Hipaa 837 Inst

005010X223A2 837
HEALTH CARE CLAIM: INSTITUTIONAL
Health Care Claim

Institutional (837) for
HCSC Shared Claims Processing
(SCP) Partners
Version 16.0
Published: April 2014
April 2014
005010X223A2 837
Health Care Service Corporation (HCSC) Shared Claims Processing

837 Companion Guide
Introduction
Scope of Companion Document
For the health care industry to achieve the potential administrative cost savings with Electronic Data
Interchange (EDI), standards have been developed and need to be implemented consistently by all
organizations. To facilitate a smooth transition into the EDI environment, uniform implementation is
critical. This Companion Guide for Health Care Service Corporation (HCSC) Shared Claims Processing
(SCP) Partners is based on the ASCX12N Implementation Guides adopted under HIPAA will clarify and
specify the data content when exchanging repriced claims electronically with HCSC. Transmissions
based on this companion document, used in tandem with the ANSI X12N Implementation Guides, are
compliant with both the X12 syntax and those guidelines. This Companion Guide is intended to convey
information that is within the framework of the ASC X12N Implementation Guides adopted for use under
HIPAA.
This implementation guide provides a detailed explanation of the transaction set by defining data content,
identifying valid code tables, and specifying values that are applicable for electronic claims payment. This
implementation guide is designed to assist those who send and/or receive Electronic Remittance Advice
(ERA) and/or payments in the 837/835 format.
Exchange of Claim Data
Claims are sent to Shared Claims partners in ANSI 837-5010 and returned in ANSI 835-5010 HIPAA
claims formats. This manual explains the use of business-specific fields for the benefit of payers receiving
electronic claims from our networks. All medical claims will be received by BCBSIL since most providers
will electronically submit their claims directly to BCBSIL. Claims data will be sent to the Fund via the 837
Record. Once the Fund has adjudicated the claims, they will be returned to BCBSIL via the 835 Record.
Version Information
This Companion Guide is based on the October 2003 ASC X12 standards, referred to as Version 5,
Release 1, Sub-release 0 (005010). The unique Version/Release/Industry Identifier Code for transaction
sets that are defined by this implementation guide is 005010X223.
The two-character Functional Identifier Code for the transaction set included in this implementation guide:
HC Health Care Claim (837)
The Version/Release/Industry Identifier Code and the applicable Functional Identifier Code must be
transmitted in the Functional Group Header (GS segment) that begins a functional group of these
transaction sets.
Implementation Purpose and Scope
For the health care industry to achieve the potential administrative cost savings with Electronic Data
Interchange (EDI), standards have been developed and need to be implemented consistently by all
organizations. To facilitate a smooth transition into the EDI environment, uniform implementation is
critical. This is the technical report document for the ANSI ASC X12N 837 Health Care Claims
(837) transaction for institutional claims and/or encounters. This document provides a definitive statement
of what trading partners must be able to support in this version of the 837. This document is intended to
be compliant with the data standards set out by the Health Insurance Portability and Accountability Act of
1996 (HIPAA) and its associated rules.
Implementation Limitations
Receiving trading partners may have system limitations which control the size of the transmission they
can receive. Some submitters may have the capability and the desire to transmit large 837 transactions
with thousands of claims contained in them. The developers of this implementation guide recommend that
trading partners limit the size of the transaction (ST-SE envelope) to a maximum of 5000 CLM segments.
Willing trading partners can agree to higher limits. There is no recommended limit to the number of ST-SE
transactions within a GS-GE or ISA-IEA.
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005010X223A2 837
Business Usage
This transaction set can be used to submit health care claim billing information, encounter information, or
both, from providers of health care services to payers, either directly or via intermediary billing services
and claims clearinghouses. It can also be used to transmit health care claims and billing payment
information between payers with different payment
The transaction defined by this implementation guide is intended to originate with the health care provider
or the health care providers designated agent. In some instances, a health care payer may originate an
837 to report a health care encounter to another payer or sponsoring organization. The 837 Transaction
provides all necessary information to allow the destination payer to at least begin to adjudicate the claim.
April 2014
005010X223A2 837
Revision History
Date
Dec 2011
Version
Version 10.0
April 2012
Version 11.0
October
2012
Version 12.0
December
2012
Version 13.0
October
2013
Version 14.0
Description of Changes
1. Removed Non Covered Charge Amount from
2320*AMT*A8.
2. Included Non-Covered Charge Amount in
2320*CAS*OA*96. CAS02 and CAS03
updated with claim adjustment reason code
as 96 and corresponding descriptions.
3. Documentation change: Line level ETR3 OI
DED AMT and the ETR3 OI COINS AMT
fields removed from CAS02.
4. Corrected the SV202-2 ETR3 field name.
Old Value: ETR3-SVC-PROCEDURE-CD
New Value: ETR3-SVC-HCPCS-CD.
5. Inclusion of Relaxed HIPAA Edits in
Appendix G
Updated Appendix G for Edits
Included Appendix H for 5010 file extensions
Included Appendix I for Default Values
Added Ambulance Mileage 45-50 in PWK06.
Page 304
Updated Appendix B to indicate Claim
Adjustment Reason Code (1) and Claim
Adjustment Reason Code (2) to right
justified. Page 304
Updated Appendix H to include File
Descriptions.
Updated Appendix I with default values for
CL101 and CL102.
ICD10 Changes
SCP Notes for Qualifiers have been removed
for the below fields as the codes are enabled
for ICD9 and ICD10.
o HI Principal Diagnosis - Page 99
o HI Admitting Diagnosis - Page 100
o HI Other Diagnosis Information - Page
116
o HI Principal Procedure Information Page 125
o HI Other Procedure Information - Page
127
Updated Appendix G for Edits
Added SVD04 element in segment 2430
Line Page 281
Added missing code DA to SV204
Updated PWK06 Position 29 30 Provider
type bytes changed to 2 Page 297
Updated PWK06 Position 31 33 Provider
Specialty bytes changed to 3 Page 297
Updated SVD01 Note is deleted Page 276
Updated Adjustment Reason Codes
Page 300
Author
SCP Labor Team
SCP Labor Team
SCP Labor Team
SCP Labor Team
SCP Labor Team
April 2014
005010X223A2 837
April 2014
Version 15.0
April 2014
Version 16.0
Updated CAS: Payer A and B (Other

Carrier Info.)
Updated Appendix J
Updated Appendix K3 (BDC & IHS field)
Update Loop 2300 HCP, HCP04 New
Provider status code for AltNet Providers
& Custom Network Provider
Update value code for Indian Health
Service Indicator
SCP Labor Team
SCP Labor Team
April 2014
005010X223A2 837
837 Health Care Claim

