9. 1350 · DTP · Date - Hearing and Vision Prescription Date · Max 1 · Optional

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

               Required when available in the payer's system. If not required by this implementation guide, do not send.
               If, for whatever reason, the data is not stored within the payer's system, do not use.

            10. 1350 · DTP · Date - Disability Dates · Max 1 · Optional

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

                Required when available in the payer's system. If not required by this implementation guide, do not send.
                If, for whatever reason, the data is not stored within the payer's system, do not use.

            11. 1350 · DTP · Date - Last Worked · Max 1 · Optional

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

                Required when available in the payer's system. If not required by this implementation guide, do not send.
                If, for whatever reason, the data is not stored within the payer's system, do not use.

            12. 1350 · DTP · Date - Authorized Return to Work · Max 1 · Optional

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

                Required when available in the payer's system. If not required by this implementation guide, do not send.
                If, for whatever reason, the data is not stored within the payer's system, do not use.

            13. 1350 · DTP · Date - Admission · Max 1 · Optional

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

                Required when available in the payer's system. If not required by this implementation guide, do not send.
                If, for whatever reason, the data is not stored within the payer's system, do not use.

            14. 1350 · DTP · Date - Discharge · Max 1 · Optional

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

                Required when available in the payer's system. If not required by this implementation guide, do not send.
                If, for whatever reason, the data is not stored within the payer's system, do not use.

            15. 1350 · DTP · Date - Assumed and Relinquished Care Dates · Max 2 · Optional

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

                Assumed Care Date is the date care was assumed by another provider during post-operative care. Relinquished Care Date is the date the provider filing this claim ceased post-operative care. See Medicare guidelines for further explanation of these dates. Example: Surgeon "A" relinquished post-operative care to Physician "B" five days after surgery. When Surgeon "A" submits a claim, "A" will use code "091 - Report End" to indicate the day the surgeon relinquished care of this patient to Physician "B". When Physician "B" submits a claim, "B" will use code "090 - Report Start" to indicate the date they assumed care of this patient from Surgeon "A".
                Required when available in the payer's system. If not required by this implementation guide, do not send.
                If, for whatever reason, the data is not stored within the payer's system, do not use.

            16. 1350 · DTP · Date - Property and Casualty Date of First Contact · Max 1 · Optional

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

                This is the date the patient first consulted the service provider for this condition. The date of first contact is the date the patient first consulted the provider by any means. It is not necessarily the Initial Treatment Date.
                Required when available in the payer's system. If not required by this implementation guide, do not send.
                If, for whatever reason, the data is not stored within the payer's system, do not use.

            17. 1350 · DTP · Date - Repricer Received Date · Max 1 · Optional

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

                If, for whatever reason, the data is not stored within the payer's system, do not use.
                Required when available in the payer's system. If not required by this implementation guide, do not send.

            18. 1550 · PWK · Claim Supplemental Information · Max 10 · Optional

                To identify the type or transmission or both of paperwork or supporting information

                Required when available in the payer's system. If not required by this implementation guide, do not send.
                If, for whatever reason, the data is not stored within the payer's system, do not use.

            19. 1600 · CN1 · Contract Information · Max 1 · Optional

                To specify basic data about the contract or contract line item

                Required when this information is necessary to satisfy contract requirements. If not required by this implementation guide, do not send.

            20. 1750 · AMT · Patient Amount Paid · Max 1 · Optional

                To indicate the total monetary amount

                Patient Amount Paid refers to the sum of all amounts paid on the claim by the patient or his or her representative(s).
                If, for whatever reason, the data is not stored within the payer's system, do not use.
                Required when available in the payer's system. If not required by this implementation guide, do not send.

            21. 1800 · REF · Service Authorization Exception Code · Max 1 · Optional

                To specify identifying information

                Required when available in the payer's system. If not required by this implementation guide, do not send.
                If, for whatever reason, the data is not stored within the payer's system, do not use.

            22. 1800 · REF · Mammography Certification Number · Max 1 · Optional

                To specify identifying information

                Required when available in the payer's system. If not required by this implementation guide, do not send.
                If, for whatever reason, the data is not stored within the payer's system, do not use.

            23. 1800 · REF · Referral Number · Max 1 · Optional

                To specify identifying information

                Numbers at this position apply to the entire claim unless they are overridden in the REF segment in Loop ID-2400. A reference identification is considered to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line.
                Required when available in the payer's system. If not required by this implementation guide, do not send.
                If, for whatever reason, the data is not stored within the payer's system, do not use.

            24. 1800 · REF · Prior Authorization · Max 1 · Optional

                To specify identifying information

                Numbers at this position apply to the entire claim unless they are overridden in the REF segment in Loop ID-2400. A reference identification is considered to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line.
                Required when available in the payer's system. If not required by this implementation guide, do not send.
                If, for whatever reason, the data is not stored within the payer's system, do not use.

            25. 1800 · REF · Payer Claim Control Number · Max 1 · Optional

                To specify identifying information

                Required when available in the payer's system. If not required by this implementation guide, do not send.
                If, for whatever reason, the data is not stored within the payer's system, do not use.

            26. 1800 · REF · Clinical Laboratory Improvement Amendment (CLIA) Number · Max 1 · Optional

                To specify identifying information

                If a CLIA number is indicated at the line level (Loop ID-2400) in addition to the claim level (Loop ID-2300), that would indicate an exception to the CLIA number at the claim level for that individual line.
                In cases where this claim contains both in-house and outsourced laboratory services, the CLIA Number for laboratory services performed by the Billing or Rendering Provider is reported in this loop. The CLIA number for laboratory services which were outsourced is reported in Loop ID-2400.
                Required when available in the payer's system. If not required by this implementation guide, do not send.
                If, for whatever reason, the data is not stored within the payer's system, do not use.

