ANSI 837 Reference


     

  • Expand
    Loop 0000A - INTERCHANGE CONTROL HEADER
    • Expand
      ISA - INTERCHANGE CONTROL HEADER
      • ISA01 - Authorization Information Qualifier
      • ISA02 - Authorization Information 
      • ISA03 - Security Information Qualifier
      • ISA04 - Security Information 
      • ISA05 - Interchange ID Qualifier
      • ISA06 - Interchange Sender ID
      • ISA07 - Interchange ID Qualifier
      • ISA08 - Interchange Receiver ID
      • ISA09 - Interchange Date
      • ISA10 - Interchange Time
      • ISA11 - Interchange Control Standards ID
      • ISA12 - Interchange Control Version Number
      • ISA13 - Interchange Control Number
      • ISA14 - Acknowledgement Requested
      • ISA15 - Usage Indicator
      • ISA16 - Component Element Separator
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    Loop 0000B - FUNCTIONAL GROUP HEADER
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      GS - FUNCTIONAL GROUP HEADER
      • GS01 - Functional Identifier Code
      • GS02 - Application Sender Code
      • GS03 - Application Receiver Code
      • GS04 - Date
      • GS05 - Time
      • GS06 - Group Control Number
      • GS07 - Responsible Agency Code
      • GS08 - Version Identifier Code
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    Loop 0000C - TRANSACTION SET HEADER
    • Expand
      ST - TRANSACTION SET HEADER
      • ST01 - Transaction Set Identifier Code
      • ST02 - Transaction Set Control Number
      • ST03 - Implementation Convention Reference
  • Expand
    Loop 0000D - BEGINNING OF HIERARCHICAL TRANSACTION
    • Expand
      BHT - BEGINNING OF HIERARCHICAL TRANSACTION
      • BHT01 - Hierarchical Structure Code
      • BHT02 - Transaction Set Purpose Code
      • BHT03 - Originator Application Transaction ID
      • BHT04 - Transaction Set Creation Date
      • BHT05 - Transaction Set Creation Time
      • BHT06 - Claim or Encounter ID
  • Expand
    Loop 1000A - SUBMITTER NAME
    • Expand
      NM1*41 - SUBMITTER NAME
      • NM101 - Entity Identifier Code
      • NM102 - Entity Type
      • NM103 - Submitter Last or Organization Name
      • NM104 - Submitter First Name
      • NM108 - Identification Code Qualifier
      • NM109 - Submitter Identifier
    • Expand
      PER - SUBMITTER EDI CONTACT INFORMATION
      • PER01 - Contact Function Code
      • PER02 - Submitter Contact Name
      • PER03 - Communication Number Qualifier
      • PER04 - Communication Number  
  • Expand
    Loop 1000B - RECEIVER NAME
    • Expand
      NM1*40 - RECEIVER NAME
      • NM101 - Entity Identifier Code
      • NM102 - Entity Type
      • NM103 - Receiver Name
      • NM108 - Identification Code Qualifier
      • NM109 - Receiver Primary Identifier
  • Expand
    Loop 2000A - BILLING PROVIDER HIERARCHICAL LEVEL
    • CUR - FOREIGN CURRENCY INFORMATION
    • Expand
      HL - BILLING PROVIDER HIERARCHICAL LEVEL
      • HL01 - Hierarchical ID Number
      • HL03 - Hierarchical Level Code
      • HL04 - Hierarchical Child Code
    • Expand
      PRV - BILLING PROVIDER SPECIALTY INFORMATION
      • PRV01 - Provider Code
      • PRV02 - Reference Identification Qualifier
      • PRV03 - Provider Taxonomy Code
  • Expand
    Loop 2000B - SUBSCRIBER HIERARCHICAL LEVEL
    • Expand
      HL - SUBSCRIBER HIERARCHICAL LEVEL
      • HL01 - Hierarchical ID Number
      • HL02 - Hierarchical Parent ID Number
      • HL03 - Hierarchical Level Code
      • HL04 - Hierarchical Child Code
    • Expand
      PAT - PATIENT INFORMATION
      • PAT07 - Unit or Basis for Measurement Code
      • PAT08 - Patient Weight 9(6)V99
    • Expand
      SBR - SUBSCRIBER INFORMATION
      • SBR01 - Payer Responsibility Sequence Number Code 
      • SBR02 - Individual Relationship Code
      • SBR03 - Insured Group or Policy Number
      • SBR04 - Insured Group Name
      • SBR05 - Insurance Type Code
      • SBR09 - Claim Filing Indicator Code
  • Expand
    Loop 2000C - PATIENT HIERARCHICAL LEVEL