Functional Group ID=
HC
Introduction:
This X12 Transaction Set contains the format and establishes the data contents of the Health Care Claim Transaction
Set (837) for use within the context of an Electronic Data Interchange (EDI) environment. This transaction set can
be used to submit health care claim billing information, encounter information, or both, from providers of health
care services to payers, either directly or via intermediary billers and claims clearinghouses. It can also be used to
transmit health care claims and billing payment information between payers with different payment responsibilities
where coordination of benefits is required or between payers and regulatory agencies to monitor the rendering,
billing, and/or payment of health care services within a specific health care/insurance industry segment. For
purposes of this standard, providers of health care products or services may include entities such as physicians,
hospitals and other medical facilities or suppliers, dentists, and pharmacies, and entities providing medical
information to meet regulatory requirements. The payer refers to a third party entity that pays claims or administers
the insurance product or benefit or both. For example, a payer may be an insurance company, health maintenance
organization (HMO), preferred provider organization (PPO), government agency (Medicare, Medicaid, Civilian
Health and Medical Program of the Uniformed Services (CHAMPUS), etc.) or an entity such as a third party
administrator (TPA) or third party organization (TPO) that may be contracted by one of those groups. A regulatory
agency is an entity responsible, by law or rule, for administering and monitoring a statutory benefits program or a
specific health care/insurance industry segment.
Heading:
Page
No.
12
Pos.
No.
0050
Seg.
ID
ST
Name
Transaction Set Header
13
0100
BHT
Beginning of Hierarchical Transaction
15
0200
NM1
17
0450
PER
SCP
Usage
M
Max.Use
1
Submitter Name
Submitter EDI Contact Information
LOOP ID - 1000A
0200
NM1
Receiver Name
Notes and
Comments
LOOP ID - 1000B
19
Loop
Repeat
1
M
Detail:
Page
No.
Pos.
No.
Seg.
ID
20
0010
HL
Billing Provider Hierarchical Level
21
0030
PRV
Billing Provider Specialty Information
22
0100
CUR
Foreign Currency Information
23
0150
NM1
Billing Provider Name
25
0250
N3
Billing Provider Address
26
0300
N4
Billing Provider City/State/ZIP Code
28
0350
REF
Billing Provider Secondary Identification
29
0400
PER
Billing Provider Contact Information
Name
LOOP ID - 2000A
SCP
Usage
Max.Use
LOOP ID - 2010AA
LOOP ID - 2010AB
Loop
Repeat
>1
Notes and
Comments
April 2014
005010X223A2 837
31
0150
NM1
Pay-To Address Name
32
0250
N3
Pay-To Address
33
0300
N4
Pay-To Address City/State/ZIP Code
35
0010
HL
Subscriber Hierarchical Level
37
0050
SBR
Subscriber Information
LOOP ID - 2000B
>1
LOOP ID - 2010BA
39
0150
NM1
Subscriber Name
41
0250
N3
Subscriber Address
42
0300
N4
Subscriber City/State/ZIP Code
44
0320
DMG
Subscriber Demographic Information
45
0350
REF
Subscriber Secondary Identification
46
0350
REF
Property and Casualty Claim Number
47
0150
NM1
Payer Name
49
0250
N3
Payer Address
50
0300
N4
Payer City/State/ZIP Code
52
0350
REF
Payer Secondary Identification
53
0350
REF
Billing Provider Secondary Identification
LOOP ID - 2010BB
LOOP ID - 2000C
>1
54
0010
HL
Patient Hierarchical Level
56
0070
PAT
Patient Information
57
0150
NM1
Patient Name
58
0250
N3
Patient Address
59
0300
N4
Patient City/State/ZIP Code
61
0320
DMG
Patient Demographic Information
62
0350
REF
Property and Casualty Claim Number
63
0375
REF
Property and Casualty Patient Identifier
LOOP ID - 2010CA
LOOP ID - 2300
100
64
1300
CLM
Claim information
67
1350
DTP
Discharge Date/Hour
68
1350
DTP
Statement Dates
69
1350
DTP
Admission Date/Hour
70
1350
DTP
Date - Repricer Received Date
71
1400
CL1
Institutional Claim Code
72
1550
PWK
Claim Supplemental Information
10
74
1600
CN1
Contract Information
76
1750
AMT
Patient Estimated Amount Due
77
1800
REF
Service Authorization Exception Code
78
1800
REF
Referral Number
79
1800
REF
Prior Authorization
80
1800
REF
Payer Claim Control Number
81
1800
REF
Repriced Claim Number
82
1800
REF
Adjusted Repriced Claim Number
83
1800
REF
Investigational Device Exemption Number
84
1800
REF
Claim Identification For Transmission
April 2014
005010X223A2 837
85
1800
REF
Intermediaries
Auto Accident State
86
1800
REF
Medical Record Number
87
1800
REF
Demonstration Project Identifier
88
1800
REF
89
1850
K3
Peer Review Organization (PRO) Approval

Number
File Information Revision 10.1.2011
10
91
1900
NTE
Claim Note
10
92
1900
NTE
Billing Note
96
2310
HI
Principal Diagnosis
95
2310
HI
Admitting Diagnosis
97
2310
HI
Patient Reason For Visit
100
2310
HI
External Cause of Injury
109
2310
HI
110
2310
HI
Diagnosis Related Group (DRG)

Information
Other Diagnosis Information
119
2310
HI
Principal Procedure Information
121
2310
HI
Other Procedure Information
130
2310
HI
Occurrence Span Information
138
2310
HI
Occurrence Information
145
2310
HI
Value Information
151
2310
HI
Condition Information
156
2310
HI
Treatment Code Information
160
2410
HCP
Claim Pricing/Repricing Information
164
2500
NM1
Attending Provider Name
166
2550
PRV
Provider Information
167
2710
REF
Attending Provider Secondary

Identification
168
2500
NM1
Operating Physician Name
170
2710
REF
Operating Physician Secondary

Identification
LOOP ID - 2310A
LOOP ID - 2310B
LOOP ID - 2310C
171
2500
NM1
Other Operating Physician Name
173
2710
REF
Other Operating Physician Secondary

Identification
174
2500
NM1
Rendering Provider Name
176
2710
REF
Rendering Provider Secondary

Identification
LOOP ID - 2310D
LOOP ID - 2310E
177
2500
NM1
Service Facility Location Name
178
2650
N3
Service Facility Location Address
179
2700
N4
181
2710
REF
Service Facility Location City, State, ZIP

Code
Service Facility Location Secondary
Identification
182
2500
NM1
Referring Provider Name
184
2710
REF
Referring Provider Secondary

Identification
LOOP ID - 2310F
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005010X223A2 837
LOOP ID - 2320
10
185
2900
SBR
Other Subscriber Information
188
2950
CAS
Claim Level Adjustments
193
3000
AMT
194
3000
AMT
Coordination of Benefits (COB) Payer Paid

Amount
Remaining Patient Liability
195
3000
AMT
196
3100
OI
Coordination of Benefits (COB) Total

Non-covered Amount
Other Insurance Coverage Information
197
3150
MIA
Inpatient Adjudication Information
201
3200
MOA
Outpatient Adjudication Information
LOOP ID - 2330A
203
3250
NM1
Other Subscriber Name
205
3320
N3
Other Subscriber Address
206
3400
N4
Other Subscriber City/State/ZIP Code
208
3550
REF
Other Subscriber Secondary Information
LOOP ID - 2330B
209
3250
NM1
Other Payer Name
211
3320
N3
Other Payer Address
212
3400
N4
Other Payer City/State/ZIP Code
214
3500
DTP
Claim Check or Remittance Date
215
3550
REF
Other Payer Secondary Identifier
216
3550
REF
Other Payer Prior Authorization Number
217
3550
REF
Other Payer Referral Number
218
3550
REF
Other Payer Claim Adjustment Indicator
219
3550
REF
Other Payer Claim Control Number
220
3250
NM1
Other Payer Attending Provider
221
3550
REF
Other Payer Attending Provider Secondary

Identification
222
3250
NM1
Other Payer Operating Physician
223
3550
REF
Other Payer Operating Physician

Secondary Identification
LOOP ID - 2330C
LOOP ID - 2330D
LOOP ID - 2330E
224
3250
NM1
Other Payer Other Operating Physician
225
3550
REF
Other Payer Other Operating Physician

Secondary Identification
226
3250
NM1
Other Payer Service Facility Location
227
3550
REF
Other Payer Service Facility Location

Identification
LOOP ID - 2330F
LOOP ID - 2330G
228
3250
NM1
Other Payer Rendering Provider Name
229
3550
REF
Other Payer Rendering Provider Secondary

Identification
230
3250
NM1
Other Payer Referring Provider
231
3550
REF
Other Payer Referring Provider Secondary

Identification
LOOP ID - 2330H
LOOP ID - 2330I
9
1
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005010X223A2 837
232
3250
NM1
Other Payer Billing Provider
233
3550
REF
Other Payer Billing Provider Secondary

Identification
LOOP ID - 2400
999
234
3650
LX
Service Line Number
235
3750
SV2
Institutional Service Line
239
4200
PWK
Line Supplemental Information
10
243
4550
DTP
Date - Service Date
245
4700
REF
Line Item Control Number
246
4700
REF
Repriced Line Item Reference Number
247
4700
REF
248
4750
AMT
Adjusted Repriced Line Item Reference

Number
Service Tax Amount
249
4750
AMT
Facility Tax Amount
250
4850
NTE
Third Party Organization Notes
251
4920
HCP
Line Pricing/Repricing Information
LOOP ID - 2410
256
4930
LIN
Drug Identification
257
4940
CTP
Drug Quantity
258
4950
REF
Prescription or Compound Drug

