CLM Health Claim

To specify basic data about the claim

Position
Element
Name
Type
Requirement
Min
Max
Repeat
CLM-01
Claim Submitter's Identifier
String (AN)
Mandatory
1
38
1
Identifier used to track a claim from creation by the health care provider through payment
CLM-02
Monetary Amount
Decimal number (R)
Optional
1
18
1
Monetary amount
CLM02 is the total amount of all submitted charges of service segments for this claim.
CLM-03
Claim Filing Indicator Code
Identifier (ID)
Optional
1
2
1
Code identifying type of claim
CLM-04
Non-Institutional Claim Type Code
Identifier (ID)
Optional
1
2
1
Code identifying the type of provider or claim
CLM-05
Health Care Service Location Information
Composite (composite)
Optional
1
01
Facility Code Value
String (AN)
Mandatory
1
2
-
Code identifying the type of facility where services were performed; the first and second positions of the Uniform Bill Type code or the Place of Service code from the Electronic Media Claims National Standard Format
02
Facility Code Qualifier
Identifier (ID)
Optional
1
2
-
Code identifying the type of facility referenced
C023-02 qualifies C023-01 and C023-03.
03
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
CLM-06
Yes/No Condition or Response Code
Identifier (ID)
Optional
1
1
1
Code indicating a Yes or No condition or response
CLM06 is provider signature on file indicator. A "Y" value indicates the provider signature is on file; an "N" value indicates the provider signature is not on file.
CLM-07
Provider Accept Assignment Code
Identifier (ID)
Optional
1
1
1
Code indicating whether the provider accepts assignment
CLM-08
Yes/No Condition or Response Code
Identifier (ID)
Optional
1
1
1
Code indicating a Yes or No condition or response
CLM08 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.
CLM-09
Release of Information Code
Identifier (ID)
Optional
1
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
CLM-10
Patient Signature Source Code
Identifier (ID)
Optional
1
1
1
Code indicating how the patient or subscriber authorization signatures were obtained and how they are being retained by the provider
CLM-11
Related Causes Information
Composite (composite)
Optional
1
01
Related-Causes Code
Identifier (ID)
Mandatory
2
3
-
Code identifying an accompanying cause of an illness, injury or an accident
02
Related-Causes Code
Identifier (ID)
Optional
2
3
-
Code identifying an accompanying cause of an illness, injury or an accident
03
Related-Causes Code
Identifier (ID)
Optional
2
3
-
Code identifying an accompanying cause of an illness, injury or an accident
04
State or Province Code
Identifier (ID)
Optional
2
2
-
Code (Standard State/Province) as defined by appropriate government agency
C024-04 and C024-05 apply only to auto accidents when C024-01, C024-02, or C024-03 is equal to "AA".
05
Country Code
Identifier (ID)
Optional
2
3
-
Code identifying the country
CLM-12
Special Program Code
Identifier (ID)
Optional
2
3
1
Code indicating the Special Program under which the services rendered to the patient were performed
CLM-13
Yes/No Condition or Response Code
Identifier (ID)
Optional
1
1
1
Code indicating a Yes or No condition or response
CLM13 is CHAMPUS nonavailability indicator. A "Y" value indicates a statement of non-availability is on file; an "N" value indicates statement of nonavailability is not on file or not necessary.
CLM-14
Level of Service Code
Identifier (ID)
Optional
1
3
1
Code specifying the level of service rendered
CLM-15
Yes/No Condition or Response Code
Identifier (ID)
Optional
1
1
1
Code indicating a Yes or No condition or response
CLM15 is charges itemized by service indicator. A "Y" value indicates charges are itemized by service; an "N" value indicates charges are summarized by service.
CLM-16
Provider Agreement Code
Identifier (ID)
Optional
1
1
1
Code indicating the type of agreement under which the provider is submitting this claim
CLM-17
Claim Status Code
Identifier (ID)
Optional
1
2
1
Code identifying the status of an entire claim as assigned by the payor, claim review organization or repricing organization
CLM-18
Yes/No Condition or Response Code
Identifier (ID)
Optional
1
1
1
Code indicating a Yes or No condition or response
CLM18 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.
CLM-19
Claim Submission Reason Code
Identifier (ID)
Optional
2
2
1
Code identifying reason for claim submission
CLM-20
Delay Reason Code
Identifier (ID)
Optional
1
2
1
Code indicating the reason why a request was delayed

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