    • Expand
      HL - PATIENT HIERARCHICAL LEVEL
      • HL01 - Hierarchical ID Number
      • HL02 - Hierarchical Parent ID Number
      • HL03 - Hierarchical Level Code
      • HL04 - Hierarchical Child Code
    • Expand
      PAT - PATIENT INFORMATION
      • PAT01 - Individual Relationship Code
  • Expand
    Loop 2010AA - BILLING PROVIDER NAME
    • Expand
      N3 - BILLING PROVIDER ADDRESS
      • N301 - Billing Provider Address Line
      • N302 - Billing Provider Address Line
    • Expand
      N4 - BILLING PROVIDER CITY/STATE/ZIP CODE
      • N401 - Billing Provider City Name
      • N402 - Billing Provider State or Province Code
      • N403 - Billing Provider Postal Zone or ZIP Code
    • Expand
      NM1*85 - BILLING PROVIDER NAME
      • NM101 - Entity Identifier Code
      • NM102 - Entity Type
      • NM103 - Billing Provider Last or Organizational Name
      • NM104 - Billing Provider First Name
      • NM105 - Billing Provider Middle Name
      • NM108 - Identification Code Qualifier
      • NM109 - Billing Provider Identifier
    • Expand
      PER - BILLING PROVIDER CONTACT INFORMATION
      • PER01 - Contact Function Code
      • PER02 - Billing Provider Contact Name
      • PER03 - Communication Number Qualifier
      • PER04 - Communication Number  
    • Expand
      REF - BILLING PROVIDER TAX IDENTIFICATION
      • REF01 - Qualifier
      • REF02 - Billing Provider Additional Identifier
    • Expand
      REF - BILLING PROVIDER UPIN/LICENSE INFORMATION
      • REF01 - Qualifier
      • REF02 - Billing Provider Additional Identifier
  • Expand
    Loop 2010AB - PAY-TO ADDRESS NAME
    • Expand
      N3 - PAY-TO PROVIDER ADDRESS
      • N301 - Pay-to Provider Address Line
      • N302 - Pay-to Provider Address Line
    • Expand
      N4 - PAY-TO PROVIDER CITY/STATE/ZIP CODE
      • N401 - Pay-to Provider City Name
      • N402 - Pay-to Provider State Code
      • N403 - Pay-to Provider Postal Zone or ZIP  Code
    • Expand
      NM1*87 - PAY-TO ADDRESS NAME
      • NM101 - Entity Identifier Code
      • NM102 - Entity Type
  • Expand
    Loop 2010AC - PAY TO PLAN NAME
    • N3 - PAY-TO PLAN ADDRESS
    • N4 - PAY-TO PLAN CITY/STATE/ZIP CODE
    • NM1 - PAY TO PLAN NAME
    • REF - PAY-TO PLAN SECONDARY IDENTIFICATION
    • REF - PAY-TO PLAN TAX IDENTIFICATION
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    Loop 2010BA - SUBSCRIBER NAME
    • Expand
      DMG - SUBSCRIBER DEMOGRAPHIC INFORMATION
      • DMG01 - Format
      • DMG02 - Subscriber Birth Date
      • DMG03 - Subscriber Gender Code
    • Expand
      N3 - SUBSCRIBER ADDRESS
      • N301 - Subscriber Address Line
    • Expand
      N4 - SUBSCRIBER CITY/STATE/ZIP CODE
      • N401 - Subscriber City Name
      • N402 - Subscriber State Code
      • N403 - Subscriber Postal Zone or ZIP Code
    • Expand
      NM1*IL - SUBSCRIBER NAME
      • NM101 - Entity Identifier Code
      • NM102 - Entity Type
      • NM103 - Subscriber Last Name
      • NM104 - Subscriber First Name
      • NM105 - Subscriber Middle Name
      • NM108 - Identification Code Qualifier
      • NM109 - Subscriber Primary Identifier
    • PER - PROPERTY AND CASUALTY SUBSCRIBER CONTACT INFORMATION
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      REF - PROPERTY AND CASUALTY CLAIM NUMBER
      • REF01 - Qualifier
    • Expand
      REF*SY - SUBSCRIBER SECONDARY IDENTIFICATION
      • REF01 - Qualifier
      • REF02 - Subscriber Supplemental Identifier
  • Expand
    Loop 2010BB - PAYER NAME
    • Expand
      N3 - PAYER ADDRESS
      • N301 - Payer Address Line
      • N302 - Payer Address Line
    • Expand
      N4 - PAYER CITY/STATE/ZIP CODE
      • N401 - Payer City Name
      • N402 - Payer State Code
      • N403 - Payer Postal Zone or ZIP Code
    • Expand
      NM1*PR - PAYER NAME
      • NM101 - Entity Identifier Code
      • NM102 - Entity Type
      • NM103 - Payer Name
      • NM108 - Identification Code Qualifier