Association Number
LOOP ID - 2420A
259
5000
NM1
Operating Physician Name
261
5250
REF
Operating Physician Secondary

Identification
20
263
5000
NM1
Other Operating Physician Name
265
5250
REF
Other Operating Physician Secondary

Identification
20
LOOP ID - 2420B
LOOP ID - 2420C
267
5000
NM1
Rendering Provider Name
269
5250
REF
Rendering Provider Secondary

Identification
20
271
5000
NM1
Referring Provider Name
273
5250
REF

Identification
20
275
5400
SVD
Line Adjudication Information
278
5450
CAS
Line Adjustment
283
5500
DTP
Line Check or Remittance Date
284
5505
AMT
Remaining Patient Liability
285
5550
SE
Transaction Set Trailer
LOOP ID - 2420D
LOOP ID - 2430
15
Transaction Set Notes

1.
Loop 1000 contains submitter and receiver information. If any intermediary receivers change or add data in
any way, then they add an occurrence to the loop as a form of identification. The added loop occurrence must
be the last occurrence of the loop.
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005010X223A2 837
2.
Loop 2010 contains information about entities that apply to all claims in loop 2300. For example, these
entities may include billing provider, pay-to provider, insurer, primary administrator, contract holder, or
claimant.
Shared Claims Processing Notes reflect specific information related to data element. Field should only be
used by SCP Accounts.
3.
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005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
ST Transaction Set Header

0050
Heading
Mandatory
1
To indicate the start of a transaction set and to assign a control number
1
Comments:
Notes:
The transaction set identifier (ST01) is used by the translation routines of the
interchange partners to select the appropriate transaction set definition (e.g., 810
selects the Invoice Transaction Set).
The implementation convention reference (ST03) is used by the translation routines
of the interchange partners to select the appropriate implementation convention to
match the transaction set definition. When used, this implementation convention
reference takes precedence over the implementation reference specified in the GS08.
TR3 Example: ST*837*987654*005010X223A2~

Data Element Summary
Ref.
Des.
ST01
ST02
ST03
Data
Element
143
329
1705
Name
Transaction Set Identifier Code
Code uniquely identifying a Transaction Set
837
Health Care Claim
Transaction Set Control Number
Base
User
Attributes
Attributes
M 1
ID 3/3
M
AN 4/9
Identifying control number that must be unique within the transaction set functional
group assigned by the originator for a transaction set
The Transaction Set Control Number in ST02 and SE02 must be identical. The number
must be unique within a specific interchange (ISA-IEA), but can repeat in other
interchanges.
Shared Claims Processing Notes:
Unique Transaction Set Control Number
Implementation Convention Reference
O 1
AN
M
1/35
Reference assigned to identify Implementation Convention
IMPLEMENTATION NAME: Version, Release, or Industry Identifier
This element must be populated with the guide identifier named in Section 1.2.
This field contains the same value as GS08. Some translator products strip off the ISA
and GS segments prior to application (ST-SE) processing. Providing the information
from the GS08 at this level will ensure that the appropriate application mapping is used
at translation time.
The following fixed value will be populated for this element:
005010X223A2
005010X223A2
Standards Approved for Publication by ASC X12 Procedures
Review Board through October 2003
12
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
BHT Beginning of Hierarchical Transaction

0100
Heading
Mandatory
1
To define the business hierarchical structure of the transaction set and identify the
business application purpose and reference data, i.e., number, date, and time
1
2
3
Comments:
Notes:
BHT03 is the number assigned by the originator to identify the transaction within the
originator's business application system.
BHT04 is the date the transaction was created within the business application
system.
BHT05 is the time the transaction was created within the business application
system.
TR3 Notes: 1. The second example denotes the case where the entire transaction
set contains ENCOUNTERS.
TR3 Example: BHT*0019*00*0123*20040618*0932*CH~
Ref.
Des.
BHT0
1
BHT0
2
BHT0
3
Data
Element
1005
353
127
Name
Hierarchical Structure Code
Base
User
Attributes
Attributes
M 1
ID 4/4
M
Code indicating the hierarchical application structure of a transaction set that utilizes
the HL segment to define the structure of the transaction set
0019
Information Source, Subscriber, Dependent
Transaction Set Purpose Code
M 1
ID 2/2
M
Code identifying purpose of transaction set
BHT02 is intended to convey the electronic transmission status of the 837 batch
contained in this ST-SE envelope. The terms "original" and "reissue" refer to the
electronic transmission status of the 837 batch, not the billing status.
00
00
Original
Original transmissions are transmissions which have never been
sent to the receiver.
Reference Identification
O 1
AN
M
1/50
Reference information as defined for a particular Transaction Set or as specified by the
Reference Identification Qualifier
IMPLEMENTATION NAME: Originator Application Transaction Identifier
The inventory file number of the transmission assigned by the submitters system. This
number operates as a batch control number.
BHT0
4
13
373
This field is limited to 30 characters.

Unique Application Transaction Number.
Date
DT 8/8
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005010X223A2 837
Date expressed as CCYYMMDD where CC represents the first two digits of the
calendar year
IMPLEMENTATION NAME: Transaction Set Creation Date
BHT0
5
BHT0
6
337
640
This is the date that the original submitter created the claim file from their business
application system.
Time
O 1
TM
M
4/8
Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or
HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S =
integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as
follows: D = tenths (0-9) and DD = hundredths (00-99)
IMPLEMENTATION NAME: Transaction Set Creation Time
This is the time that the original submitter created the claim or encounter file from
their business application system.
Transaction Type Code
O 1
ID 2/2
M
Code specifying the type of transaction
IMPLEMENTATION NAME: Claim Identifier
CH
CH
Chargeable
Use CH when the transaction contains only fee for service
claims or claims with at least one
chargeable line item. If it is not clear whether a transaction
contains claims or capitated
encounters, or if the transaction contains a mix of claims and
capitated encounters, use CH.
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005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
NM1 Submitter Name

0200
1000A
Heading
Mandatory
1
To supply the full name of an individual or organizational entity
1 If either NM108 or NM109 is present, then the other is required.
2 If NM111 is present, then NM110 is required.
1 NM102 qualifies NM103.
1 NM110 and NM111 further define the type of entity in NM101.
2 NM112 can identify a second surname.
TR3 Notes: 1. The submitter is the entity responsible for the creation and formatting of
this transaction.
TR3 Example: NM1*41*2*HCSCLABOR*****46*121.621~
Ref.
Des.
NM10
1
NM10
2
NM10
3
Data
Element
98
Name
Entity Identifier Code
Base
User
Attributes
Attributes
M 1
ID 2/3
M
1065
Code identifying an organizational entity, a physical location, property or an individual

41
Submitter
Entity transmitting transaction set
Entity Type Qualifier
M 1
ID 1/1
M
1035
Code qualifying the type of entity

2
2
Non-Person Entity
Name Last or Organization Name
X 1
NM10
4
1036
NM10
5
1037
AN
1/60
Individual last name or organizational name

IMPLEMENTATION NAME: Submitter Last or Organization Name
HCSCLABOR
Name First
O 1
AN
O
1/35
Individual first name
SITUATIONAL RULE: Required when NM102 = 1 (person) and the person has a first
name. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Submitter First Name
Name Middle
AN
1/25
Individual middle name or initial

SITUATIONAL RULE: Required when NM102 = 1 (person) and the middle name or
initial of the person is needed to identify the individual. If not required by this
implementation guide, do not send.
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005010X223A2 837
NM10
8
NM10
9
16
66
67
IMPLEMENTATION NAME: Submitter Middle Name or Initial

Identification Code Qualifier
X 1
ID 1/2
Code designating the system/method of code structure used for Identification Code
(67)
46
Electronic Transmitter Identification Number (ETIN)
A unique number assigned to each transmitter and software
developer
Established by trading partner agreement.
Identification Code
X 1
AN
M
2/80
Code identifying a party or other code
IMPLEMENTATION NAME: Submitter Identifier
121.621
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
PER Submitter EDI Contact Information

