Loop 0000A - INTERCHANGE CONTROL HEADER
Loop 0000B - FUNCTIONAL GROUP HEADER
Loop 0000D - TRANSACTION HEADER
Loop 0000E - TRANSACTION HEADER
Loop 1000A - SUBMITTER NAME
Loop 1000B - RECEIVER NAME
NM1*40 - Receiver Name
NM103 - Receiver Name
NM109 - Receiver ID #
Loop 2000A - BILLING/PAY-TO PROVIDER
Loop 2000B - SUBSCRIBER HIERARCHICAL LEVEL
HL - Subscriber Hierarchical Level
PAT - Patient Information
SBR - Subscriber Information
SBR01 - Destination Payer Responsibility Sequence #
SBR02 - Patient Relationship to Insured
SBR03 - Insured Group or Policy Number
SBR04 - Group Name
SBR05 - Insurance Type Code
SBR09 - Claim Filing Indicator
Loop 2000C - PATIENT HIERARCHICAL LEVEL
Loop 2010AA - BILLING PROVIDER NAME
N3 - Billing Provider Address
N4 - Billing Provider City, State, ZIP Code
N401 - Billing Provider City
N402 - Billing Provider State
N403 - Billing Provider Zip
NM1*85 - Billing Provider Name
NM102 - Entity Type Qualifier
NM103 - Billing Provider Last Name or Organizational Name*
NM104 - Billing Provider First Name*
NM105 - Billing Provider Middle Init*
NM108 - Provider Primary Type
NM109 - Provider Primary #
REF - Billing Provider Secondary Identification
Loop 2010AB - PAY-TO PROVIDER NAME
N3 - Pay-To Provider Address
N4 - Pay-To Provider Address City, State, ZIP Code
N401 - Pay To Provider City
N402 - Pay To Provider State
N403 - Pay To Provider Zip
NM1*87 - Pay-To Provider Name
NM102 - Entity Type Qualifier
NM103 - Pay To Provider Last Name or Organizational Name*
NM104 - Pay To Provider First Name*
NM105 - Pay To Provider Middle Init*
NM108 - Pay To Provider ID Type
NM109 - Pay To Provider Tax ID #
Loop 2010BA - SUBSCRIBER NAME
DMG - Subscriber Demographic Information
N3 - Subscriber Address
N4 - Subscriber City, State, ZIP Code
N401 - Subscriber City
N402 - Subscriber State
N403 - Subscriber Zip
NM1*IL - Subscriber Name
NM103 - Subscriber Last Name
NM104 - Subscriber First Name
NM105 - Subscriber Middle Init
NM108 - Identification Code Qualifier
NM109 - Subscriber Insured ID Number
REF*Y4 - Property and Casualty Claim Number
REF*SY - Subsciber SSN
REF*1W - Subscriber Secondary Identification
Loop 2010BB - PAYER NAME
N3 - Payer Address
N301 - Payer Address, Line 1
N302 - Payer Address, Line 2
N4 - Payer City, State, ZIP Code
N401 - Payer City
N402 - Payer State
N403 - Payer Zip Code
NM1*PR - Payer Name
NM103 - Payer Name - Destination
NM108 - Identification Code Qualifier
NM109 - Payer ID - Destination
REF*2U - Payer Secondary Identification
REF*EI - Payer Secondary Identification
REF*FY - Payer Secondary Identification
Loop 2010CA - PATIENT NAME
DMG - Patient Demographic Information
DMG03 - Patient DOB
DMG03 - Patient Gender
N3 - Patient Address
N4 - Patient City, State, ZIP Code
N401 - Patient City
N402 - Patient State
N403 - Patient Zip
NM1*QC - Patient Name
NM103 - Patient Last Name
NM104 - Patient First Name
NM105 - Patient Middle Init
NM108 - Identification Code Qualifier
NM109 - Patient Primary Indentifier
REF*Y4 - Property and Casualty Claim Number
REF*SY - Subsciber SSN
Loop 2300 - CLAIM INFORMATION
AMT*F5 - Patient Amount Paid
CLM - Claim Information
CLM01 - Claim Submitter's Identifier
CLM02 - Total Claim Charges
CLM05 - Resubmission Code - Claim Frequency Type Code
CLM05 - Place of Service (Facility Type Code)
CLM06 - Provider Signature Indicator
CLM07 - Provider Assignment Indicator
CLM08 - Assignment of Benefits
CLM09 - Release of Information Indicator
CLM10 - Patient Signature Source
CLM11 - Accident/Employment/Related Causes
CLM11 - Accident State
CLM12 - Special Program Indicator
CLM16 - Provider Agreement Code
CLM20 - Delay Reason Code
CN1 - Contract Information
CR1 - Ambulance Transport Information
CR102 - Patient Weight
CR103 - Ambulance Transport Code
CR104 - Ambulance Transport Reason Code
CR106 - Transport Distance
CR109 - Round Trip Purpose Description
CR110 - Stretcher Purpose Description
CRC*07 - Ambulance Certification