            27. 1800 · REF · Repriced Claim Number · Max 1 · Optional

                To specify identifying information

                Required when available in the payer's system. If not required by this implementation guide, do not send.
                If, for whatever reason, the data is not stored within the payer's system, do not use.

            28. 1800 · REF · Adjusted Repriced Claim Number · Max 1 · Optional

                To specify identifying information

                Required when available in the payer's system. If not required by this implementation guide, do not send.
                If, for whatever reason, the data is not stored within the payer's system, do not use.

            29. 1800 · REF · Investigational Device Exemption Number · Max 1 · Optional

                To specify identifying information

                Required when available in the payer's system. If not required by this implementation guide, do not send.
                If, for whatever reason, the data is not stored within the payer's system, do not use.

            30. 1800 · REF · Claim Identifier For Transmission Intermediaries · Max 1 · Optional

                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.
                The data conveyed in this segment is not related to the provider submission to the payer. This segment is used only when the payer is submitting this transaction to the Data Receiver through an intermediary that assigns their own unique claim number.

            31. 1800 · REF · Medical Record Number · Max 1 · Optional

                To specify identifying information

                Required when available in the payer's system. If not required by this implementation guide, do not send.
                If, for whatever reason, the data is not stored within the payer's system, do not use.

            32. 1850 · K3 · File Information · Max 10 · Optional

                To transmit a fixed-format record or matrix contents

                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).
                Required when available in the payer's system. If not required by this implementation guide, do not send.
                If, for whatever reason, the data is not stored within the payer's system, do not use.

            33. 1900 · NTE · Claim Note · Max 1 · Optional

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

                Information in the NTE segment in Loop ID-2300 applies to the entire claim unless overridden by information in the NTE segment in Loop ID-2400. Information is considered to be overridden when the value in NTE01 in Loop ID-2400 is the same as the value in NTE01 in Loop ID-2300.
                The developers of this implementation guide discourage using narrative information within the 837. Trading partners who use narrative information with claims are strongly encouraged to codify that information within the X12 environment.
                If, for whatever reason, the data is not stored within the payer's system, do not use.
                Required when available in the payer's system. If not required by this implementation guide, do not send.

            34. 1950 · CR1 · Ambulance Transport Information · Max 1 · Optional

                To supply information related to the ambulance service rendered to a patient

                The CR1 segment in Loop ID-2300 applies to the entire claim unless overridden by a CR1 segment at the service line level in Loop ID-2400 with the same value in CR101.
                If, for whatever reason, the data is not stored within the payer's system, do not use.
                Required when available in the payer's system. If not required by this implementation guide, do not send.

            35. 2000 · CR2 · Spinal Manipulation Service Information · Max 1 · Optional

                To supply information related to the chiropractic service rendered to a patient

                Required when available in the payer's system. If not required by this implementation guide, do not send.
                If, for whatever reason, the data is not stored within the payer's system, do not use.

            36. 2200 · CRC · Ambulance Certification · Max 3 · Optional

                To supply information on conditions

                The CRC segment in Loop ID-2300 applies to the entire claim unless overridden by a CRC segment at the service line level in Loop ID-2400 with the same value in CRC01.
                Repeat this segment only when it is necessary to report additional unique values to those reported in CRC03 thru CRC07.
                If, for whatever reason, the data is not stored within the payer's system, do not use.
                Required when available in the payer's system. If not required by this implementation guide, do not send.

            37. 2200 · CRC · Patient Condition Information: Vision · Max 3 · Optional

                To supply information on conditions

                If, for whatever reason, the data is not stored within the payer's system, do not use.
                Required when available in the payer's system. If not required by this implementation guide, do not send.

            38. 2200 · CRC · Homebound Indicator · Max 1 · Optional

                To supply information on conditions

                Required when available in the payer's system. If not required by this implementation guide, do not send.
                If, for whatever reason, the data is not stored within the payer's system, do not use.

            39. 2200 · CRC · EPSDT Referral · Max 1 · Optional

                To supply information on conditions

                Required when available in the payer's system. If not required by this implementation guide, do not send.
                If, for whatever reason, the data is not stored within the payer's system, do not use.

            40. 2310 · HI · Health Care Diagnosis Code · Max 1 · Mandatory

                To supply information related to the delivery of health care

                Do not transmit the decimal point for ICD codes. The decimal point is implied.

            41. 2310 · HI · Anesthesia Related Procedure · Max 1 · Optional

                To supply information related to the delivery of health care

                If, for whatever reason, the data is not stored within the payer's system, do not use.
                Required when available in the payer's system. If not required by this implementation guide, do not send.

            42. 2310 · HI · Condition Information · Max 2 · Optional

                To supply information related to the delivery of health care

                Required when available in the payer's system. If not required by this implementation guide, do not send.
                If, for whatever reason, the data is not stored within the payer's system, do not use.

            43. 2410 · HCP · Claim Pricing/Repricing Information · Max 1 · Optional

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

                If, for whatever reason, the data is not stored within the payer's system, do not use.
                Required when available in the payer's system. If not required by this implementation guide, do not send.