0450
1000A
Heading
Mandatory
2
To identify a person or office to whom administrative communications should be directed
1 If either PER03 or PER04 is present, then the other is required.
TR3 Notes: 1. When the communication number represents a telephone number in the
United States and other countries using the North American Dialing Plan (for voice, data,
fax, etc.), the communication number must always include the area code and phone
number using the format AAABBBCCCC where AAA is the area code, BBB is the
telephone number prefix, and CCCC is the telephone number. Therefore, the following
telephone number (555) 555-1234 would be represented as 5555551234. Do not submit
long distance access numbers, such as "1", in the telephone number. Telephone
extensions, when applicable, must be submitted in the next element immediately
following the telephone number. When submitting telephone extensions, only submit the
numeric extension. Do not include data that indicates an extension, such as "ext" or "x-".
2. The contact information in this segment identifies the person in the submitter
organization who deals with data transmission issues. If data transmission problems arise,
this is the person to contact in the submitter organization.
3. There are 2 repetitions of the PER segment to allow for six possible combinations of
communication numbers including extensions.
TR3 Example: PER*IC*HCSCLABOR*EM*NOTAVAILABLE@HCSC.COM**EX*123~
Ref.
Des.
PER01
Data
Element
366
PER02
93
PER03
17
365
Base
User
Name
Attributes
Attributes
Contact Function Code
M
1 ID 2/2
M
Code identifying the major duty or responsibility of the person or group named
IC
Information Contact
Name
O
1 AN 1/60
O
Free-form name
SITUATIONAL RULE: Required when the contact name is different than the name
contained in the Submitter Name (NM1) segment of this loop, AND it is the first iteration
of the Submitter EDI Contact Information (PER) segment. If not required by this
IMPLEMENTATION NAME: Submitter Contact Name
HCSCLABOR
Communication Number Qualifier
X
Code identifying the type of communication number
EM
EM
Electronic Mail
1 ID 2/2
April 2014
005010X223A2 837
PER04
364
PER05
365
PER06
364
PER07
365
PER08
364
18
FX
Facsimile
TE
Telephone
Communication Number
X
1 AN 1/256 M
Complete communications number including country or area code when applicable
NOTAVAILABLE@HCSC.COM
X
1 ID 2/2
O
SITUATIONAL RULE: Required when this information is deemed necessary by the
submitter. If not required by this implementation guide, do not send.
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
TE
Telephone
X
1 AN 1/256 O
X
1 ID 2/2
O
submitter not required by this implementation guide, do not send.
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
TE
Telephone
X
1 AN 1/256 O
submitter not required by this implementation guide, do not send.
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
NM1 Receiver Name

0200
1000B
Heading
Mandatory
1
TR3 Example: NM1*40*2*LABOR999*****46*CGZ~
Ref.
Des.
NM10
1
NM10
2
NM10
3
NM10
8
NM10
9
19
Data
Element
98
Name
Base
User
Attributes
Attributes
M 1
ID 2/3
M
1065

40
Receiver
Entity to accept transmission
M 1
ID 1/1
M
1035

2
Non-Person Entity
AN
1/60

IMPLEMENTATION NAME: Receiver Name
Unique ID assigned to each Fund by BCBSIL
ID 1/2
66
67
(67)
46
Electronic Transmitter Identification Number (ETIN)
A unique number assigned to each transmitter and software
developer
Identification Code
X 1
AN
M
2/80
IMPLEMENTATION NAME: Receiver Primary Identifier
CGZ
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
HL Billing Provider Hierarchical Level

0010
2000A
Detail
Mandatory
1
To identify dependencies among and the content of hierarchically related groups of data
segments
The HL segment is used to identify levels of detail information using a hierarchical

structure, such as relating line-item data to shipment data, and packaging data to lineitem data.
The HL segment defines a top-down/left-right ordered structure.
2 HL01 shall contain a unique alphanumeric number for each occurrence of the HL
segment in the transaction set. For example, HL01 could be used to indicate the
number of occurrences of the HL segment, in which case the value of HL01 would
be "1" for the initial HL segment and would be incremented by one in each
subsequent HL segment within the transaction.
3 HL02 identifies the hierarchical ID number of the HL segment to which the current
HL segment is subordinate.
4 HL03 indicates the context of the series of segments following the current HL
segment up to the next occurrence of an HL segment in the transaction. For example,
HL03 is used to indicate that subsequent segments in the HL loop form a logical
grouping of data referring to shipment, order, or item-level information.
5 HL04 indicates whether or not there are subordinate (or child) HL segments related
to the current HL segment.
TR3 Example: HL*1**20*1~
Ref.
Des.
HL01
Data
Element
628
HL03
735
HL04
736
20
Base
User
Name
Attributes
Attributes
Hierarchical ID Number
M
1 AN 1/12
M
A unique number assigned by the sender to identify a particular data segment in a
hierarchical structure
The first HL01 within each ST-SE envelope must begin with "1", and be incremented by
one each time an HL is used in the transaction. Only numeric values are allowed in HL01.
Hierarchical Level Code
M
1 ID 1/2
M
Code defining the characteristic of a level in a hierarchical structure
20
Information Source
Identifies the payor, maintainer, or source of the information
Hierarchical Child Code
O
1 ID 1/1
M
Code indicating if there are hierarchical child data segments subordinate to the level being
described
1
Additional Subordinate HL Data Segment in This Hierarchical
Structure.
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
PRV Billing Provider Specialty Information

0030
2000A
Detail
Optional
1
To specify the identifying characteristics of a provider
1 If either PRV02 or PRV03 is present, then the other is required.
Situational Rule: Required when the payers adjudication is known to be impacted by the
provider taxonomy code. If not required by this implementation guide, do not send.
TR3 Example: PRV*BI*PXC*282NR1301X~
Ref.
Des.
PRV01
Data
Element
1221
PRV02
128
PRV03
127
21
Base
User
Name
Attributes
Attributes
Provider Code
M
1 ID 1/3
M
Code identifying the type of provider
BI
Billing
X
1 ID 2/3
M
Code qualifying the Reference Identification
PXC
Health Care Provider Taxonomy Code
X
1 AN 1/50
M
IMPLEMENTATION NAME: Provider Taxonomy Code
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
CUR Foreign Currency Information

0100
2000A
Detail
Optional
1
To specify the currency (dollars, pounds, francs, etc.) used in a transaction
1 If CUR08 is present, then CUR07 is required.
3 If CUR10 is present, then at least one of CUR11 or CUR12 is required.
1 See Figures Appendix for examples detailing the use of the CUR segment.
Situational Rule: Required when the amounts represented in this transaction are
currencies other than the United States dollar. If not required by this implementation
guide, do not send.
TR3 Notes: 1. It is REQUIRED that all amounts reported within the transaction are of the
currency named in this segment. If this segment is not used, then it is required that all
amounts in this transaction be expressed in US dollars.
TR3 Example: CUR*85*CAD~
Ref.
Des.
CUR01
Data
Element
98
CUR02
100
Base
User
Name
Attributes
Attributes
M
1 ID 2/3
M
85
Billing Provider
Currency Code
M
1 ID 3/3
M
Code (Standard ISO) for country in whose currency the charges are specified
CODE SOURCE 5: Countries, Currencies and Funds
The submitter must use the Currency Code, not the Country Code, for this element. For
example, the Currency Code CAD = Canadian dollars would be valid, while CA = Canada
would be invalid.
22
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
NM1 Billing Provider Name