      • NM109 - Payer Identifier
    • REF - BILLING PROVIDER SECONDARY IDENTIFICATION
    • Expand
      REF - PAYER SECONDARY IDENTIFICATION
      • REF01 - Qualifier
      • REF02 - Payer Additional Identifier
  • Expand
    Loop 2010CA - PATIENT NAME
    • Expand
      DMG - PATIENT DEMOGRAPHIC INFORMATION
      • DMG01 - Format
      • DMG02 - Patient Birth Date
      • DMG03 - Patient Gender Code
    • Expand
      N3 - PATIENT ADDRESS
      • N301 - Patient Address Line
    • Expand
      N4 - PATIENT CITY/STATE/ZIP CODE
      • N401 - Patient City Name
      • N402 - Patient State Code
      • N403 - Patient Postal Zone or ZIP Code
    • Expand
      NM1*QC - PATIENT NAME
      • NM101 - Entity Identifier Code
      • NM102 - Entity Type
      • NM103 - Patient Last Name
      • NM104 - Patient First Name
      • NM105 - Patient Middle Name
    • PER - PROPERTY AND CASUALTY PATIENT CONTACT INFORMATION
    • Expand
      REF*Y4 - PROPERTY AND CASUALTY CLAIM NUMBER
      • REF01 - Qualifier
      • REF02 - Property Casualty Claim Number
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      REF*SY - PROPERTY AND CASUALTY PATIENT IDENTIFIER
      • REF02 - Social Security Number
    • Expand
      REF*1W - PROPERTY AND CASUALTY PATIENT IDENTIFIER
      • REF02 - Member ID
  • Expand
    Loop 2300 - CLAIM INFORMATION
    • Expand
      AMT*F5 - PATIENT AMOUNT PAID
      • AMT01 - Qualifier
      • AMT02 - Patient Amount Paid S9(7)V99
    • Expand
      CLM - CLAIM INFORMATION
      • CLM01 - Patient Account Number
      • CLM02 - Total Claim Charge Amount S9(7)V99
      • CLM05 - HEALTH CARE SERVICE LOCATION INFORMATION
      • CLM05-1 - Facility Type Code
      • CLM05-2 - Facility Code Qualifier
      • CLM05-3 - Claim Frequency Code
      • CLM06 - Provider or Supplier Signature Indicator
      • CLM07 - Medicare Assignment Code
      • CLM08 - Benefits Assignment Certification Indicator
      • CLM09 - Release of Information Code
      • CLM10 - Patient Signature Source Code
      • CLM11 - RELATED CAUSES INFORMATION
      • CLM11-1 - Related Causes Code
      • CLM11-4 - Auto Accident State or Province Code
      • CLM12 - Special Program Indicator
      • CLM20 - Delay Reason Code
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      CN1 - CONTRACT INFORMATION
      • CN101 - Contract Type Code
      • CN102 - Contract Amount S9(7)V99
      • CN103 - Contract Percentage 9(2)V99
      • CN104 - Contract Code
      • CN105 - Terms Discount Percent 9(2)V99
      • CN106 - Contract Version Identifier
    • Expand
      CR1 - AMBULANCE TRANSPORT INFORMATION
      • CR101 - Unit or Basis for Measurement Code
      • CR102 - Patient Weight 9(3)
      • CR104 - Ambulance Transport Reason Code
      • CR105 - Unit or Basis for Measurement Code
      • CR106 - Transport Distance 9(4)
      • CR109 - Round Trip Purpose Description
      • CR110 - Stretcher Purpose Description
    • Expand
      CR2 - SPINAL MANIPULATION SERVICE INFORMATION
      • CR208 - Patient Condition Code
      • CR210 - Patient Condition Description
      • CR211 - Patient Condition Description
    • Expand
      CRC - AMBULANCE CERTIFICATION
      • CRC01 - Code Category
      • CRC02 - Certification Condition Indicator
      • CRC03 - Condition Code
    • Expand
      CRC - EPSDT REFERRAL
      • CRC01 - Code Category
      • CRC02 - Certification Condition Indicator
      • CRC03 - Condition Code
    • Expand
      CRC - HOMEBOUND INDICATOR
      • CRC01 - Code Category
      • CRC02 - Certification Condition Indicator
      • CRC03 - Homebound Indicator
    • CRC - PATIENT CONDITION INFORMATION:  VISION
    • Expand
      DTP*439 - DATE - ACCIDENT
      • DTP01 - Qualifier
      • DTP02 - Format
      • DTP03 - Accident Date
    • Expand
      DTP*453 - DATE - ACUTE MANIFESTATION
      • DTP01 - Qualifier
      • DTP02 - Format
      • DTP03 - Acute Manifestation Date
    • Expand
      DTP*435 - DATE - ADMISSION
      • DTP01 - Qualifier