            44. 2310A Loop Optional Repeat 2

                1. 2500 · NM1 · Referring Provider Name · Max 1 · Mandatory

                   To supply the full name of an individual or organizational entity

                   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.
                   When reporting the provider who ordered services such as diagnostic and lab, use Loop ID-2310A at the claim level. For ordered services such as Durable Medical Equipment, use Loop ID-2420E at the line level.
                   When there is only one referral on the claim, use code "DN - Referring Provider". When more than one referral exists and there is a requirement to report the additional referral, use code DN in the first iteration of this loop to indicate the referral received by the rendering provider on this claim. Use code "P3 - Primary Care Provider" in the second iteration of the loop to indicate the initial referral from the primary care provider or whatever provider wrote the initial referral for this patient's episode of care being billed/reported in this transaction.
                   Required when available in the payer's system. If not required by this implementation guide, do not send.
                   If, for whatever reason, the data is not stored within the payer's system, do not use.

                2. 2710 · REF · Referring Provider Secondary Identification · Max 2 · Optional

                   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 when available in the payer's system. If not required by this implementation guide, do not send.
                   If, for whatever reason, the data is not stored within the payer's system, do not use.

            45. 2310B Loop Optional Repeat 1

                1. 2500 · NM1 · Rendering Provider Name · Max 1 · Mandatory

                   To supply the full name of an individual or organizational entity

                   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.
                   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.
                   If, for whatever reason, the data is not stored within the payer's system, do not use.
                   Required when the Rendering Provider information is different than that carried in Loop ID-2010AA - Billing Provider. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.

                2. 2550 · PRV · Rendering Provider Specialty Information · Max 1 · Optional

                   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.
                   Required when available in the payer's system. If not required by this implementation guide, do not send.
                   If, for whatever reason, the data is not stored within the payer's system, do not use.

                3. 2710 · REF · Rendering Provider Secondary Identification · Max 3 · Optional

                   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 when available in the payer's system. If not required by this implementation guide, do not send.
                   If, for whatever reason, the data is not stored within the payer's system, do not use.

            46. 2310C Loop Mandatory Repeat 1

                1. 2500 · NM1 · Service Facility Location Name · Max 1 · Mandatory

                   To supply the full name of an individual or organizational entity

                   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.
                   This is the Service Location as reported on the originally submitted claim from the provider. If the Service Location loop was not used on the original claim, use the address information reported in Loop 2010AA of the provider's claim.

                2. 2650 · N3 · Service Facility Location Address · Max 1 · Mandatory

                   To specify the location of the named party

                   This is the Service Location as reported on the originally submitted claim from the provider. If the Service Location loop was not used on the original claim, use the address information reported in Loop 2010AA of the provider's claim.

                3. 2700 · N4 · Service Facility Location City, State, ZIP Code · Max 1 · Mandatory

                   To specify the geographic place of the named party

                   This is the Service Location as reported on the originally submitted claim from the provider. If the Service Location loop was not used on the original claim, use the address information reported in Loop 2010AA of the provider's claim.

                4. 2710 · REF · Service Facility Location Secondary Identification · Max 3 · Optional

                   To specify identifying information

                   Required when available in the payer's system. If not required by this implementation guide, do not send.
                   If, for whatever reason, the data is not stored within the payer's system, do not use.

            47. 2310D Loop Optional Repeat 1

                1. 2500 · NM1 · Supervising Provider Name · Max 1 · Mandatory

                   To supply the full name of an individual or organizational entity

                   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.
                   Required when available in the payer's system. If not required by this implementation guide, do not send.
                   If, for whatever reason, the data is not stored within the payer's system, do not use.

                2. 2710 · REF · Supervising Provider Secondary Identification · Max 3 · Optional

                   To specify identifying information

                   Required when available in the payer's system. If not required by this implementation guide, do not send.
                   If, for whatever reason, the data is not stored within the payer's system, do not use.

            48. 2310E Loop Optional Repeat 1

                1. 2500 · NM1 · Ambulance Pick-up Location · Max 1 · Mandatory

                   To supply the full name of an individual or organizational entity

                   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.
                   If, for whatever reason, the data is not stored within the payer's system, do not use.
                   Required when available in the payer's system. If not required by this implementation guide, do not send.

                2. 2650 · N3 · Ambulance Pick-up Location Address · Max 1 · Mandatory

                   To specify the location of the named party

                   If the ambulance pickup location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".)
                   The information provided in this segment is intended to be representative of the information as known to the payer's system.

                3. 2700 · N4 · Ambulance Pick-up Location City, State, ZIP Code · Max 1 · Mandatory

                   To specify the geographic place of the named party

                   The information provided in this segment is intended to be representative of the information as known to the payer's system.

            49. 2310F Loop Optional Repeat 1

                1. 2500 · NM1 · Ambulance Drop-Off Location · Max 1 · Mandatory

                   To supply the full name of an individual or organizational entity

                   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.
                   Required when available in the payer's system. If not required by this implementation guide, do not send.

                2. 2650 · N3 · Ambulance Drop-Off Location Address · Max 1 · Mandatory

                   To specify the location of the named party

                3. 2700 · N4 · Ambulance Drop-Off Location City, State, ZIP Code · Max 1 · Mandatory

                   To specify the geographic place of the named party

            50. 2320 Loop Mandatory Repeat 10

                1. 2900 · SBR · Other Subscriber Information · Max 1 · Mandatory

                   To record information specific to the primary insured and the insurance carrier for that insured

                   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.;
                   Loop ID 2320 and its suboordinate 2330 and 2430 loops convey information demonstrating how this claim was adjudicated by both the submitting payer and other payers who have previously adjudicated the claim. This loop is not to be provided for payers who have not adjudicated the claim. For example, the provider submitted claim includes payer information that is subsequent to the payer submitting this transaction. SBR06 identifies to the receiver whether the respective iteration of Loop ID 2320 was adjudicated by the submitting plan or an Other Payer. When SBR06 = 1, the payer and adjudication information related to this iteration of Loop ID 2320 and 2430 represents processing performed prior to the adjudication of this claim and the Other Payer information is to be reported as received from the provider. When SBR06 = 6, the payer and adjudication information related to this iteration of Loop ID 2320 and 2430 represents the adjudication results of the submitting payer.