0150
2010AA
Detail
Mandatory
1
TR3 Notes: 1. Beginning on the NPI compliance date: When the Billing Provider is an
organization health care provider, the organization health care providers NPI or its
subparts NPI is reported in NM109. When a health care provider organization has
determined that it needs to enumerate its subparts, it will report the NPI of a subpart as
the Billing Provider. The subpart reported as the Billing Provider MUST always
represent the most detailed level of enumeration as determined by the organization health
care provider and MUST be the same identifier sent to any trading partner. For additional
explanation, see section 1.10.3 Organization Health Care Provider Subpart Presentation.
2. Prior to the NPI compliance date, proprietary identifiers necessary for the receiver to
identify the Billing Provider entity are to be reported in the REF segment of Loop ID2010BB.
3. The Taxpayer Identifying Number (TIN) of the Billing Provider to be used for 1099
purposes must be reported in the REF segment of this loop.
4. When the individual or the organization is not a health care provider and, thus, not
eligible to receive an NPI (For example, personal care services, carpenters, etc), the
Billing Provider should be the legal entity. However, willing trading partners may agree
upon varying definitions. Proprietary identifiers necessary for the receiver to identify the
entity are to be reported in the Loop ID-2010BB REF, Billing Provider Secondary
Identification segment. The TIN to be used for 1099 purposes must be reported in the
REF (Tax Identification Number) segment of this loop.
TR3 Example: NM1*85*2*ABC HOSPITAL*****XX*1234567890~
Ref.
Des.
NM10
1
NM10
2
NM10
3
Data
Element
98
Name
Base
User
Attributes
Attributes
M 1
ID 2/3
M
1065

85
Billing Provider
M 1
ID 1/1
M
1035

2
Non-Person Entity
AN
1/60

IMPLEMENTATION NAME: Billing Provider Organizational Name
23
April 2014
005010X223A2 837
NM10
8
66
Information on provider submitting claim for payment

X
ID 1/2
(67)
SITUATIONAL RULE: Required for providers in the United States or its territories on
or after the mandated HIPAA National Provider Identifier (NPI) implementation date
when the provider is eligible to receive an NPI.
OR
Required for providers not in the United States or its territories on or after the
mandated HIPAA National Provider Identifier (NPI) implementation date when the
provider has received an NPI.
OR
NM10
9
67
Required for providers prior to the mandated NPI implementation date when the
provider has received an NPI and the submitter has the capability to send it. If not
required by this implementation guide, do not send.
XX
Centers for Medicare and Medicaid Services National Provider
Identifier
CODE SOURCE 537: Centers for Medicare and Medicaid
Services National Provider Identifier
Identification Code
X 1
AN
O
2/80
OR
OR
IMPLEMENTATION NAME: Billing Provider Identifier
24
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
N3 Billing Provider Address

0250
2010AA
Detail
Mandatory
1
To specify the location of the named party
TR3 Notes: 1. The Billing Provider Address must be a street address. Post Office Box or
Lock Box addresses are to be sent in the Pay-To Address Loop (Loop ID-2010AB), if
necessary.
TR3 Example: N3*123 MAIN STREET~
Ref.
Des.
N301
N302
Data
Element
166
166
Name
Address Information
Base
User
Attributes
Attributes
M 1
AN
M
1/55
Address information
IMPLEMENTATION NAME: Billing Provider Address Line
Address Information
O 1
AN
1/55
Address information
SITUATIONAL RULE: Required when there is a second address line. If not required
by this implementation guide, do not send.
IMPLEMENTATION NAME: Billing Provider Address Line
25
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
N4 Billing Provider City/State/ZIP Code

0300
2010AA
Detail
Mandatory
1
To specify the geographic place of the named party
1 Only one of N402 or N407 may be present.
2 If N406 is present, then N405 is required.
1
A combination of either N401 through N404, or N405 and N406 may be adequate to
specify a location.
2 N402 is required only if city name (N401) is in the U.S. or Canada.
TR3 Example: N4*KANSAS*MO*64108~
Ref.
Des.
N401
N402
Data
Element
19
156
Name
City Name
Base
User
Attributes
Attributes
O 1
AN
M
2/30
Free-form text for city name

IMPLEMENTATION NAME: Billing Provider City Name
State or Province Code
X 1
ID 2/2
Code (Standard State/Province) as defined by appropriate government agency

SITUATIONAL RULE: Required when address is within the United States or Canada.
If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Billing Provider State or Province Code
N403
116
CODE SOURCE 22: States and Provinces

Postal Code
ID
O
3/15
Code defining international postal zone code excluding punctuation and blanks (zip
code for United States)
SITUATIONAL RULE: Required when the address is in the United States of
America, including its territories, or Canada, or when a postal code exists for the
country in N404. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Billing Provider Postal Zone or ZIP Code
CODE SOURCE 51: ZIP Code
CODE SOURCE 932: Universal Postal Codes
N404
26
When reporting the ZIP code for U.S. addresses, the full nine digit ZIP code must be
provided.
Country Code
X 1
ID 2/3
O
Code identifying the country
SITUATIONAL RULE: Required when the address is outside the United States of
America. If not required by this implementation guide, do not send.
26
April 2014
005010X223A2 837
N407
1715
Use the alpha-2 country codes from Part 1 of ISO 3166.

Country Subdivision Code
X
ID 1/3
Code identifying the country subdivision

SITUATIONAL RULE: Required when the address is not in the United States of
America, including its territories, or Canada, and the country in N404 has
administrative subdivisions such as but not limited to states, provinces, cantons, etc. If
not required by this implementation guide, do not send.
Use the country subdivision codes from Part 2 of ISO 3166.
27
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
REF Billing Provider Secondary Identification

0350
2010AA
Detail
Mandatory
1
To specify identifying information
1 At least one of REF02 or REF03 is required.
2 If either C04003 or C04004 is present, then the other is required.
1 REF04 contains data relating to the value cited in REF02.
TR3 Notes: 1. This is the tax identification number (TIN) of the entity to be paid for the
submitted services.
TR3 Example: REF*EI*123456789~
Ref.
Des.
REF0
1
Data
Element
128
Name
Base
User
Attributes
Attributes
M 1
ID 2/3
M

As of the mandated implementation date of the National Provider Identifier rule, the
only valid value for Health Care Providers is EI. Non-Health Care Providers can use
any of the listed values, as required by the receiver to identify the provider.
EI
Employer's Identification Number
The Employers Identification Number must be a string of
exactly nine numbers with no separators.
REF0
2
28
127
For example, "001122333" would be valid, while sending "00112-2333" or "00-1122333" would be invalid.
X 1
AN
M
1/50
IMPLEMENTATION NAME: Billing Provider Tax Identification Number
Federally assigned Tax Identification number of the billing provider
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
PER Billing Provider Contact Information

0400
2010AA
Detail
Optional
2
To identify a person or office to whom administrative communications should be directed
Situational Rule: Required when this information is different than that contained in the
Loop ID-1000A - Submitter PER segment. If not required by this implementation guide,
do not send.
TR3 Notes: 1. When the communication number represents a telephone number in the
United States and other countries using the North American Dialing Plan (for voice, data,
fax, etc.), the communication number must always include the area code and phone
number using the format AAABBBCCCC where AAA is the area code, BBB is the
telephone number prefix, and CCCC is the telephone number.
Therefore, the following telephone number (555) 555-1234 would be represented as
5555551234. Do not submit long distance access numbers, such as "1", in the telephone
number. Telephone extensions, when applicable, must be submitted in the next element
immediately following the telephone number. When submitting telephone extensions,
only submit the numeric extension. Do not include data that indicates an extension, such
as "ext" or "x-".
2. There are 2 repetitions of the PER segment to allow for six possible combinations of
communication numbers including extensions.
TR3 Example: PER*IC*JOHN SMITH*TE*5555551234*EX*123~
Ref.
Des.
PER01
Data
Element
366
PER02
93
PER03
365
PER04
364
PER05
365
29
Base
User
Name
Attributes
Attributes
Contact Function Code
M
1 ID 2/2
M
Code identifying the major duty or responsibility of the person or group named
IC
Information Contact
Name
O
1 AN 1/60
O
Free-form name
SITUATIONAL RULE: Required in the first iteration of the Billing Provider Contact
Information segment. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Billing Provider Contact Name
X
1 ID 2/2
M
EM
Electronic Mail
FX
Facsimile
TE
Telephone
X
1 AN 1/256 M
X
1 ID 2/2
O
April 2014
005010X223A2 837
PER06
364
PER07
365
PER08
364
30

EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
TE
Telephone
X
1 AN 1/256 O
X
1 ID 2/2
O
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
TE
Telephone
X
1 AN 1/256 O
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
NM1 Pay-To Address Name