      • DTP02 - Format
      • DTP03 - Related Hospitalization Admission Date
    • Expand
      DTP*090 - DATE - ASSUMED CARE DATES
      • DTP01 - Qualifier
      • DTP02 - Format
      • DTP03 - Assumed Care Date
    • Expand
      DTP*296 - DATE - AUTHORIZED RETURN TO WORK
      • DTP01 - Qualifier
      • DTP02 - Format
      • DTP03 - Work Return Date
    • Expand
      DTP*304 - DATE - DATE LAST SEEN
      • DTP01 - Qualifier
      • DTP02 - Format
      • DTP03 - Last Seen Date
    • Expand
      DTP*360 - DATE - DISABILITY DATES
      • DTP01 - Qualifier
      • DTP02 - Format
      • DTP03 - Disability From Date
    • Expand
      DTP*361 - DATE - DISABILITY DATES
      • DTP01 - Qualifier
      • DTP02 - Format
      • DTP03 - Disability From Date
    • Expand
      DTP*314 - DATE - DISABILITY DATES
      • DTP01 - Qualifier
      • DTP02 - Format
      • DTP03 - Disability From Date
    • Expand
      DTP*096 - DATE - DISCHARGE
      • DTP01 - Qualifier
      • DTP02 - Format
      • DTP03 - Related Hospitalization Discharge Date
    • Expand
      DTP*471 - DATE - HEARING AND VISION PRESCRIPTION DATE
      • DTP01 - Qualifier
      • DTP02 - Format
      • DTP03 - Prescription Date
    • Expand
      DTP*454 - DATE - INITIAL TREATMENT
      • DTP01 - Qualifier
      • DTP02 - Format
      • DTP03 - Initial Treatment Date
    • Expand
      DTP*484 - DATE - LAST MENSTRUAL PERIOD
      • DTP01 - Qualifier
      • DTP02 - Format
      • DTP03 - Last Menstrual Period Date
    • Expand
      DTP*297 - DATE - LAST WORKED
      • DTP01 - Qualifier
      • DTP02 - Format
      • DTP03 - Last Worked Date
    • Expand
      DTP*455 - DATE - LAST X-RAY
      • DTP01 - Qualifier
      • DTP02 - Format
      • DTP03 - Last X-Ray Date
    • Expand
      DTP*431 - DATE - ONSET OF CURRENT ILLNESS/SYMPTOM
      • DTP01 - Qualifier
      • DTP02 - Format
      • DTP03 - Onset of Current Illness or Injury Date
    • DTP - DATE - PROPERTY AND CASUALTY DATE OF FIRST CONTACT
    • Expand
      DTP*091 - DATE - RELINQUISHED CARE DATES
      • DTP01 - Qualifier
      • DTP02 - Format
      • DTP03 - Relinquished Care Date
    • DTP - DATE - REPRICER RECEIVED DATE
    • HCP - CLAIM PRICING/REPRICING INFORMATION
    • Expand
      HI - ANESTHESIA RELATED PROCEDURE
      • HI01 - HEALTH CARE CODE INFORMATION
      • HI01-1 - Code List Qualifier
      • HI01-2 - Anesthesia Related Surgical Procedure
      • HI02 - HEALTH CARE CODE INFORMATION
      • HI02-1 - Code List Qualifier
      • HI02-2 - Anesthesia Related Surgical Procedure
    • Expand
      HI - CONDITION INFORMATION
      • HI01 - HEALTH CARE CODE INFORMATION
    • Expand
      HI - HEALTH CARE DIAGNOSIS CODE
      • HI01 - HEALTH CARE CODE INFORMATION
      • HI01-1 - Diagnosis Type Code
      • HI01-2 - Diagnosis Code
      • HI02 - HEALTH CARE CODE INFORMATION
      • HI02-1 - Diagnosis Type Code
      • HI02-2 - Diagnosis Code
      • HI03 - HEALTH CARE CODE INFORMATION
      • HI03-1 - Diagnosis Type Code
      • HI03-2 - Diagnosis Code
      • HI04 - HEALTH CARE CODE INFORMATION
      • HI04-1 - Diagnosis Type Code
      • HI04-2 - Diagnosis Code
      • HI05 - HEALTH CARE CODE INFORMATION
      • HI05-1 - Diagnosis Type Code
      • HI05-2 - Diagnosis Code
      • HI06 - HEALTH CARE CODE INFORMATION
      • HI06-1 - Diagnosis Type Code
      • HI06-2 - Diagnosis Code
      • HI07 - HEALTH CARE CODE INFORMATION
      • HI07-1 - Diagnosis Type Code
      • HI07-2 - Diagnosis Code
      • HI08 - HEALTH CARE CODE INFORMATION
      • HI08-1 - Diagnosis Type Code
      • HI08-2 - Diagnosis Code
      • HI09 - HEALTH CARE CODE INFORMATION
      • HI10 - HEALTH CARE CODE INFORMATION
      • HI11 - HEALTH CARE CODE INFORMATION
      • HI12 - HEALTH CARE CODE INFORMATION
    • Expand
      K3 - FILE INFORMATION - 2300
      • K301 - Fixed format information
    • Expand
      NTE - CLAIM NOTE
      • NTE01 - Note Reference Code
      • NTE02 - Claim Note Text
    • Expand