                2. 2950 · CAS · Claim Level Adjustments · Max 5 · Optional

                   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 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.
                   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).
                   When the payer identified is not the submitting payer, codes and associated amounts must be reported as submitted by the provider. When the payer identified is the submitting payer, codes and amounts must be reported the same as if creating the 835 to send to the provider.

                3. 3000 · AMT · Coordination of Benefits (COB) Payer Paid Amount · Max 1 · Mandatory

                   To indicate the total monetary amount

                4. 3000 · AMT · Remaining Patient Liability · Max 1 · Optional

                   To indicate the total monetary amount

                   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.
                   If, for whatever reason, the data is not stored within the payer's system, do not use.
                   Required when available in the payer's system. If not required by this implementation guide, do not send.

                5. 3200 · MOA · Outpatient Adjudication Information · Max 1 · Optional

                   To convey claim-level data related to the adjudication of Medicare claims not related to an inpatient setting

                   Required when SBR06 = 6; and the submitting payer would be required to provide this information when generating an 835 for the provider. OR Required when SBR06 = 1; and this information was provided on the original claim from the provider. If not required by this implementation guide, do not send.

                6. 2330A Loop Mandatory Repeat 1

                   1. 3250 · NM1 · Other Subscriber Name · Max 1 · Mandatory

                      To supply the full name of an individual or organizational entity

                      When SBR06 = 1, the information in this segment represents the Subscriber as submitted by the provider for the payer identified in Loop ID 2330B. When SBR06 = 6, the information in this segment represents the Subscriber as known by the submitting payer.

                   2. 3320 · N3 · Other Subscriber Address · Max 1 · Optional

                      To specify the location of the named party

                      Required when available in the payer's system. If not required by this implementation guide, do not send.
                      If, for whatever reason, the data is not stored within the payer's system, do not use.

                   3. 3400 · N4 · Other Subscriber City, State, ZIP Code · Max 1 · Optional

                      To specify the geographic place of the named party

                      Required when available in the payer's system. If not required by this implementation guide, do not send.
                      If, for whatever reason, the data is not stored within the payer's system, do not use.

                   4. 3550 · REF · Other Subscriber Social Security Number · Max 1 · Optional

                      To specify identifying information

                      Required when: The entity identified as the data receiver in Loop ID 2010BB is an All Payer Claims Database or Health Insurance Exchange. AND The social security number is allowed to be used for this purpose under applicable law or regulation. AND The social security number is available in the payer's system. If not required by this implementation guide, do not send.
                      Trading partners using this segment are encouraged to explicitly address necessary safeguards in the trading partner agreement.

                7. 2330B Loop Mandatory Repeat 1

                   1. 3250 · NM1 · Other Payer Name · Max 1 · Mandatory

                      To supply the full name of an individual or organizational entity

                   2. 3450 · DTP · Claim Check or Remittance Date · Max 1 · Mandatory

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

                   3. 3550 · REF · Other Payer Secondary Identifier · Max 4 · Optional

                      To specify identifying information

                      Required when available in the payer's system. If not required by this implementation guide, do not send.

                   4. 3550 · REF · Other Payer Claim Adjustment Indicator · Max 1 · Optional

                      To specify identifying information

                      Required when SBR06 = 6; and this claim is a void or adjustment of a previously adjudicated claim. If not required by this implementation guide, do not send.

                   5. 3550 · REF · Other Payer Claim Control Number · Max 1 · Optional

                      To specify identifying information

                      If, for whatever reason, the data is not stored within the payer's system, do not use.
                      Required when SBR06 = 6. OR Required when available in the payer's system. If not required by this implementation guide, do not send.

                   6. 3550 · REF · Other Payer Adjusted Claim Control Number · Max 1 · Optional

                      To specify identifying information

                      If, for whatever reason, the data is not stored within the payer's system, do not use.
                      Required when SBR06 = 6 and the submitting payer has adjusted this claim. OR Required when available in the payer's system. If not required by this implementation guide, do not send.

                8. 2330C Loop Optional Repeat 1

                   1. 3250 · NM1 · Other Patient Name · Max 1 · Mandatory

                      To supply the full name of an individual or organizational entity

                      NM1*QC*1*DOE*JOHN*T**JR*MI*123456~
                      When SBR06 = 1, the information in this segment represents the Patient as submitted by the provider for the payer identified in Loop ID 2330B. When SBR06 = 6, the information in this segment represents the Patient as known by the submitting payer.
                      Required when the entity reported in Loop ID 2330A (Other Payer Subscriber) is not the patient.

                   2. 3320 · N3 · Other Patient Address · Max 1 · Optional

                      To specify the location of the named party

                      If, for whatever reason, the data is not stored within the payer's system, do not use.
                      Required when available in the payer's system. If not required by this implementation guide, do not send.

                   3. 3400 · N4 · Other Patient City, State, ZIP Code · Max 1 · Optional

                      To specify the geographic place of the named party

                      Required when available in the payer's system. If not required by this implementation guide, do not send.
                      If, for whatever reason, the data is not stored within the payer's system, do not use.

                   4. 3550 · REF · Other Patient Secondary Identification · Max 3 · Optional

                      To specify identifying information

                      Required when: The entity identified as the data receiver in Loop ID 2010BB is an All Payer Claims Database or Health Insurance Exchange. AND The social security number is allowed to be used for this purpose under applicable law or regulation. AND The social security number is available in the payer's system. If not required by this implementation guide, do not send.
                      Trading partners using this segment are encouraged to explicitly address necessary safeguards in the trading partner agreement.