0150
2010AB
Detail
Optional
1
Situational Rule: Required when the address for payment is different than that of the
Billing Provider. If not required by this implementation guide, do not send.
TR3 Notes: 1. The purpose of Loop ID-2010AB has changed from previous versions.
Loop ID-2010AB only contains address information when different from the Billing
Provider Address. There are no applicable identifiers for Pay-To Address information.
TR3 Example: NM1*87*2~
Ref.
Des.
NM101
Data
Element
98
NM102
1065
31
Base
User
Name
Attributes
Attributes
M
1 ID 2/3
M
87
Pay-to Provider
M
1 ID 1/1
M
2
Non-Person Entity
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
N3 Pay-To Address
0250
2010AB
Detail
Mandatory
1

Ref.
Des.
N301
Data
Element
166
N302
166
Base
User
Name
Attributes
Attributes
Address Information
M
1 AN 1/55
M
Address information
IMPLEMENTATION NAME: Pay-To Address Line
Address Information
O
1 AN 1/55
O
Address information
SITUATIONAL RULE: Required when there is a second address line. If not required by
this implementation guide, do not send.
IMPLEMENTATION NAME: Pay-To Address Line
32
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
N4 Pay-To Address City/State/ZIP Code

0300
2010AB
Detail
Mandatory
1
1
specify a location.
TR3 Example: N4*KANSAS CITY*MO*64108~
Ref.
Des.
N401
Data
Element
19
N402
156
Base
User
Name
Attributes
Attributes
City Name
O
1 AN 2/30
M
IMPLEMENTATION NAME: Pay-to Address City Name
X
1 ID 2/2
O
SITUATIONAL RULE:Required when the address is in the United States of America,
including its territories, or Canada. If not required by this implementation guide, do not
send.
IMPLEMENTATION NAME: Pay-to Address State Code
N403
116

Postal Code
O
1 ID 3/15
O
Code defining international postal zone code excluding punctuation and blanks (zip code
for United States)
SITUATIONAL RULE: Required when the address is in the United States of America,
including its territories, or Canada, or when a postal code exists for the country in N404. If
IMPLEMENTATION NAME: Pay-to Address Postal Zone or ZIP Code
N404
26

Country Code
X
1 ID 2/3
O
N407
33
1715
Use the alpha-country codes from Part 1 of ISO 3166.

X
1 ID 1/3
O
SITUATIONAL RULE: Required when the address is not in the United States of America,
including its territories, or Canada, and the country in N404 has administrative
subdivisions such as but not limited to states, provinces, cantons, etc. If not required by this
April 2014
005010X223A2 837

34
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
HL Subscriber Hierarchical Level

0010
2000B
Detail
Mandatory
1
segments

TR3 Notes: 1. If a patient can be uniquely identified to the destination payer in Loop ID2010BB by a unique Member Identification Number, then the patient is the subscriber or
is considered to be the subscriber and is identified at this level, and the patient HL in
Loop ID-2000C is not used.
2. If the patient is not the subscriber and cannot be identified to the destination payer by a
unique Member Identification Number or it is not known to the sender if the Member
Identification number is unique, both this HL and the patient HL in Loop ID- 2000C are
required.
TR3 Example: HL*2*1*22*1~
Ref.
Des.
HL01
Data
Element
628
HL02
734
HL03
735
35
Base
User
Name
Attributes
Attributes
M
1 AN 1/12
M
The first HL01 within each ST-SE envelope must begin with "1", and be incremented by
one each time an HL is used in the transaction. Only numeric values are allowed in HL01.
Hierarchical Parent ID Number
O
1 AN 1/12
M
Identification number of the next higher hierarchical data segment that the data segment
being described is subordinate to
M
1 ID 1/2
M
22
Subscriber
Identifies the employee or group member who is covered for
insurance and to whom, or on behalf of whom, the insurer agrees to
pay benefits
April 2014
005010X223A2 837
HL04
736

O
1 ID 1/1
M
described
The claim loop (Loop ID-2300) can be used when HL04 has no subordinate levels (HL04 =
0) or when HL04 has subordinate levels indicated (HL04 = 1).
In the first case (HL04 = 0), the subscriber is the patient and there are no dependent claims.
The second case (HL04 = 1) happens when claims for one or more dependents of the
subscriber are being sent under the same billing provider HL (for example, a spouse and
son are both treated by the same provider). In that case, the subscriber HL04 = 1 because
there is at least one dependent to this subscriber. The dependent HL (spouse) would then be
sent followed by the Loop ID-2300 for the spouse. The next HL would be the dependent
HL for the son followed by the Loop ID-2300 for the son.
In order to send claims for the subscriber and one or more dependents, the Subscriber HL,
with Relationship Code SBR02=18 (Self), would be followed by the Subscribers Loop ID2300 for the Subscribers claims. Then the Subscriber HL would be repeated, followed by
one or more Patient HL loops for the dependents, with the proper Relationship Code in
PAT01, each followed by their respective Loop ID-2300 for each dependents claims.
0
No Subordinate HL Segment in This Hierarchical Structure.
1
Additional Subordinate HL Data Segment in This Hierarchical
Structure.
36
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
SBR Subscriber Information

0050
2000B
Detail
Mandatory
1
To record information specific to the primary insured and the insurance carrier for that
insured
1
2
3
4
SBR02 specifies the relationship to the person insured.

SBR03 is policy or group number.
SBR04 is plan name.
SBR07 is destination payer code. A "Y" value indicates the payer is the destination
payer; an "N" value indicates the payer is not the destination payer.
TR3 Example: SBR*P*18*P00123******WC~

Ref.
Des.
SBR0
1
SBR0
2
SBR0
3
37
Data
Element
1138
1069
127
Name
Payer Responsibility Sequence Number Code
Base
User
Attributes
Attributes
M 1
ID 1/1
M
Code identifying the insurance carrier's level of responsibility for a payment of a claim
Within a given claim, the various values for the Payer Responsibility Sequence
Number Code (other than value "U") may occur no more than once.
A
Payer Responsibility Four
B
Payer Responsibility Five
C
Payer Responsibility Six
D
Payer Responsibility Seven
E
Payer Responsibility Eight
F
Payer Responsibility Nine
G
Payer Responsibility Ten
H
Payer Responsibility Eleven
P
Primary
S
Secondary
T
Tertiary
U
Unknown
This code may only be used in payer to payer COB claims
when the original payer determined the presence of this
coverage from eligibility files received from this payer or when
the original claim did not provide the responsibility sequence
for this payer.
Individual Relationship Code
O 1
ID 2/2
M
Code indicating the relationship between two individuals or entities
SITUATIONAL RULE: Required when the patient is the subscriber or is considered
to be the subscriber. If not required by this implementation guide, do not send.
18
Self
O 1
AN
M
1/50
SITUATIONAL RULE: Required when the subscribers identification card for the
April 2014
005010X223A2 837
destination payer (Loop ID-2010BB) shows a group number. If not required by this
IMPLEMENTATION NAME: Subscriber Group or Policy Number
SBR0
4
93
SBR0
9
1032
This is not the number uniquely identifying the subscriber. The unique subscriber
number is submitted in Loop ID-2010BA-NM109.
An identification number assigned by BCBSIL
Name
O 1
AN
O
1/60
Free-form name
SITUATIONAL RULE: Required when SBR03 is not used and the group name is
available. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Subscriber Group Name
Claim Filing Indicator Code
O
ID 1/2
Code identifying type of claim

SITUATIONAL RULE: Required prior to mandated use of the HIPAA National Plan
ID. If not required by this implementation guide, do not send.
The following value(s) will be populated for this element:
WC or ZZ
WC
ZZ
38
Workers' Compensation Health Claim

Mutually Defined
Use Code ZZ when Type of Insurance is not known.
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
NM1 Subscriber Name

0150
2010BA
Detail
Mandatory
1
TR3 Notes: 1. In workers compensation or other property and casualty claims, the
"subscriber" may be a non-person entity (for example, the employer). However, this
varies by state.
TR3 Example: NM1*IL*1*DOE*JOHN*T**JR*MI*123451236ABC~
Ref.
Des.
NM10
1
NM10
2
NM10
3
NM10
4
Data
Element
98
Name
Base
User
Attributes
Attributes
M 1
ID 2/3
M
1065