      PWK - CLAIM SUPPLEMENTAL INFORMATION
      • PWK01 - Attachment Report Type Code
      • PWK02 - Attachment Transmission Code
      • PWK05 - Identification Code Qualifier
      • PWK06 - Attachment Control Number
    • REF*9C - ADJUSTED REPRICED CLAIM NUMBER
    • REF*1J - CARE PLAN OVERSIGHT
    • Expand
      REF*D9 - CLAIM IDENTIFIER FOR TRANSMISSION INTERMEDIARIES
      • REF01 - Qualifier
      • REF02 - Value Added Network Trace Number
    • Expand
      REF*X4 - CLINICAL LABORATORY IMPROVEMENT AMENDMENT (CLIA) NUMBER
      • REF01 - Qualifier
      • REF02 - Clinical Laboratory Improvement Amendment Number
    • REF*P4 - DEMONSTRATION PROJECT IDENTIFIER
    • Expand
      REF*LX - INVESTIGATIONAL DEVICE EXEMPTION NUMBER
      • REF01 - Qualifier
      • REF02 - Investigational Device Exemption Number
    • Expand
      REF*EW - MAMMOGRAPHY CERTIFICATION NUMBER
      • REF01 - Qualifier
      • REF02 - Mammography Certification Number
    • REF*F5 - MANDATORY MEDICARE (SECTION 4081) CROSSOVER INDICATOR
    • Expand
      REF*EA - MEDICAL RECORD NUMBER
      • REF01 - Qualifier
      • REF02 - Medical Record Number
    • Expand
      REF*F8 - PAYER CLAIM CONTROL NUMBER
      • REF02 - Original Reference Number
    • Expand
      REF*G1 - PRIOR AUTHORIZATION
      • REF01 - Qualifier
      • REF02 - Prior Authorization or Referral Number
    • REF*9F - REFERRAL NUMBER
    • REF*9A - REPRICED CLAIM NUMBER
    • REF*4N - SERVICE AUTHORIZATION EXCEPTION CODE
  • Expand
    Loop 2310A - REFERRING PROVIDER NAME
    • Expand
      NM1 - REFERRING PROVIDER NAME
      • NM101 - Entity Identifier Code
      • NM102 - Entity Type
      • NM103 - Referring Provider Last Name
      • NM104 - Referring Provider First Name
      • NM105 - Referring Provider Middle Name
      • NM108 - Identification Code Qualifier
      • NM109 - Referring Provider Identifier
    • Expand
      REF - REFERRING PROVIDER SECONDARY IDENTIFICATION
      • REF01 - Qualifier
      • REF02 - Referring Provider Secondary Identifier
  • Expand
    Loop 2310B - RENDERING PROVIDER NAME
    • Expand
      NM1*82 - RENDERING PROVIDER NAME
      • NM101 - Entity Identifier Code
      • NM102 - Entity Type
      • NM103 - Rendering Provider Last or Organization Name
      • NM104 - Rendering Provider First Name
      • NM105 - Rendering Provider Middle Name
      • NM108 - Identification Code Qualifier
      • NM109 - Rendering Provider Identifier
    • Expand
      PRV - RENDERING PROVIDER SPECIALTY INFORMATION
      • PRV01 - Provider Code
      • PRV02 - Reference Identification Qualifier
      • PRV03 - Provider Taxonomy Code
    • Expand
      REF - RENDERING PROVIDER SECONDARY IDENTIFICATION
      • REF01 - Qualifier
      • REF02 - Rendering Provider Secondary Identifier
  • Expand
    Loop 2310C - SERVICE FACILITY LOCATION
    • Expand
      N3 - SERVICE FACILITY LOCATION ADDRESS
      • N301 - Laboratory or Facility Address Line
      • N302 - Laboratory or Facility Address Line
    • Expand
      N4 - SERVICE FACILITY LOCATION CITY/STATE/ZIP
      • N401 - Laboratory or Facility City Name
      • N402 - Laboratory or Facility State or Province Code
      • N403 - Laboratory or Facility                                                              Postal Zone ZIP Code
    • Expand
      NM1*77 - SERVICE FACILITY LOCATION
      • NM101 - Entity Identifier Code
      • NM102 - Entity Type
      • NM103 - Laboratory or Facility Name
      • NM108 - Identification Code Qualifier
      • NM109 - Laboratory or Facility Primary Identifier
    • PER - SERVICE FACILITY CONTACT INFORMATION
    • Expand
      REF - SERVICE FACILITY LOCATION SECONDARY IDENTIFICATION
      • REF01 - Qualifier
      • REF02 - Laboratory or Facility Secondary Identifier
  • Expand
    Loop 2310D - SUPERVISING PROVIDER NAME
    • Expand
      NM1*DQ - SUPERVISING PROVIDER NAME
      • NM101 - Entity Identifier Code
      • NM102 - Entity Type
      • NM103 - Supervising Provider Last Name