CRC*ZZ - EPSDT Referral
CRC*75 - Homebound Indicator
DTP*439 - Date - Accident
DTP*453 - Date - Acute Manifestation
DTP*435 - Date - Admission
DTP*090 - Date - Assumed Care
DTP01 - Qualifier
DTP02 - Report Start
DTP*304 - Date - Date Last Seen
DTP*454 - Date - Initial Treatment
DTP*431 - Date - Onset of Current Illness/Symptom
DTP*091 - Relinquished Care Date
DTP01 - Qualifier
DTP02 - Report End
HI - Health Care Diagnosis Code
HI01 - Diagnosis Codes 1
HI02 - Diagnosis Codes 2
HI03 - Diagnosis Codes 3
HI04 - Diagnosis Codes 4
K3 - File Information
NTE*ADD - Claim Note
PWK - Claim Supplemental Information
PWK01 - Attachment Report Type Code
PWK02 - Report Transmission Code
PWK05 - Identification Code Qualifier
PWK06 - Attachment Control Number
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*F8 - Original Reference Number (ICN/DCN)
REF*G1 - Prior Authorization or Referral Number
REF*9F - Prior Authorization or Referral Number
REF*4N - Service Authorization Exception Code
Loop 2310A - REFERRING PROVIDER NAME
Loop 2310B - RENDERING PROVIDER NAME
NM1*82 - Rendering Provider Name
NM1 - Rendering Provider Name, Tax ID and Provider ID#
NM103 - Rendering Provider Last Name
NM108 - Rendering Provider ID Type
NM109 - Rendering Provider ID
PRV*PE - Rendering Provider Specialty Information
REF - Rendering Provider Secondary Identification
Loop 2310C - SERVICE FACILITY LOCATION
N3 - Service Facility Location Address
N4 - Service Facility Location City, State, ZIP Code
N401 - Facility City
N402 - Facility State
N403 - Facility Zip
NM1*77 - Service Facility Location
REF - Service Facility Location Secondary Identification
Loop 2310D - SUPERVISING PROVIDER NAME
Loop 2310E - AMBULANCE PICK-UP LOCATION
Loop 2310F - AMBULANCE DROP-OFF LOCATION
Loop 2320 - OTHER SUBSCRIBER INFORMATION
AMT*B6 - Coordination of Benefits (COB) Allowed Amount
AMT*D - Coordination of Benefits (COB) Payer Paid Amount
CAS - Claim Level Adjustments
DMG - Subscriber Demographic Information
MOA - Medicare Outpatient Adjudication Information
OI - Other Insurance Coverage Information
SBR - Other Subscriber Information
SBR01 - Other Payer Responsibility Sequence #
SBR02 - Patient Relationship to Insured
SBR02 - Individual Relationship Code
SBR03 - Other Insured Group or Policy Number
SBR04 - Other Group Name
SBR04 - Other Insured Group Name
SBR05 - Other Insurance Type Code
SBR09 - Other Claim Filing Indicator
Loop 2330A - OTHER SUBSCRIBER NAME
Loop 2330B - OTHER PAYER NAME
Loop 2330F - OTHER PAYER PURCHASED SERVICE PROVIDER
Loop 2400 - SERVICE LINE
AMT*AAE - Approved Amount
CN1 - Contract Information
CR5 - Home Oxygen Therapy Information
CR501 - Certification Type Code
CR502 - Treatment Period Count
CR510 - Arterial Blood Gas Quantity
CR511 - Oxygen Saturation Quantity
CR512 - Oxygen Test Condition Code
CR513 - Oxygen Test Finding Code
CR514 - Oxygen Test Finding Code
CR515 - Oxygen Test Finding Code
CRC*70 - Hospice Employee Indicator
DTP*463 - Date - Begin Therapy
DTP*607 - Date - Certification Revision
DTP*461 - Date - Last Certification
DTP*480 - Date - Oxygen Arterial Blood Gas Test
DTP*119 - Date - Oxygen Arterial Blood Gas Test
DTP*481 - Date - Oxygen Saturation Blood Gas Test
DTP*472 - Date - Service Date
LX - Service Line
MEA - Test Results
MEA01 - Measurement Reference ID Code
MEA02 - Measurement Qualifier
MEA03 - Measurement Value
NTE - Line Note
QTY - Anesthesia Modifying Units
REF*6R - Line Item Control Number
REF*G1 - Prior Authorization or Referral Number
SV1 - Professional Service
SV101 - Procedure Code
SV101 - Procedure Code Modifiers
SV102 - Line Charges
SV104 - Units of Service
SV105 - Place of Service
SV107 - Diagnosis Code Line Number
SV109 - Emergency Indicator
SV111 - EPSDT Indicator
SV112 - Family Planning Indicator
Loop 2410 - DRUG IDENTIFICATION
Loop 2420E - ORDERING PROVIDER NAME
Loop 2430 - LINE ADJUDICATION INFORMATION
Loop 2440 - FORM IDENTIFICATION CODE