IL
Insured or Subscriber
M 1
ID 1/1
M
1035

1
1
Person
X 1
1036

IMPLEMENTATION NAME: Subscriber Last Name
Name First
O
AN
1/60
AN
1/35

NM10
5
1037
IMPLEMENTATION NAME: Subscriber First Name

Name Middle
O
AN
1/25

SITUATIONAL RULE: Required when NM102 = 1 and the middle name/initial of the
person is needed to identify the individual. If not required by this implementation
guide, do not send.
NM10
7
39
1039
IMPLEMENTATION NAME: Subscriber Middle Name or Initial

Name Suffix
O 1
AN
1/10
April 2014
005010X223A2 837
Suffix to individual name

SITUATIONAL RULE: Required when NM102 = 1 and the name suffix of the person
is needed to identify the individual. If not required by this implementation guide, do
not send.
IMPLEMENTATION NAME: Subscriber Name Suffix
NM10
8
66
Examples: I, II, III, IV, Jr, Sr

This data element is used only to indicate generation or patronymic.
X 1
ID 1/2
(67)
Situational Rule: Required when NM102 = 1 (person). If not required by this
MI
MI
Member Identification Number
The code MI is intended to be the subscribers identification
number as assigned by the payer. (For example, Insureds ID,
Subscribers ID, Health Insurance Claim Number (HIC), etc.)
MI is also intended to be used in claims submitted to the Indian
Health Service/Contract Health Services (IHS/CHS) Fiscal
Intermediary for the purpose of reporting the Tribe Residency
Code (Tribe County State). In the event that a Social Security
Number (SSN) is also available on an IHS/CHS claim, put the
SSN in REF02.
NM10
9
67
When sending the Social Security Number as the Member ID, it

must be a string of exactly nine
numbers with no separators. For example, sending "111002222"
would be valid, while sending "111-00- 2222" would be invalid.
Identification Code
X 1
AN
O
2/80
IMPLEMENTATION NAME: Subscriber Primary Identifier
Insured's Member ID with Group's Alpha Prefix
Field Position:
1-9 = Member's ID Number
10-12 = Group's Alpha Prefix
40
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
N3 Subscriber Address
0250
2010BA
Detail
Mandatory
1
Situational Rule: Required when the patient is the subscriber or considered to be the
subscriber. If not required by this implementation guide, do not send.
TR3 Example: N3*123 Main Street~
Ref.
Des.
N301
N302
Data
Element
166
166
Name
Address Information
Base
User
Attributes
Attributes
M 1
AN
M
1/55
Address information
IMPLEMENTATION NAME: Subscriber Address Line
Address Information
O
AN
1/55
Address information
IMPLEMENTATION NAME: Subscriber Address Line
41
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
N4 Subscriber City/State/ZIP Code

0300
2010BA
Detail
Mandatory
1
1
specify a location.
Ref.
Des.
N401
N402
Data
Element
19
156
Name
City Name
Base
User
Attributes
Attributes
O 1
AN
M
2/30

IMPLEMENTATION NAME: Subscriber City Name
X
ID 2/2

America, including its territories, or Canada. If not required by this implementation
guide, do not send.
IMPLEMENTATION NAME: Subscriber State Code
N403
116

Postal Code
ID
O
3/15
IMPLEMENTATION NAME: Subscriber Postal Zone or ZIP Code
N404
26

Country Code
ID 2/3

42
April 2014
005010X223A2 837
N407
1715

X
ID 1/3

43
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
DMG Subscriber Demographic Information

0320
2010BA
Detail
Mandatory
1
To supply demographic information
1 If either DMG01 or DMG02 is present, then the other is required.
3 If DMG11 is present, then DMG05 is required.
1 DMG02 is the date of birth.
2 DMG07 is the country of citizenship.
3 DMG09 is the age in years.
4 DMG11 is used to specify how the information in DMG05, including repeats of
C056, was collected.
TR3 Example: DMG*D8*19690815*M~
Ref.
Des.
DMG
01
Data
Element
1250
DMG
02
1251
DMG
03
1068
Name
Date Time Period Format Qualifier
Base
User
Attributes
Attributes
X 1
ID 2/3
M
Code indicating the date format, time format, or date and time format
D8
Date Expressed in Format CCYYMMDD
Date Time Period
X 1
AN
1/35
Expression of a date, a time, or range of dates, times or dates and times
IMPLEMENTATION NAME: Subscriber Birth Date
Gender Code
O 1
ID 1/1
Code indicating the sex of the individual

IMPLEMENTATION NAME: Subscriber Gender Code
F
Female
M
Male
U
Unknown
44
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
REF Subscriber Secondary Identification

0350
2010BA
Detail
Optional
1
Situational Rule: Required when an additional identification number to that provided in
NM109 of this loop is necessary for the claim processor to identify the entity. If not
TR3 Example: REF*SY*123004567~
Ref.
Des.
REF01
Data
Element
128
REF02
127
45
Base
User
Name
Attributes
Attributes
M
1 ID 2/3
M
SY
Social Security Number
The Social Security Number must be a string of exactly nine
numbers with no separators. For
example, sending "111002222" would be valid, while sending "11100-2222" would be invalid.
X
1 AN 1/50
M
IMPLEMENTATION NAME: Subscriber Supplemental Identifier
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
REF Property and Casualty Claim Number

0350
2010BA
Detail
Optional
1
Situational Rule: Required when the services included in this claim are to be considered
as part of a property and casualty claim. If not required by this implementation guide, do
not send.
TR3 Notes: 1. This is a property and casualty payer-assigned claim number. Providers
receive this number from the property and casualty payer during eligibility
determinations or some other communication with that payer. See Section 1.4.2, Property
and Casualty, for additional information about property and casualty claims.
2. This segment is not a HIPAA requirement as of this writing.
TR3 Example: REF*Y4*4445555~
Ref.
Des.
REF01
Data
Element
128
REF02
127
46
Base
User
Name
Attributes
Attributes
M
1 ID 2/3
M
Y4
Agency Claim Number
X
1 AN 1/50
M
IMPLEMENTATION NAME: Property Casualty Claim Number
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
NM1 Payer Name

0150
2010BB
Detail
Mandatory
1
TR3 Notes: 1. This is the destination payer.
2. For the purposes of this implementation the term payer is synonymous with several
other terms, such as, repricer and third party administrator.
TR3 Example: NM1*PR*2*HCSC*****PI*121.621~
Ref.
Des.
NM10
1
NM10
2
NM10
3
NM10
8
Data
Element
98
Name
Base
User
Attributes
Attributes
M 1
ID 2/3
M
1065

PR
Payer
M 1
ID 1/1
M
1035

2
Non-Person Entity
66

IMPLEMENTATION NAME: Payer Name
HCSC
X 1
AN
1/60
ID 1/2
(67)
On or after the mandated implementation date for the HIPAA National Plan Identifier
(National Plan ID), XV must be sent. Prior to the mandated implementation date and
prior to any phase-in period identified by Federal regulation, PI must be sent.
If a phase-in period is designated, PI must be sent unless:
1. Both the sender and receiver agree to use the National Plan ID,
2. The receiver has a National Plan ID, and
3. The sender has the capability to send the National Plan ID.
If all of the above conditions are true, XV must be sent. In this case the Payer
Identification Number that would have been sent using qualifier PI can be sent in the
corresponding REF segment using qualifier 2U.
47
April 2014
005010X223A2 837
NM10
9
67

PI
PI
Payor Identification
Identification Code
X 1
AN
2/80

IMPLEMENTATION NAME: Payer Identifier
121.621
48
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
N3 Payer Address
0250
2010BB
Detail
Optional
1
Situational Rule: Required when the payer address is available and the submitter intends
for the claim to be printed on paper at the next EDI location (for example, a
clearinghouse). If not required by this implementation guide, do not send.
Ref.
Des.
N301
Data
Element
166
N302
166
Base
User
Name
Attributes
Attributes
Address Information
M
1 AN 1/55
M
Address information
IMPLEMENTATION NAME: Payer Address Line
Address Information
O
1 AN 1/55
O
Address information
IMPLEMENTATION NAME: Payer Address Line
49
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
N4 Payer City/State/ZIP Code

