
AMT*F5 - PATIENT AMOUNT PAID

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

CN1 - CONTRACT INFORMATION
CN101 - Contract Type Code
CN102 - Contract Amount
CN103 - Contract Percentage
CN104 - Contract Code
CN105 - Terms Discount Percent 9(2)V99
CN106 - Contract Version Identifier

CR1 - AMBULANCE TRANSPORT INFORMATION
CR101 - Unit or Basis for Measurement Code
CR102 - Patient Weight
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

CR2 - SPINAL MANIPULATION SERVICE INFORMATION
CR208 - Patient Condition Code
CR210 - Patient Condition Description
CR211 - Patient Condition Description

CRC*07 - AMBULANCE CERTIFICATION

CRC*ZZ - EPSDT REFERRAL

CRC*75 - HOMEBOUND INDICATOR
CRC*E1 - PATIENT CONDITION INFORMATION: VISION

DTP*439 - DATE - ACCIDENT
DTP01 - Qualifier
DTP02 - Format
DTP03 - Accident Date

DTP*453 - DATE - ACUTE MANIFESTATION

DTP*435 - DATE - ADMISSION

DTP*090 - DATE - ASSUMED CARE DATES

DTP*296 - DATE - AUTHORIZED RETURN TO WORK
DTP01 - Qualifier
DTP02 - Format
DTP03 - Work Return Date

DTP*304 - DATE - DATE LAST SEEN
DTP01 - Qualifier
DTP02 - Format
DTP03 - Last Seen Date

DTP*360 - DATE - DISABILITY DATES

DTP*361 - DATE - DISABILITY DATES

DTP*314 - DATE - DISABILITY DATES

DTP*096 - DATE - DISCHARGE

DTP*471 - DATE - HEARING AND VISION PRESCRIPTION DATE

DTP*454 - DATE - INITIAL TREATMENT

DTP*484 - DATE - LAST MENSTRUAL PERIOD

DTP*297 - DATE - LAST WORKED
DTP01 - Qualifier
DTP02 - Format
DTP03 - Last Worked

DTP*455 - DATE - LAST X-RAY
DTP01 - Qualifier
DTP02 - Format
DTP03 - Last X-Ray Date

DTP*431 - DATE - ONSET OF CURRENT ILLNESS/SYMPTOM
DTP - DATE - PROPERTY AND CASUALTY DATE OF FIRST CONTACT

DTP*091 - DATE - RELINQUISHED CARE DATES
DTP - DATE - REPRICER RECEIVED DATE

HCP - CLAIM PRICING/REPRICING INFORMATION

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

HI - CONDITION INFORMATION

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
HI09-1 - Diagnosis Type Code
HI09-2 - Diagnosis Code
HI10 - HEALTH CARE CODE INFORMATION
HI10-1 - Diagnosis Type Code
HI10-2 - Diagnosis Code
HI11 - HEALTH CARE CODE INFORMATION
HI11-1 - Diagnosis Type Code
HI11-2 - Diagnosis Code
HI12 - HEALTH CARE CODE INFORMATION
HI12-1 - Diagnosis Type Code
HI12-2 - Diagnosis Code

K3 - FILE INFORMATION - 2300

NTE - CLAIM NOTE

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

REF*D9 - CLAIM IDENTIFIER FOR TRANSMISSION INTERMEDIARIES

REF*X4 - CLINICAL LABORATORY IMPROVEMENT AMENDMENT (CLIA) NUMBER
REF*P4 - DEMONSTRATION PROJECT IDENTIFIER

REF*LX - INVESTIGATIONAL DEVICE EXEMPTION NUMBER

REF*EW - MAMMOGRAPHY CERTIFICATION NUMBER
REF*F5 - MANDATORY MEDICARE (SECTION 4081) CROSSOVER INDICATOR

REF*EA - MEDICAL RECORD NUMBER

REF*F8 - PAYER CLAIM CONTROL NUMBER

REF*G1 - PRIOR AUTHORIZATION

REF*9F - REFERRAL NUMBER
REF01 - Qualifier
REF02 - Referral Number
REF*9A - REPRICED CLAIM NUMBER
REF*4N - SERVICE AUTHORIZATION EXCEPTION CODE