            51. 2400 Loop Mandatory Repeat 50

                1. 3650 · LX · Service Line Number · Max 1 · Mandatory

                   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 1.4.2.4 for more information on bundling and section 1.4.2.6 for more information on unbundling.

                2. 3700 · SV1 · Professional Service · Max 1 · Mandatory

                   To specify the service line item detail for a health care professional

                3. 4200 · PWK · Line Supplemental Information · Max 10 · Optional

                   To identify the type or transmission or both of paperwork or supporting information

                   If, for whatever reason, the data is not stored within the payer's system, do not use.
                   Required when available in the payer's system. If not required by this implementation guide, do not send.

                4. 4200 · PWK · Durable Medical Equipment Certificate of Medical Necessity Indicator · Max 1 · Optional

                   To identify the type or transmission or both of paperwork or supporting information

                   If, for whatever reason, the data is not stored within the payer's system, do not use.
                   Required when available in the payer's system. If not required by this implementation guide, do not send.

                5. 4250 · CR1 · Ambulance Transport Information · Max 1 · Optional

                   To supply information related to the ambulance service rendered to a patient

                   If, for whatever reason, the data is not stored within the payer's system, do not use.
                   Required when available in the payer's system. If not required by this implementation guide, do not send.

                6. 4350 · CR3 · Durable Medical Equipment Certification · Max 1 · Optional

                   To supply information regarding a physician's certification for durable medical equipment

                   If, for whatever reason, the data is not stored within the payer's system, do not use.
                   Required when available in the payer's system. If not required by this implementation guide, do not send.

                7. 4500 · CRC · Ambulance Certification · Max 3 · Optional

                   To supply information on conditions

                   The maximum number of CRC segments which can occur per Loop ID-2400 is 3. Submitters are free to mix and match the three types of service line level CRC segments shown in this implementation guide to meet their billing or reporting needs but no more than a total of 3 CRC segments per Loop ID-2400 are allowed.
                   If, for whatever reason, the data is not stored within the payer's system, do not use.
                   Required when available in the payer's system. If not required by this implementation guide, do not send.

                8. 4500 · CRC · Hospice Employee Indicator · Max 1 · Optional

                   To supply information on conditions

                   The maximum number of CRC segments which can occur per Loop ID-2400 is 3. Submitters are free to mix and match the three types of service line level CRC segments shown in this implementation guide to meet their billing or reporting needs but no more than a total of 3 CRC segments per Loop ID-2400 are allowed.
                   The example shows the method used to indicate whether the rendering provider is an employee of the hospice.
                   If, for whatever reason, the data is not stored within the payer's system, do not use.
                   Required when available in the payer's system. If not required by this implementation guide, do not send.

                9. 4500 · CRC · Condition Indicator/Durable Medical Equipment · Max 1 · Optional

                   To supply information on conditions

                   The maximum number of CRC segments which can occur per Loop ID-2400 is 3. Submitters are free to mix and match the three types of service line level CRC segments shown in this implementation guide to meet their billing or reporting needs but no more than a total of 3 CRC segments per Loop ID-2400 are allowed.
                   The first example shows a case where an item billed was not a replacement item.
                   If, for whatever reason, the data is not stored within the payer's system, do not use.
                   Required when available in the payer's system. If not required by this implementation guide, do not send.

                10. 4550 · DTP · Date - Service Date · Max 1 · Mandatory

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

                    The intent is to capture the data as provided on the original claim from the submitter.

                11. 4550 · DTP · Date - Prescription Date · Max 1 · Optional

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

                    If, for whatever reason, the data is not stored within the payer's system, do not use.
                    Required when available in the payer's system. If not required by this implementation guide, do not send.

                12. 4550 · DTP · Date - Certification Revision/Recertification Date · Max 1 · Optional

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

                    Required when available in the payer's system. If not required by this implementation guide, do not send.
                    If, for whatever reason, the data is not stored within the payer's system, do not use.

                13. 4550 · DTP · Date - Begin Therapy Date · Max 1 · Optional

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

                    Required when available in the payer's system. If not required by this implementation guide, do not send.
                    If, for whatever reason, the data is not stored within the payer's system, do not use.

                14. 4550 · DTP · Date - Last Certification Date · Max 1 · Optional

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

                    This is the date the ordering physician signed the CMN or Oxygen Therapy Certification, or the date the supplier signed the DMERC Information Form (DIF).
                    If, for whatever reason, the data is not stored within the payer's system, do not use.
                    Required when available in the payer's system. If not required by this implementation guide, do not send.

                15. 4550 · DTP · Date - Last Seen Date · Max 1 · Optional

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

                    Required when available in the payer's system. If not required by this implementation guide, do not send.
                    If, for whatever reason, the data is not stored within the payer's system, do not use.

                16. 4550 · DTP · Date - Test Date · Max 2 · Optional

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

                    Required when available in the payer's system. If not required by this implementation guide, do not send.
                    If, for whatever reason, the data is not stored within the payer's system, do not use.

                17. 4550 · DTP · Date - Shipped Date · Max 1 · Optional

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

                    Required when available in the payer's system. If not required by this implementation guide, do not send.
                    If, for whatever reason, the data is not stored within the payer's system, do not use.

                18. 4550 · DTP · Date - Last X-ray Date · Max 1 · Optional

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

                    Required when available in the payer's system. If not required by this implementation guide, do not send.
                    If, for whatever reason, the data is not stored within the payer's system, do not use.