      • NM104 - Supervising Provider First Name
      • NM105 - Supervising Provider Middle Name
      • NM108 - Identification Code Qualifier
      • NM109 - Supervising Provider Identifier
    • Expand
      REF - SUPERVISING PROVIDER SECONDARY IDENTIFIER
      • REF01 - Qualifier
      • REF02 - Supervising Provider Secondary Identifier
  • Expand
    Loop 2310E - AMBULANCE PICK UP LOCATION
    • Expand
      N3 - AMBULANCE PICK UP LOCATION ADDRESS
      • N301 - Ambulance Pick Up Address Line
    • Expand
      N4 - AMBULANCE PICK UP LOCATION CITY/STATE/ZIP
      • N401 - Ambulance Pick Up City Name
      • N402 - Ambulance Pick Up State or Province Code
      • N403 - Ambulance Pick Up Postal Zone ZIP Code
    • Expand
      NM1*PW - AMBULANCE PICK UP LOCATION
      • NM101 - Entity Identifier Code
      • NM102 - Entity Type
  • Expand
    Loop 2310F - AMBULANCE DROP OFF LOCATION
    • Expand
      N3 - AMBULANCE DROP OFF LOCATION ADDRESS
      • N301 - Ambulance Drop Off Address Line
    • Expand
      N4 - AMBULANCE DROP OFF LOCATION CITY/STATE/ZIP
      • N401 - Ambulance Drop Off City Name
      • N402 - Ambulance Drop Off State or Province Code
      • N403 - Ambulance Drop Off Postal Zone ZIP Code
    • Expand
      NM1*45 - AMBULANCE DROP OFF LOCATION
      • NM101 - Entity Identifier Code
      • NM102 - Entity Type
      • NM103 - Ambulance Drop Off Location
  • Expand
    Loop 2320 - OTHER SUBSCRIBER INFORMATION
    • Expand
      AMT*D - COB PAYER PAID AMOUNT
      • AMT01 - Qualifier
      • AMT02 - Payer Paid Amount S9(7)V99
    • AMT - COB TOTAL NON-COVERED AMOUNT
    • AMT - REMAINING PATIENT LIABILITY
    • CAS - CLAIM LEVEL ADJUSTMENTS
    • Expand
      MOA - MEDICARE OUTPATIENT ADJUDICATION INFORMATION
      • MOA03 - Remark Code
    • Expand
      OI - OTHER INSURANCE COVERAGE INFORMATION
      • OI03 - Benefits Assignment Certification Indicator
      • OI04 - Patient Signature Source Code
      • OI06 - Release of Information Code
    • Expand
      SBR - OTHER SUBSCRIBER INFORMATION
      • SBR01 - Payer Responsibility Sequence Number Code
      • SBR02 - Individual Relationship Code
      • SBR03 - Insured Group or Policy Number
      • SBR04 - Other Insured Group Name 
      • SBR05 - Insurance Type Code
      • SBR09 - Claim Filing Indicator Code
  • Expand
    Loop 2330A - OTHER SUBSCRIBER NAME
    • Expand
      N3 - OTHER SUBSCRIBER ADDRESS
      • N301 - Other Insured Address Line
    • Expand
      N4 - OTHER SUBSCRIBER CITY/STATE/ZIP CODE
      • N401 - Other Insured City Name
      • N402 - Other Insured State Code
      • N403 - Other Insured Postal Zone or ZIP Code
    • Expand
      NM1*IL - OTHER SUBSCRIBER NAME
      • NM101 - Entity Identifier Code
      • NM102 - Entity Type
      • NM103 - Other Insured Last Name
      • NM104 - Other Insured First Name
      • NM105 - Other Insured Middle Name
      • NM108 - Identification Code Qualifier
      • NM109 - Other Insured Identifier
    • REF - OTHER SUBSCRIBER SECONDARY IDENTIFICATION
  • Expand
    Loop 2330B - OTHER PAYER NAME
    • DTP - DATE - CLAIM CHECK OR REMITTANCE DATE
    • N3 - OTHER PAYER ADDRESS
    • N4 - OTHER PAYER CITY/STATE/ZIP CODE
    • Expand
      NM1*PR - OTHER PAYER NAME
      • NM101 - Entity Identifier Code
      • NM102 - Entity Type
      • NM103 - Other Payer Last or Organization Name
      • NM108 - Identification Code Qualifier
      • NM109 - Other Payer Primary Identifier
    • REF - OTHER PAYER CLAIM ADJUSTMENT INDICATOR
    • Expand
      REF*F8 - OTHER PAYER CLAIM CONTROL NUMBER
      • REF01 - Reference Identification Qualifier
    • REF - OTHER PAYER PRIOR AUTHORIZATION NUMBER
    • REF - OTHER PAYER REFERRAL NUMBER
    • REF - OTHER PAYER SECONDARY IDENTIFICATION
  • Expand
    Loop 2330C - OTHER PAYER REFERRING PROVIDER
    • NM1 - OTHER PAYER REFERRING PROVIDER
    • REF - OTHER PAYER REFERRING PROVIDER SECONDARY IDENTIFICATION
  • Expand
    Loop 2330D - OTHER PAYER RENDERING PROVIDER
