ANSI 837 Reference

Premier Professional
Premier Institutional
Advanced Professional

Default View

Segment Index

Loop 0000A - INTERCHANGE CONTROL HEADER
- 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
Loop 0000B - FUNCTIONAL GROUP HEADER
- 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
Loop 0000C - TRANSACTION SET HEADER
- ST - TRANSACTION SET HEADER
  - ST01 - Transaction Set Identifier Code
  - ST02 - Transaction Set Control Number
  - ST03 - Implementation Convention Reference
Loop 0000D - BEGINNING OF HIERARCHICAL TRANSACTION
- 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
Loop 1000A - SUBMITTER NAME
- 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
- PER - SUBMITTER EDI CONTACT INFORMATION
  - PER01 - Contact Function Code
  - PER02 - Submitter Contact Name
  - PER03 - Communication Number Qualifier
  - PER04 - Communication Number
Loop 1000B - RECEIVER NAME
- NM1*40 - RECEIVER NAME
  - NM101 - Entity Identifier Code
  - NM102 - Entity Type
  - NM108 - Identification Code Qualifier
  - NM109 - Receiver Primary Identifier
Loop 2000A - BILLING PROVIDER HIERARCHICAL LEVEL
- CUR - FOREIGN CURRENCY INFORMATION
- HL - BILLING PROVIDER HIERARCHICAL LEVEL
  - HL01 - Hierarchical ID Number
  - HL03 - Hierarchical Level Code
  - HL04 - Hierarchical Child Code
- PRV - BILLING PROVIDER SPECIALTY INFORMATION
  - PRV01 - Provider Code
  - PRV02 - Reference Identification Qualifier
  - PRV03 - Provider Taxonomy Code
Loop 2000B - SUBSCRIBER HIERARCHICAL LEVEL
- HL - SUBSCRIBER HIERARCHICAL LEVEL
  - HL01 - Hierarchical ID Number
  - HL02 - Hierarchical Parent ID Number
  - HL03 - Hierarchical Level Code
  - HL04 - Hierarchical Child Code
- PAT - PATIENT INFORMATION
  - PAT07 - Unit or Basis for Measurement Code
  - PAT08 - Patient Weight
- 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
Loop 2000C - PATIENT HIERARCHICAL LEVEL
- HL - PATIENT HIERARCHICAL LEVEL
  - HL01 - Hierarchical ID Number
  - HL02 - Hierarchical Parent ID Number
  - HL03 - Hierarchical Level Code
  - HL04 - Hierarchical Child Code
- PAT - PATIENT INFORMATION
  - PAT01 - Individual Relationship Code
Loop 2010AA - BILLING PROVIDER NAME
- N3 - BILLING PROVIDER ADDRESS
  - N301 - Billing Provider Address Line
  - N302 - Billing Provider Address Line
- 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
- 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
- PER - BILLING PROVIDER CONTACT INFORMATION
  - PER01 - Contact Function Code
  - PER02 - Billing Provider Contact Name
  - PER03 - Communication Number Qualifier
  - PER04 - Communication Number
- REF - BILLING PROVIDER TAX IDENTIFICATION
  - REF01 - Qualifier
  - REF02 - Billing Provider Additional Identifier
- REF - BILLING PROVIDER UPIN/LICENSE INFORMATION
  - REF01 - Qualifier
  - REF02 - Billing Provider Additional Identifier
Loop 2010AB - PAY-TO ADDRESS NAME
- N3 - PAY-TO PROVIDER ADDRESS
  - N301 - Pay-to Provider Address Line
  - N302 - Pay-to Provider Address Line
- 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
- NM1*87 - PAY-TO ADDRESS NAME
  - NM101 - Entity Identifier Code
  - NM102 - Entity Type
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