                19. 4550 · DTP · Date - Initial Treatment Date · Max 1 · Optional

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

                    Required when available in the payer's system. If not required by this implementation guide, do not send.
                    If, for whatever reason, the data is not stored within the payer's system, do not use.

                20. 4600 · QTY · Ambulance Patient Count · Max 1 · Optional

                    To specify quantity information

                    The QTY02 is the only place to report the number of patients when there are multiple patients transported.
                    Required when available in the payer's system. If not required by this implementation guide, do not send.
                    If, for whatever reason, the data is not stored within the payer's system, do not use.

                21. 4600 · QTY · Obstetric Anesthesia Additional Units · Max 1 · Optional

                    To specify quantity information

                    Required when available in the payer's system. If not required by this implementation guide, do not send.
                    If, for whatever reason, the data is not stored within the payer's system, do not use.

                22. 4620 · MEA · Test Result · Max 5 · Optional

                    To specify physical measurements or counts, including dimensions, tolerances, variances, and weights (See Figures Appendix for example of use of C001)

                    Required when available in the payer's system. If not required by this implementation guide, do not send.
                    If, for whatever reason, the data is not stored within the payer's system, do not use.

                23. 4650 · CN1 · Contract Information · Max 1 · Optional

                    To specify basic data about the contract or contract line item

                    Required when this information is necessary to satisfy contract requirements. If not required by this implementation guide, do not send.

                24. 4700 · REF · Repriced Line Item Reference Number · Max 1 · Optional

                    To specify identifying information

                    If, for whatever reason, the data is not stored within the payer's system, do not use.
                    Required when available in the payer's system. If not required by this implementation guide, do not send.

                25. 4700 · REF · Adjusted Repriced Line Item Reference Number · Max 1 · Optional

                    To specify identifying information

                    Required when available in the payer's system. If not required by this implementation guide, do not send.
                    If, for whatever reason, the data is not stored within the payer's system, do not use.

                26. 4700 · REF · Prior Authorization · Max 1 · Optional

                    To specify identifying information

                    Required when available in the payer's system. If not required by this implementation guide, do not send.
                    If, for whatever reason, the data is not stored within the payer's system, do not use.

                27. 4700 · REF · Line Item Control Number · Max 1 · Optional

                    To specify identifying information

                    If, for whatever reason, the data is not stored within the payer's system, do not use.
                    Required when available in the payer's system. If not required by this implementation guide, do not send.

                28. 4700 · REF · Mammography Certification Number · Max 1 · Optional

                    To specify identifying information

                    Required when available in the payer's system. If not required by this implementation guide, do not send.
                    If, for whatever reason, the data is not stored within the payer's system, do not use.

                29. 4700 · REF · Clinical Laboratory Improvement Amendment (CLIA) Number · Max 1 · Optional

                    To specify identifying information

                    Required when available in the payer's system. If not required by this implementation guide, do not send.
                    If, for whatever reason, the data is not stored within the payer's system, do not use.

                30. 4700 · REF · Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification · Max 1 · Optional

                    To specify identifying information

                    Required when available in the payer's system. If not required by this implementation guide, do not send.
                    If, for whatever reason, the data is not stored within the payer's system, do not use.

                31. 4700 · REF · Immunization Batch Number · Max 1 · Optional

                    To specify identifying information

                    If, for whatever reason, the data is not stored within the payer's system, do not use.
                    Required when available in the payer's system. If not required by this implementation guide, do not send.

                32. 4700 · REF · Referral Number · Max 1 · Optional

                    To specify identifying information

                    Required when available in the payer's system. If not required by this implementation guide, do not send.
                    If, for whatever reason, the data is not stored within the payer's system, do not use.

                33. 4750 · AMT · Sales Tax Amount · Max 1 · Optional

                    To indicate the total monetary amount

                    When reporting the Sales Tax Amount (AMT02), the amount reported in the Line Item Charge Amount (SV102) for this service line must include the amount reported in the Sales Tax Amount.
                    If, for whatever reason, the data is not stored within the payer's system, do not use.
                    Required when available in the payer's system. If not required by this implementation guide, do not send.

                34. 4750 · AMT · Postage Claimed Amount · Max 1 · Optional

                    To indicate the total monetary amount

                    When reporting the Postage Claimed Amount (AMT02), the amount reported in the Line Item Charge Amount (SV102) for this service line must include the amount reported in the Postage Claimed Amount.
                    If, for whatever reason, the data is not stored within the payer's system, do not use.
                    Required when available in the payer's system. If not required by this implementation guide, do not send.

                35. 4800 · K3 · File Information · Max 10 · Optional

                    To transmit a fixed-format record or matrix contents

                    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).
                    Required when available in the payer's system. If not required by this implementation guide, do not send.
                    If, for whatever reason, the data is not stored within the payer's system, do not use.

                36. 4850 · NTE · Line Note · Max 1 · Optional

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

                    Use SV101-7 to describe non-specific procedure codes. Do not use this NTE Segment to describe a non-specific procedure code. If an NDC code is reported in Loop 2410, do not use this segment for a description of the procedure code. The NDC in loop 2410 will provide the description.
                    If, for whatever reason, the data is not stored within the payer's system, do not use.
                    Required when available in the payer's system. If not required by this implementation guide, do not send.

                37. 4850 · NTE · Third Party Organization Notes · Max 1 · Optional

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

                    If, for whatever reason, the data is not stored within the payer's system, do not use.
                    Required when available in the payer's system. If not required by this implementation guide, do not send.