    • NM1 - OTHER PAYER RENDERING PROVIDER
    • REF - OTHER PAYER RENDERING PROVIDER SECONDARY IDENTIFICATION
  • Expand
    Loop 2330E - OTHER PAYER SERVICE FACILITY LOCATION
    • NM1 - OTHER PAYER SERVICE FACILITY LOCATION
    • REF - OTHER PAYER SERVICE FACILITY LOCATION SECONDARY IDENTIFICATION
  • Expand
    Loop 2330F - OTHER PAYER SUPERVISING PROVIDER
    • NM1 - OTHER PAYER SUPERVISING PROVIDER
    • REF - OTHER PAYER SUPERVISING PROVIDER SECONDARY IDENTIFICATION
  • Expand
    Loop 2330G - OTHER PAYER BILLING PROVIDER
    • NM1 - OTHER PAYER BILLING PROVIDER
    • REF - OTHER PAYER BILLING PROVIDER SECONDARY IDENTIFICATION
  • Expand
    Loop 2400 - SERVICE LINE
    • AMT - POSTAGE CLAIMED AMOUNT
    • AMT - SALES TAX AMOUNT
    • CN1 - CONTRACT INFORMATION
    • CR1 - AMBULANCE TRANSPORT INFORMATION
    • CR3 - DURABLE MEDICAL EQUIPMENT CERTIFICATION
    • CRC - AMBULANCE CERTIFICATION
    • CRC - CONDITION INDICATOR/DURABLE MEDICAL EQUIPMENT
    • CRC - HOSPICE EMPLOYEE INDICATOR
    • DTP - DATE - BEGIN THERAPY DATE
    • DTP - DATE - CERTIFICATION REVISION/RECERTIFICATION DATE
    • DTP - DATE - DATE LAST SEEN
    • DTP - DATE - INITIAL TREATMENT
    • DTP - DATE - LAST CERTIFICATION DATE
    • DTP - DATE - LAST X-RAY
    • DTP - DATE - PRESCRIPTION DATE
    • Expand
      DTP*472 - DATE - SERVICE DATE
      • DTP01 - Qualifier
      • DTP02 - Format
      • DTP03 - Service Date
    • DTP - DATE - SHIPPED DATE
    • DTP - DATE - TEST DATE
    • HCP - LINE PRICING/REPRICING INFORMATION
    • Expand
      K3 - FILE INFORMATION - 2400
      • K301 - Fixed Format Information
    • Expand
      LX - SERVICE LINE NUMBER
      • LX01 - Assigned Number
    • MEA - TEST RESULT
    • Expand
      NTE - LINE NOTE
      • NTE01 - Note Reference Code
      • NTE02 - Line Note Text
    • NTE - THIRD PARTY ORGANIZATION NOTES
    • PS1 - PURCHASED SERVICE INFORMATION
    • PWK - DURABLE MEDICAL EQUIPMENT CERTIFICATE OF MEDICAL NECESSITY INDICATOR
    • PWK - LINE SUPPLEMENTAL INFORMATION
    • QTY - AMBULANCE PATIENT COUNT
    • QTY - OBSTETRIC ANESTHESIA ADDITIONAL UNITS
    • REF - ADJUSTED REPRICED LINE ITEM REFERENCE NUMBER
    • REF - CLINICAL LABORATORY IMPROVEMENT AMENDMENT (CLIA) NUMBER
    • REF - IMMUNIZATION BATCH NUMBER
    • Expand
      REF*6R - LINE ITEM CONTROL NUMBER
      • REF01 - Qualifier
      • REF02 - Line Item Control Number
    • REF - MAMMOGRAPHY CERTIFICATION NUMBER
    • REF - PRIOR AUTHORIZATION
    • REF - REFERRAL NUMBER
    • REF - REFERRING CLINICAL LABORATORY IMPROVEMENT AMENDMENT (CLIA) FACILITY IDENTIFICATION
    • REF - REPRICED LINE ITEM REFERENCE NUMBER
    • Expand
      SV1 - PROFESSIONAL SERVICE
      • SV101 - COMPOSITE MEDICAL PROCEDURE IDENTIFIER
      • SV101-1 - Product or Service ID Qualifier
      • SV101-2 - Procedure Code
      • SV101-3 - Procedure Modifier 
      • SV101-4 - Procedure Modifier 
      • SV101-5 - Procedure Modifier 
      • SV101-6 - Procedure Modifier 
      • SV101-7 - Description
      • SV102 - Line Item Charge Amount S9(7)V99
      • SV103 - Unit or Basis for Measurement Code
      • SV104 - Service Unit Count "MJ" = 9(4) "UN" = 9(3)V9
      • SV105 - Place of Service Code
      • SV107 - COMPOSITE DIAGNOSIS CODE POINTER
      • SV107-1 - Diagnosis Code Pointer
      • SV107-2 - Diagnosis Code Pointer
      • SV107-3 - Diagnosis Code Pointer
      • SV107-4 - Diagnosis Code Pointer
      • SV109 - Emergency Indicator
      • SV111 - EPSDT Indicator
      • SV112 - Family Planning Indicator
    • SV5 - DURABLE MEDICAL EQUIPMENT SERVICE
  • Expand
    Loop 2410 - DRUG IDENTIFICATION
    • Expand
      CTP - DRUG QUANTITY
      • CTP04 - National Drug Unit Count
      • CTP05 - COMPOSITE UNIT OF MEASURE
      • CTP05-1 - Unit or Basis For Measurement Code
    • Expand
      LIN - DRUG IDENTIFICATION
      • LIN02 - Product or Service ID Qualifier
      • LIN03 - National Drug Code
    • Expand
      REF - PRESCRIPTION OR COMPOUND DRUG ASSOCIATION NUMBER