Loop 2010BA - SUBSCRIBER NAME
- DMG - SUBSCRIBER DEMOGRAPHIC INFORMATION
  - DMG01 - Format
  - DMG02 - Subscriber Birth Date
  - DMG03 - Subscriber Gender Code
- N3 - SUBSCRIBER ADDRESS
  - N301 - Subscriber Address Line
- N4 - SUBSCRIBER CITY/STATE/ZIP CODE
  - N401 - Subscriber City Name
  - N402 - Subscriber State Code
  - N403 - Subscriber Postal Zone or ZIP Code
- 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
- REF*Y4 - PROPERTY AND CASUALTY CLAIM NUMBER
  - REF01 - Qualifier
- REF*SY - SUBSCRIBER SECONDARY IDENTIFICATION
  - REF01 - Qualifier
  - REF02 - Subscriber Supplemental Identifier
Loop 2010BB - PAYER NAME
- N3 - PAYER ADDRESS
  - N301 - Payer Address Line
  - N302 - Payer Address Line
- N4 - PAYER CITY/STATE/ZIP CODE
  - N401 - Payer City Name
  - N402 - Payer State Code
  - N403 - Payer Postal Zone or ZIP Code
- 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
- REF - PAYER SECONDARY IDENTIFICATION
  - REF01 - Qualifier
  - REF02 - Payer Additional Identifier
Loop 2010CA - PATIENT NAME
- DMG - PATIENT DEMOGRAPHIC INFORMATION
  - DMG01 - Format
  - DMG02 - Patient Birth Date
  - DMG03 - Patient Gender Code
- N3 - PATIENT ADDRESS
  - N301 - Patient Address Line
- N4 - PATIENT CITY/STATE/ZIP CODE
  - N401 - Patient City Name
  - N402 - Patient State Code
  - N403 - Patient Postal Zone or ZIP Code
- 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
- REF*Y4 - PROPERTY AND CASUALTY CLAIM NUMBER
  - REF01 - Qualifier
  - REF02 - Property Casualty Claim Number
- REF*SY - PROPERTY AND CASUALTY PATIENT IDENTIFIER
  - REF02 - Social Security Number
- REF*1W - PROPERTY AND CASUALTY PATIENT IDENTIFIER
  - REF02 - Member ID
Loop 2300 - CLAIM INFORMATION
- AMT*F5 - PATIENT AMOUNT PAID
  - AMT01 - Qualifier
  - AMT02 - 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
  - CRC01 - Code Category
  - CRC02 - Certification Condition Indicator
  - CRC03 - Condition Code
- CRC*ZZ - EPSDT REFERRAL
  - CRC01 - Code Category
  - CRC02 - Certification Condition Indicator
  - CRC03 - Condition Code
- CRC*75 - HOMEBOUND INDICATOR
  - CRC01 - Code Category
  - CRC02 - Certification Condition Indicator
  - CRC03 - Homebound Indicator
- CRC*E1 - PATIENT CONDITION INFORMATION: VISION
- DTP*439 - DATE - ACCIDENT
  - DTP01 - Qualifier
  - DTP02 - Format
  - DTP03 - Accident Date
- DTP*453 - DATE - ACUTE MANIFESTATION
  - DTP01 - Qualifier
  - DTP02 - Format
  - DTP03 - Acute Manifestation Date
- DTP*435 - DATE - ADMISSION
  - DTP01 - Qualifier
  - DTP02 - Format
  - DTP03 - Related Hospitalization Admission Date
- DTP*090 - DATE - ASSUMED CARE DATES
  - DTP01 - Qualifier
  - DTP02 - Format
  - DTP03 - Assumed Care Date
- 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
  - DTP01 - Qualifier
  - DTP02 - Format
  - DTP03 - Disability From Date
- DTP*361 - DATE - DISABILITY DATES
  - DTP01 - Qualifier
  - DTP02 - Format
  - DTP03 - Disability From Date
- DTP*314 - DATE - DISABILITY DATES
  - DTP01 - Qualifier
  - DTP02 - Format
  - DTP03 - Disability From Date
- DTP*096 - DATE - DISCHARGE
  - DTP01 - Qualifier
  - DTP02 - Format
  - DTP03 - Related Hospitalization Discharge Date