                38. 4880 · PS1 · Purchased Service Information · Max 1 · Optional

                    To specify the information about services that are purchased

                    Required when available in the payer's system. If not required by this implementation guide, do not send.
                    If, for whatever reason, the data is not stored within the payer's system, do not use.

                39. 4920 · HCP · Line Pricing/Repricing Information · Max 1 · Optional

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

                    If, for whatever reason, the data is not stored within the payer's system, do not use.
                    Required when available in the payer's system. If not required by this implementation guide, do not send.

                40. 2410 Loop Optional Repeat 1

                    1. 4930 · LIN · Drug Identification · Max 1 · Mandatory

                       To specify basic item identification data

                       Drugs and biologics reported in this segment are a further specification of service(s) described in the SV1 segment of this Service Line Loop ID-2400.
                       Required when available in the payer's system. If not required by this implementation guide, do not send.
                       If, for whatever reason, the data is not stored within the payer's system, do not use.

                    2. 4940 · CTP · Drug Quantity · Max 1 · Mandatory

                       To specify pricing information

                       The intent is to capture the information as stored in the payer's system.

                    3. 4950 · REF · Prescription or Compound Drug Association Number · Max 1 · Optional

                       To specify identifying information

                       In cases where a compound drug is being billed, the components of the compound will all have the same prescription number. Payers receiving the claim can relate all the components by matching the prescription number.
                       For cases where the drug is provided without a prescription (for example, from a physician's office), the value provided in this segment is a "link sequence number". The link sequence number is a provider assigned number that is unique to this claim. Its purpose is to enable the receiver to piece together the components of the compound.
                       Required when available in the payer's system. If not required by this implementation guide, do not send.
                       If, for whatever reason, the data is not stored within the payer's system, do not use.

                41. 2420A Loop Optional Repeat 1

                    1. 5000 · NM1 · Rendering Provider Name · Max 1 · Mandatory

                       To supply the full name of an individual or organizational entity

                       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.
                       If, for whatever reason, the data is not stored within the payer's system, do not use.
                       Required when the Rendering Provider NM1 information is different than that carried in the Loop ID-2310B Rendering Provider. OR Required when Loop ID-2310B Rendering Provider is not used AND this particular line item has different Rendering Provider information than that which is carried in Loop ID-2010AA Billing Provider. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.

                    2. 5050 · PRV · Rendering Provider Specialty Information · Max 1 · Optional

                       To specify the identifying characteristics of a provider

                       Required when available in the payer's system. If not required by this implementation guide, do not send.
                       If, for whatever reason, the data is not stored within the payer's system, do not use.

                    3. 5250 · REF · Rendering Provider Secondary Identification · Max 3 · Optional

                       To specify identifying information

                       Required when available in the payer's system. If not required by this implementation guide, do not send.
                       If, for whatever reason, the data is not stored within the payer's system, do not use.

                42. 2420B Loop Optional Repeat 1

                    1. 5000 · NM1 · Purchased Service Provider Name · Max 1 · Mandatory

                       To supply the full name of an individual or organizational entity

                       Purchased services are situations where, for example, a physician purchases a diagnostic exam from an outside entity. Purchased services do not include substitute (locum tenens) provider situations.
                       Required when available in the payer's system. If not required by this implementation guide, do not send.
                       If, for whatever reason, the data is not stored within the payer's system, do not use.

                    2. 5250 · REF · Purchased Service Provider Secondary Identification · Max 2 · Optional

                       To specify identifying information

                       Required when available in the payer's system. If not required by this implementation guide, do not send.
                       If, for whatever reason, the data is not stored within the payer's system, do not use.

                43. 2420C Loop Optional Repeat 1

                    1. 5000 · NM1 · Service Facility Location Name · Max 1 · Mandatory

                       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.
                       The purpose of this loop is to identify specifically where the service was rendered. When reporting ambulance services, do not use this loop. Use the pick-up (2420G) and drop-off location (2420H) loops elsewhere in this transaction.;
                       If, for whatever reason, the data is not stored within the payer's system, do not use.
                       Required when the Service Facility Location for this line is different than the Service Facility Location reported in Loop ID-2310C (claim level) and is available in the payer's system. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.

                    2. 5140 · N3 · Service Facility Location Address · Max 1 · Mandatory

                       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. 5200 · N4 · Service Facility Location City, State, ZIP Code · Max 1 · Mandatory

                       To specify the geographic place of the named party

                    4. 5250 · REF · Service Facility Location Secondary Identification · Max 3 · Optional

                       To specify identifying information

                       If, for whatever reason, the data is not stored within the payer's system, do not use.
                       Required when available in the payer's system. If not required by this implementation guide, do not send.

                44. 2420D Loop Optional Repeat 1

                    1. 5000 · NM1 · Supervising Provider Name · Max 1 · Mandatory

                       To supply the full name of an individual or organizational entity

                       If, for whatever reason, the data is not stored within the payer's system, do not use.
                       Required when the Supervising Provider for this line is different than the Supervising Provider reported in Loop ID-2310D (claim level) and is available in the payer's system. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.

                    2. 5250 · REF · Supervising Provider Secondary Identification · Max 3 · Optional

                       To specify identifying information

                       Required when available in the payer's system. If not required by this implementation guide, do not send.
                       If, for whatever reason, the data is not stored within the payer's system, do not use.

                45. 2420E Loop Optional Repeat 1

                    1. 5000 · NM1 · Ordering Provider Name · Max 1 · Mandatory

                       To supply the full name of an individual or organizational entity

                       Required when available in the payer's system. If not required by this implementation guide, do not send.
                       If, for whatever reason, the data is not stored within the payer's system, do not use.