      • REF01 - Qualifier
      • REF02 - Prescription Number
  • Expand
    Loop 2420A - RENDERING PROVIDER NAME
    • NM1 - RENDERING PROVIDER NAME
    • PRV - RENDERING PROVIDER SPECIALTY INFORMATION
    • REF - RENDERING PROVIDER SECONDARY IDENTIFICATION
  • Expand
    Loop 2420B - PURCHASED SERVICE PROVIDER NAME
    • NM1 - PURCHASED SERVICE PROVIDER NAME
    • REF - PURCHASED SERVICE PROVIDER SECONDARY INDENTIFICATION
  • Expand
    Loop 2420C - SERVICE FACILITY LOCATION NAME
    • N3 - SERVICE FACILITY LOCATION ADDRESS
    • N4 - SERVICE FACILITY LOCATION CITY/STATE/ZIP
    • NM1 - SERVICE FACILITY LOCATION
    • REF - SERVICE FACILITY LOCATION SECONDARY IDENTIFICATION
  • Expand
    Loop 2420D - SUPERVISING PROVIDER NAME
    • NM1 - SUPERVISING PROVIDER NAME
    • REF - SUPERVISING PROVIDER SECONDARY IDENTIFIER
  • Expand
    Loop 2420E - ORDERING PROVIDER NAME
    • Expand
      N3 - ORDERING PROVIDER ADDRESS
      • N301 - Ordering Provider Address Line
      • N302 - Ordering Provider Address Line
    • Expand
      N4 - ORDERING PROVIDER CITY/STATE/ZIP CODE
      • N401 - Ordering Provider City Name
      • N402 - Ordering Provider State or Province Code
      • N403 - Ordering Provider Postal Zone ZIP Code
    • Expand
      NM1*DK - ORDERING PROVIDER NAME
      • NM101 - Entity Identifier Code
      • NM102 - Entity Type
      • NM103 - Ordering Provider Last Name
      • NM104 - Ordering Provider First Name
      • NM105 - Ordering Provider Middle Name or Initial
      • NM108 - Identification Code Qualifier
      • NM109 - Other Payer Primary Identifier
    • Expand
      PER - ORDERING PROVIDER CONTACT INFORMATION
      • PER01 - Contact Function Code
      • PER02 - Ordering Provider Contact Name
      • PER03 - Communication Number Qualifier
      • PER04 - Communication Number   
    • Expand
      REF - ORDERING PROVIDER SECONDARY IDENTIFICATION
      • REF01 - Qualifier
      • REF02 - Ordering Provider Secondary Identifier
  • Expand
    Loop 2420F - REFERRING PROVIDER NAME
    • NM1 - REFERRING PROVIDER NAME
    • REF - REFERRING PROVIDER SECONDARY IDENTIFICATION
  • Expand
    Loop 2420G - AMBULANCE PICK UP LOCATION
    • N3 - AMBULANCE PICK UP LOCATION ADDRESS
    • N4 - AMBULANCE PICK UP LOCATION CITY/STATE/ZIP
    • NM1 - AMBULANCE PICK UP LOCATION
  • Expand
    Loop 2420H - AMBULANCE DROP OFF LOCATION
    • N3 - AMBULANCE DROP OFF LOCATION ADDRESS
    • N4 - AMBULANCE DROP OFF LOCATION CITY/STATE/ZIP
    • NM1 - AMBULANCE DROP OFF LOCATION
  • Expand
    Loop 2430 - LINE ADJUDICATION INFORMATION
    • AMT - REMAINING PATIENT LIABILITY
    • Expand
      CAS - LINE ADJUSTMENT
      • CAS01 - Claim Adjustment Group Code
      • CAS02 - Adjustment Reason Code
      • CAS03 - Adjustment Amount S9(7)V99
      • CAS04 - Adjustment Quantity 9(7)
    • Expand
      DTP*573 - LINE CHECK OR REMITTANCE DATE
      • DTP01 - Qualifier
      • DTP02 - Format
      • DTP03 - Adjudication or Payment Date
    • Expand
      SVD - LINE ADJUDICATION INFORMATION
      • SVD01 - Other Payer Primary Identifier
      • SVD02 - Service Line Paid Amount S9(7)V99
      • SVD03 - COMPOSITE MEDICAL PROCEDURE IDENTIFIER
      • SVD03-1 - Product or Service ID Qualifier
      • SVD03-2 - Procedure Code
      • SVD03-3 - Procedure Modifier
      • SVD03-4 - Procedure Modifier
      • SVD03-5 - Procedure Modifier
      • SVD03-6 - Procedure Modifier
      • SVD05 - Paid Service Unit Count 9(7)V999                                                                                                               
  • Expand
    Loop 2440 - FORM IDENTIFICATION CODE
    • Expand
      FRM - SUPPORTING DOCUMENTATION
      • FRM01 - Question Number/Letter
      • FRM02 - Question Response
      • FRM03 - Question Response
      • FRM04 - Question Response
      • FRM05 - Question Response 9(3)V9
    • Expand
      LQ - FORM IDENTIFICATION CODE
      • LQ01 - Code List Qualifier Code
      • LQ02 - Form Identifier