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Segment
in
X12 Release 003040

CLM Health Claim

To specify basic data about the claim
Sequence
Element
Name
Type
Requirement
Min
Max
Repeat
01
1028
Claim Submitter's Identifier
String (AN)
Mandatory
1
38
-
Identifier used to track a claim from creation by the health care provider through payment.
02
Monetary Amount
Decimal number (R)
Optional
1
15
-
Monetary amount.
CLM02 is the total amount of all submitted charges of service segments for this claim.
03
Claim Filing Indicator Code
Identifier (ID)
Optional
1
2
-
Code identifying type of claim
Codes (26)
04
Non-Institutional Claim Type Code
Identifier (ID)
Optional
1
2
-
Code identifying the type of provider or claim
Codes (37)
05
Facility Code Qualifier
Identifier (ID)
Conditional
1
2
-
Code identifying the type of facility referenced
P0506
Codes (2)
06
Facility Code Value
String (AN)
Conditional
1
2
-
Code identifying the type of facility where services were performed; the first and second position of the uniform bill type or place of service from health care financing administration claim form, or place of treatment from the dental claim form
07
Claim Frequency Type Code
Identifier (ID)
Optional
1
1
-
Code specifying the frequency of the claim; this is the third position of the Uniform Billing Claim Form Bill Type
08
Yes/No Condition or Response Code
Identifier (ID)
Optional
1
1
-
Code indicating a Yes or No condition or response.
CLM08 is provider signature on file indicator. A ``Y'' value indicates the provider signature is on file. A ``N'' value indicates the provider signature is not on file.
Codes (3)
09
Provider Accept Assignment Code
Identifier (ID)
Optional
1
1
-
Code indicating whether the provider accepts assignment
Codes (3)
10
Yes/No Condition or Response Code
Identifier (ID)
Optional
1
1
-
Code indicating a Yes or No condition or response.
CLM10 is assignment of benefits indicator. A ``Y'' value indicates insured or authorized person authorizes benefits to be assigned to the provider. An ``N'' value indicates benefits have not been assigned to the provider.
Codes (3)
11
Release of Information Code
Identifier (ID)
Optional
1
1
-
Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations in order to adjudicate the claim
Codes (3)
12
Patient Signature Source Code
Identifier (ID)
Optional
1
1
-
Code indicating how the patient or subscriber authorization signatures were obtained and how they are being retained by the provider
Codes (5)
13
Related-Causes Code
Identifier (ID)
Optional
2
3
-
Code identifying an accompanying cause of an illness or an accident
Codes (6)
14
Related-Causes Code
Identifier (ID)
Optional
2
3
-
Code identifying an accompanying cause of an illness or an accident
Codes (6)
15
Related-Causes Code
Identifier (ID)
Optional
2
3
-
Code identifying an accompanying cause of an illness or an accident
Codes (6)
16
State or Province Code
Identifier (ID)
Optional
2
2
-
Code (Standard State/Province) as defined by appropriate government agency.
CLM16 and CLM17 apply only to auto accidents when CLM13, CLM14, or CLM15 is equal to AA.
17
Country Code
Identifier (ID)
Optional
2
3
-
Code identifying the country.
18
Special Program Code
Identifier (ID)
Optional
2
3
-
Code indicating the Special Program under which the services rendered to the patient were performed
Codes (10)
19
Yes/No Condition or Response Code
Identifier (ID)
Optional
1
1
-
Code indicating a Yes or No condition or response.
CLM19 is CHAMPUS non-availability indicator. A ``Y'' value indicates a statement of non-availability is on file. An ``N'' value indicates statement of non-availability is not on file or not necessary.
Codes (3)
20
Level of Service Code
Identifier (ID)
Optional
1
3
-
Code specifying the level of service rendered
Codes (12)
21
Yes/No Condition or Response Code
Identifier (ID)
Optional
1
1
-
Code indicating a Yes or No condition or response.
CLM21 is charges itemized by service indicator. A ``Y'' value indicates charges are itemized by service. An ``N'' value indicates charges are summarized by service.
Codes (3)
22
Provider Agreement Code
Identifier (ID)
Optional
1
1
-
Code indicating the type of agreement under which the provider is submitting this claim
Codes (7)
23
Claim Status Code
Identifier (ID)
Optional
1
2
-
Code identifying the status of an entire claim as assigned by the payor.
Codes (28)
24
Yes/No Condition or Response Code
Identifier (ID)
Optional
1
1
-
Code indicating a Yes or No condition or response.
CLM24 is explanation of benefit (EOB) indicator. A ``Y'' value indicates that a paper EOB is requested. An ``N'' value indicates that no paper EOB is requested.
Codes (3)
25
Claim Submission Reason Code
Identifier (ID)
Optional
2
2
-
Code identifying reason for claim submission
Codes (15)
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Stedi is a registered trademark of Stedi, Inc. Stedi's EDI Reference and Mapping Guides are provided for marketing purposes and are free of charge. All names, logos, and brands of third parties listed on our site are trademarks of their respective owners (including “X12”, which is a trademark of X12 Incorporated). Stedi, Inc. and its products and services are not endorsed by, sponsored by, or affiliated with these third parties. Our use of these names, logos, and brands is for identification purposes only, and does not imply any such endorsement, sponsorship, or affiliation.