- DTP*471 - DATE - HEARING AND VISION PRESCRIPTION DATE
  - DTP01 - Qualifier
  - DTP02 - Format
  - DTP03 - Prescription Date
- DTP*454 - DATE - INITIAL TREATMENT
  - DTP01 - Qualifier
  - DTP02 - Format
  - DTP03 - Initial Treatment Date
- DTP*484 - DATE - LAST MENSTRUAL PERIOD
  - DTP01 - Qualifier
  - DTP02 - Format
  - DTP03 - Last Menstrual Period Date
- 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
  - DTP01 - Qualifier
  - DTP02 - Format
  - DTP03 - Onset of Current Illness or Injury Date
- DTP - DATE - PROPERTY AND CASUALTY DATE OF FIRST CONTACT
- DTP*091 - DATE - RELINQUISHED CARE DATES
  - DTP01 - Qualifier
  - DTP02 - Format
  - DTP03 - Relinquished Care Date
- DTP - DATE - REPRICER RECEIVED DATE
- HCP - CLAIM PRICING/REPRICING INFORMATION
  - HCP01 - Pricing Methodology
  - HCP02 - Allowed Amount
  - HCP15 - Exception Code
- 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
  - HI01 - HEALTH CARE CODE 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
  - K301 - Fixed format information
- NTE - CLAIM NOTE
  - NTE01 - Note Reference Code
  - NTE02 - Claim Note Text
- 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
  - REF01 - Qualifier
  - REF02 - Value Added Network Trace Number
- REF*X4 - CLINICAL LABORATORY IMPROVEMENT AMENDMENT (CLIA) NUMBER
  - REF01 - Qualifier
  - REF02 - Clinical Laboratory Improvement Amendment Number
- REF*P4 - DEMONSTRATION PROJECT IDENTIFIER
- REF*LX - INVESTIGATIONAL DEVICE EXEMPTION NUMBER
  - REF01 - Qualifier
  - REF02 - Investigational Device Exemption Number
- REF*EW - MAMMOGRAPHY CERTIFICATION NUMBER
  - REF01 - Qualifier
  - REF02 - Mammography Certification Number
- REF*F5 - MANDATORY MEDICARE (SECTION 4081) CROSSOVER INDICATOR
- REF*EA - MEDICAL RECORD NUMBER
  - REF01 - Qualifier
  - REF02 - Medical Record Number
- REF*F8 - PAYER CLAIM CONTROL NUMBER
  - REF02 - Original Reference Number
- REF*G1 - PRIOR AUTHORIZATION
  - REF01 - Qualifier
  - REF02 - Prior Authorization
- REF*9F - REFERRAL NUMBER
  - REF01 - Qualifier
  - REF02 - Referral Number
- REF*9A - REPRICED CLAIM NUMBER
- REF*4N - SERVICE AUTHORIZATION EXCEPTION CODE
Loop 2310A - REFERRING PROVIDER NAME
- NM1*DN - REFERRING PROVIDER NAME
  - NM101 - Entity Identifier Code
  - NM102 - Referring Provider 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
- REF - REFERRING PROVIDER SECONDARY IDENTIFICATION
  - REF01 - Qualifier
  - REF02 - Referring Provider Secondary Identifier
Loop 2310B - RENDERING PROVIDER NAME
- NM1*82 - RENDERING PROVIDER NAME
  - NM101 - Entity Identifier Code
  - NM102 - Entity Type
  - NM103 - Rendering Provider Last or Organization Name
  - NM103 - Receiver Name
  - NM104 - Rendering Provider First Name
  - NM105 - Rendering Provider Middle Name
  - NM108 - Identification Code Qualifier
  - NM109 - Rendering Provider Identifier
- PRV - RENDERING PROVIDER SPECIALTY INFORMATION
  - PRV01 - Provider Code
  - PRV02 - Reference Identification Qualifier
  - PRV03 - Provider Taxonomy Code
- REF - RENDERING PROVIDER SECONDARY IDENTIFICATION
  - REF01 - Qualifier
  - REF02 - Rendering Provider Secondary Identifier
Loop 2310C - SERVICE FACILITY LOCATION