                    2. 5140 · N3 · Ordering Provider Address · Max 1 · Optional

                       To specify the location of the named party

                       If, for whatever reason, the data is not stored within the payer's system, do not use.
                       Required when available in the payer's system. If not required by this implementation guide, do not send.

                    3. 5200 · N4 · Ordering Provider City, State, ZIP Code · Max 1 · Optional

                       To specify the geographic place of the named party

                       If, for whatever reason, the data is not stored within the payer's system, do not use.
                       Required when available in the payer's system. If not required by this implementation guide, do not send.

                    4. 5250 · REF · Ordering Provider Secondary Identification · Max 2 · Optional

                       To specify identifying information

                       Required when available in the payer's system. If not required by this implementation guide, do not send.
                       If, for whatever reason, the data is not stored within the payer's system, do not use.

                    5. 5300 · PER · Ordering Provider Contact Information · Max 1 · Optional

                       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-".
                       If, for whatever reason, the data is not stored within the payer's system, do not use.
                       Required when available in the payer's system. If not required by this implementation guide, do not send.

                46. 2420F Loop Optional Repeat 2

                    1. 5000 · NM1 · Referring Provider Name · Max 1 · Mandatory

                       To supply the full name of an individual or organizational entity

                       When reporting the provider who ordered services such as diagnostic and lab, use Loop ID-2310A at the claim level. For ordered services such as Durable Medical Equipment, use Loop ID-2420E at the line level.
                       When there is only one referral on the claim, use code "DN - Referring Provider". When more than one referral exists and there is a requirement to report the additional referral, use code DN in the first iteration of this loop to indicate the referral received by the rendering provider on this claim. Use code "P3 - Primary Care Provider" in the second iteration of the loop to indicate the initial referral from the primary care provider or whatever provider wrote the initial referral for this patient's episode of care being billed/reported in this transaction.
                       If, for whatever reason, the data is not stored within the payer's system, do not use.
                       Required when the Referring Provider for this line is different than the Referring Provider reported in Loop ID-2310A (claim level) and is available in the payer's system. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.

                    2. 5250 · REF · Referring Provider Secondary Identification · Max 2 · Optional

                       To specify identifying information

                       Required when available in the payer's system. If not required by this implementation guide, do not send.
                       If, for whatever reason, the data is not stored within the payer's system, do not use.

                47. 2420G Loop Optional Repeat 1

                    1. 5000 · NM1 · Ambulance Pick-up Location · Max 1 · Mandatory

                       To supply the full name of an individual or organizational entity

                       Required when the ambulance pick-up location for this service line is different than the ambulance pick-up location reported in Loop ID-2310E and is available in the payer's system. If not required by this implementation guide, do not send.

                    2. 5140 · N3 · Ambulance Pick-up Location Address · Max 1 · Mandatory

                       To specify the location of the named party

                    3. 5200 · N4 · Ambulance Pick-up Location City, State, ZIP Code · Max 1 · Mandatory

                       To specify the geographic place of the named party

                48. 2420H Loop Optional Repeat 1

                    1. 5000 · NM1 · Ambulance Drop-Off Location · Max 1 · Mandatory

                       To supply the full name of an individual or organizational entity

                       Required when the ambulance drop-off location for this service line is different than the ambulance drop-off location reported in Loop ID-2310F and is available in the payer's system. If not required by this implementation guide, do not send.

                    2. 5140 · N3 · Ambulance Drop-Off Location Address · Max 1 · Mandatory

                       To specify the location of the named party

                    3. 5200 · N4 · Ambulance Drop-Off Location City, State, ZIP Code · Max 1 · Mandatory

                       To specify the geographic place of the named party

                49. 2430 Loop Optional Repeat 15

                    1. 5400 · SVD · Line Adjudication Information · Max 1 · Mandatory

                       To convey service line adjudication information for coordination of benefits between the initial payers of a health care claim and all subsequent payers

                       Loop ID 2430 conveys information demonstrating how this line was adjudicated by both the submitting payer and other payers who have previously adjudicated the line. Loop 2430 and the related 2320 loop are linked using the value reported in Loop 2320 SBR01 and Loop 2430 SVD01. Loop 2320 SBR06 identifies to the receiver whether the respective iteration of Loop ID 2320 was adjudicated by the submitting plan or an Other Payer. When SBR06 = 1, the payer and adjudication information related to this iteration of Loop ID 2320 and 2430 represents processing performed prior to the adjudication of this claim and the Other Payer information is to be reported as received from the provider. When SBR06 = 6, the payer and adjudication information related to this iteration of Loop ID 2320 and 2430 represents the adjudication results of the submitting payer.
                       Required when 2320 SBR06 = 6 and an 835 sent to the provider would have included service line detail. OR Required when the related Loop ID 2320 SBR06 = 1; and the data was present on the provider submitted claim. If not required by this implementation guide, do not send.

                    2. 5450 · CAS · Line Adjustment · Max 5 · Optional

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

                       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).
                       Required when the payer identified in this Line Adjudication Information Loop ID-2430 made line level adjustments which caused the dollar amount paid for the service line (SVD02) to differ from the amount originally charged for this service. If not required by this implementation guide, do not send.

                    3. 5500 · DTP · Line Check or Remittance Date · Max 1 · Mandatory

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

                    4. 5505 · AMT · Remaining Patient Liability · Max 1 · Optional

                       To indicate the total monetary amount

                       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.
                       If, for whatever reason, the data is not stored within the payer's system, do not use.
                       Required when available in the payer's system. If not required by this implementation guide, do not send.

2. 5550 · SE · Transaction Set Trailer · Max 1 · Mandatory

   To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments)