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
3
-
Code identifying where services were, or may be, performed; the National Uniform Billing Committee (NUBC) Facility Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services.
C023-01 does not contain the last position of the Uniform Bill Type Code (the Claim Frequency Code).
02
Facility Code Qualifier
Identifier (ID)
Mandatory
1
2
-
Code identifying the type of facility referenced
C023-02 qualifies C023-01.
03
Claim Frequency Type Code
Identifier (ID)
Optional
1
1
-
Code specifying the Type of Bill Frequency Code. It is the last digit of Type of Bill in the UB manual, as defined by the National Uniform Billing Committee
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 specifying the 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
CLM-21
Claim Authorization Exception Code
Identifier (ID)
Optional
1
2
1
Code identifying the reason for requesting an exception to standard processing of the claim

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