- N3 - SERVICE FACILITY LOCATION ADDRESS
  - N301 - Laboratory or Facility Address Line
  - N302 - Laboratory or Facility Address Line
- 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
- 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
- REF - SERVICE FACILITY LOCATION SECONDARY IDENTIFICATION
  - REF01 - Qualifier
  - REF02 - Laboratory or Facility Secondary Identifier
Loop 2310D - SUPERVISING PROVIDER NAME
- NM1*DQ - SUPERVISING PROVIDER NAME
  - NM101 - Entity Identifier Code
  - NM102 - Supervising Provider 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
- REF - SUPERVISING PROVIDER SECONDARY IDENTIFIER
  - REF01 - Qualifier
  - REF02 - Supervising Provider Secondary Identifier
Loop 2310E - AMBULANCE PICK UP LOCATION
- N3 - AMBULANCE PICK UP LOCATION ADDRESS
  - N301 - Ambulance Pick Up Address Line
- 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
- NM1*PW - AMBULANCE PICK UP LOCATION
  - NM101 - Entity Identifier Code
  - NM102 - Entity Type
Loop 2310F - AMBULANCE DROP OFF LOCATION
- N3 - AMBULANCE DROP OFF LOCATION ADDRESS
  - N301 - Ambulance Drop Off Address Line
- 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
- NM1*45 - AMBULANCE DROP OFF LOCATION
  - NM101 - Entity Identifier Code
  - NM102 - Entity Type
  - NM103 - Ambulance Drop Off Location
Loop 2320 - OTHER SUBSCRIBER INFORMATION
- AMT*D - COB PAYER PAID AMOUNT
  - AMT01 - Qualifier
  - AMT02 - Payer Paid Amount
- AMT - COB TOTAL NON-COVERED AMOUNT
- AMT*EAF - REMAINING PATIENT LIABILITY
- CAS - CLAIM LEVEL ADJUSTMENTS
- MOA - MEDICARE OUTPATIENT ADJUDICATION INFORMATION
  - MOA03 - Remark Code
- OI - OTHER INSURANCE COVERAGE INFORMATION
  - OI03 - Benefits Assignment Certification Indicator
  - OI04 - Patient Signature Source Code
  - OI06 - Release of Information Code
- 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
Loop 2330A - OTHER SUBSCRIBER NAME
- N3 - OTHER SUBSCRIBER ADDRESS
  - N301 - Other Insured Address Line
- 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
- 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
Loop 2330B - OTHER PAYER NAME
- DTP - DATE - CLAIM CHECK OR REMITTANCE DATE
- N3 - OTHER PAYER ADDRESS
- N4 - OTHER PAYER CITY/STATE/ZIP CODE
- 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
- 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
Loop 2330C - OTHER PAYER REFERRING PROVIDER
- NM1 - OTHER PAYER REFERRING PROVIDER
- REF - OTHER PAYER REFERRING PROVIDER SECONDARY IDENTIFICATION
Loop 2330D - OTHER PAYER RENDERING PROVIDER
- NM1 - OTHER PAYER RENDERING PROVIDER
- REF - OTHER PAYER RENDERING PROVIDER SECONDARY IDENTIFICATION
Loop 2330E - OTHER PAYER SERVICE FACILITY LOCATION
- NM1 - OTHER PAYER SERVICE FACILITY LOCATION
- REF - OTHER PAYER SERVICE FACILITY LOCATION SECONDARY IDENTIFICATION
Loop 2330F - OTHER PAYER SUPERVISING PROVIDER
- NM1 - OTHER PAYER SUPERVISING PROVIDER
- REF - OTHER PAYER SUPERVISING PROVIDER SECONDARY IDENTIFICATION
Loop 2330G - OTHER PAYER BILLING PROVIDER
- NM1 - OTHER PAYER BILLING PROVIDER
- REF - OTHER PAYER BILLING PROVIDER SECONDARY IDENTIFICATION
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
- 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
  - HCP01 - Pricing Methodology
  - HCP02 - Allowed Amount
- K3 - FILE INFORMATION - 2400
  - K301 - Fixed Format Information
- LX - SERVICE LINE NUMBER
  - LX01 - Assigned Number
- MEA - TEST RESULT
  - MEA - Test Results
- 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
- 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
- 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
  - SV103 - Unit or Basis for Measurement Code
  - SV104 - Service Unit Count
  - 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
Loop 2410 - DRUG IDENTIFICATION
- CTP - DRUG QUANTITY
  - CTP04 - National Drug Unit Count
  - CTP05 - COMPOSITE UNIT OF MEASURE
  - CTP05-1 - Unit or Basis For Measurement Code
- LIN - DRUG IDENTIFICATION
  - LIN02 - Product or Service ID Qualifier
  - LIN03 - National Drug Code
- REF - PRESCRIPTION OR COMPOUND DRUG ASSOCIATION NUMBER
  - REF01 - Qualifier
  - REF02 - Prescription Number
Loop 2420A - RENDERING PROVIDER NAME
- NM1 - RENDERING PROVIDER NAME
- PRV - RENDERING PROVIDER SPECIALTY INFORMATION
- REF - RENDERING PROVIDER SECONDARY IDENTIFICATION
Loop 2420B - PURCHASED SERVICE PROVIDER NAME
- NM1 - PURCHASED SERVICE PROVIDER NAME
- REF - PURCHASED SERVICE PROVIDER SECONDARY INDENTIFICATION
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
Loop 2420D - SUPERVISING PROVIDER NAME
- NM1 - SUPERVISING PROVIDER NAME
- REF - SUPERVISING PROVIDER SECONDARY IDENTIFIER
Loop 2420E - ORDERING PROVIDER NAME
- N3 - ORDERING PROVIDER ADDRESS
  - N301 - Ordering Provider Address Line
  - N302 - Ordering Provider Address Line
- 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
- 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
- PER - ORDERING PROVIDER CONTACT INFORMATION
  - PER01 - Contact Function Code
  - PER02 - Ordering Provider Contact Name
  - PER03 - Communication Number Qualifier
  - PER04 - Communication Number
- REF - ORDERING PROVIDER SECONDARY IDENTIFICATION
  - REF01 - Qualifier
  - REF02 - Ordering Provider Secondary Identifier
Loop 2420F - REFERRING PROVIDER NAME
- NM1 - REFERRING PROVIDER NAME
- REF - REFERRING PROVIDER SECONDARY IDENTIFICATION
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
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
Loop 2430 - LINE ADJUDICATION INFORMATION
- AMT*EAF - REMAINING PATIENT LIABILITY
  - AMT02 - Remaining Patient Liability
- CAS - LINE ADJUSTMENT
  - CAS01 - Claim Adjustment Group Code
  - CAS02 - Adjustment Reason Code
  - CAS03 - Adjustment Amount
  - CAS04 - Adjustment Quantity
- DTP*573 - LINE CHECK OR REMITTANCE DATE
  - DTP01 - Qualifier
  - DTP02 - Format
  - DTP03 - Adjudication or Payment Date
- SVD - LINE ADJUDICATION INFORMATION
  - SVD01 - Other Payer Primary Identifier
  - SVD02 - Service Line Paid Amount
  - 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
Loop 2440 - FORM IDENTIFICATION CODE
- FRM - SUPPORTING DOCUMENTATION
  - FRM01 - Question Number/Letter
  - FRM02 - Question Response
  - FRM03 - Question Response
  - FRM04 - Question Response
  - FRM05 - Question Response
- LQ - FORM IDENTIFICATION CODE
  - LQ01 - Code List Qualifier Code
  - LQ02 - Form Identifier