0300
2010BB
Detail
Optional
1
1
specify a location.
clearinghouse). If no required by this implementation guide, do not send.
Ref.
Des.
N401
Data
Element
19
N402
156
Base
User
Name
Attributes
Attributes
City Name
O
1 AN 2/30
M
IMPLEMENTATION NAME: Payer City Name
X
1 ID 2/2
O
send.
IMPLEMENTATION NAME: Payer State Code
N403
116

Postal Code
O
1 ID 3/15
O
for United States)
IMPLEMENTATION NAME: Payer Postal Zone or ZIP Code
N404
26

Country Code
X
1 ID 2/3
O
N407
50
1715

X
1 ID 1/3
April 2014
005010X223A2 837
51
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
REF Payer Secondary Identification

0350
2010BB
Detail
Optional
3
Situational Rule: Required prior to the mandated implementation date for the HIPAA
National Plan Identifier when an additional identification number to that provided in the
TR3 Example: REF*FY*435261708~
Ref.
Des.
REF01
REF02
52
Data
Element
128
127
Base
User
Name
Attributes
Attributes
M
1 ID 2/3
M
2U
Payer Identification Number
This code is only allowed when the National Plan Identifier is
reported in NM109 of this loop.
EI
The Employers Identification Number must be a string of exactly
nine numbers. The sole exception is that a hyphen is allowed
between the second and third digits, but the hyphen can not be
required by the receiver.
For example, both "001122333" and "00-1122333" would be valid,
but "001-12-2333" would be invalid.
FY
Claim Office Number
The identification of the specific payer's location designated as
responsible for the submitted claim
NF
National Association of Insurance Commissioners (NAIC) Code
A unique number assigned to each insurance company
CODE SOURCE 245: National Association of Insurance
Commissioners (NAIC) Code
X
1 AN 1/50
M
IMPLEMENTATION NAME: Payer Additional Identifier
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
REF Billing Provider Secondary Identification

0350
2010BB
Detail
Optional
1
Situational Rule: Required prior to the mandated NPI Implementation Date when an
additional identification number is necessary for the receiver to identify the provider.
OR
Required on or after the mandated NPI Implementation Date when NM109 in Loop
2010AA is not used and an identification number other than the NPI is necessary for the
receiver to identify the provider. If not required by this implementation guide, do not
send.
TR3 Example: REF*G2*12345~
Ref.
Des.
REF01
Data
Element
128
REF02
127
53
Base
User
Name
Attributes
Attributes
M
1 ID 2/3
M
G2
Provider Commercial Number
A unique number assigned to a provider by a commercial insurer
This code designates a proprietary provider number for the
destination payer identified in the Payer Name loop, Loop ID2010BB, associated with this claim. This is to be used by all payers
including: Medicare, Medicaid, Blue Cross, etc.
LU
Location Number
X
1 AN 1/50
M
IMPLEMENTATION NAME: Billing Provider Secondary Identifier
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
HL Patient Hierarchical Level

0010
2000C
Detail
Optional
1
segments

Situational Rule: Required when the patient is a dependent of the subscriber identified in
Loop ID-2000B and cannot be uniquely identified to the payer using the subscribers
identifier in the Subscriber Level. If not required by this implementation guide, do not
send.
TR3 Notes: 1. There are no HLs subordinate to the Patient HL.
2. If a patient is a dependent of a subscriber and can be uniquely identified to the payer
by a unique Identification Number, then the patient is considered the subscriber and is to
be identified in the Subscriber Level.
TR3 Example: HL*3*2*23*0~
Ref.
Des.
HL01
Data
Element
628
HL02
734
HL03
735
54
Base
User
Name
Attributes
Attributes
M
1 AN 1/12
M
Hierarchical Parent ID Number
O
1 AN 1/12
M
Identification number of the next higher hierarchical data segment that the data segment
being described is subordinate to
M
1 ID 1/2
M
23
Dependent
Identifies the individual who is affiliated with the subscriber, such as
spouse, child, etc., and therefore may be entitled to benefits
The code DEPENDENT conveys that the information in this HL
applies to the patient when the subscriber and the patient are not the
same person.
April 2014
005010X223A2 837
HL04
55
736

O
1 ID 1/1
M
described
0
No Subordinate HL Segment in This Hierarchical Structure.
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
PAT Patient Information

0070
2000C
Detail
Mandatory
1
To supply patient information
1 If either PAT05 or PAT06 is present, then the other is required.
2 If either PAT07 or PAT08 is present, then the other is required.
1 PAT06 is the date of death.
2 PAT08 is the patient's weight.
3 PAT09 indicates whether the patient is pregnant or not pregnant. Code "Y" indicates
the patient is pregnant; code "N" indicates the patient is not pregnant.
TR3 Example: PAT*01~
Ref.
Des.
PAT0
1
Data
Element
1069
Name
Base
User
Attributes
Attributes
O 1
ID 2/2
M

Specifies the patients relationship to the person insured.
01, 19
01
Spouse
19
Child
Dependent between the ages of 0 and 19; age qualifications
may vary depending on policy
56
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
NM1 Patient Name

0150
2010CA
Detail
Mandatory
1
TR3 Example: NM1*QC*1*DOE*SALLY*J~
Ref.
Des.
NM10
1
NM10
2
NM10
3
NM10
4
Data
Element
98
Name
Base
User
Attributes
Attributes
M 1
ID 2/3
M
1065

QC
Patient
Individual receiving medical care
M 1
ID 1/1
M
1035

1
Person
AN
1/60
1036

IMPLEMENTATION NAME: Patient Last Name
Name First
AN
1/35

SITUATIONAL RULE: Required when the person has a first name. If not required by
NM10
5
1037
IMPLEMENTATION NAME: Patient First Name

Name Middle
AN
1/25

SITUATIONAL RULE: Required when the middle name or initial of the person is
needed to identify the individual. If not required by this implementation guide, do not
send.
NM10
7
1039
IMPLEMENTATION NAME: Patient Middle Name or Initial

Name Suffix
O 1
AN
1/10

SITUATIONAL RULE: Required when the name suffix is needed to identify the
individual. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Patient Name Suffix
57
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
N3 Patient Address
0250
2010CA
Detail
Mandatory
1

Ref.
Des.
N301
Data
Element
166
N302
166
Base
User
Name
Attributes
Attributes
Address Information
M
1 AN 1/55
M
Address information
IMPLEMENTATION NAME: Patient Address Line
Address Information
O
1 AN 1/55
O
Address information
IMPLEMENTATION NAME: Patient Address Line
58
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
N4 Patient City/State/ZIP Code

0300
2010CA
Detail
Mandatory
1
1
specify a location.
Ref.
Des.
N401
Data
Element
19
N402
156
Base
User
Name
Attributes
Attributes
City Name
O
1 AN 2/30
M
IMPLEMENTATION NAME: Patient City Name
X
1 ID 2/2
O
send.
IMPLEMENTATION NAME: Patient State Code
N403
116

Postal Code
O
1 ID 3/15
O
for United States)
IMPLEMENTATION NAME: Patient Postal Zone or ZIP Code
N404
26

Country Code
X
1 ID 2/3
O
N407
59
1715

X
1 ID 1/3
O
Required when the address is not in the United States of America, including its territories,
or Canada, and the country in N404 has administrative subdivisions such as but not limited
to states, provinces, cantons, etc. If not required by this implementation guide, do not send.
April 2014
005010X223A2 837

60
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
DMG Patient Demographic Information

0320
2010CA
Detail
Mandatory
1
To supply demographic information
3 If DMG11 is present, then DMG05 is required.
1 DMG02 is the date of birth.
2 DMG07 is the country of citizenship.
3 DMG09 is the age in years.
4 DMG11 is used to specify how the information in DMG05, including repeats of
C056, was collected.
TR3 Example: DMG*D8*19690815*M~
Ref.
Des.
DMG
01
Data
Element
1250
DMG
02
1251
DMG
03
1068
Name
Base
User
Attributes
Attributes
X 1
ID 2/3
M
D8
Date Time Period
X 1
AN
1/35
IMPLEMENTATION NAME: Patient Birth Date
Gender Code
O 1
ID 1/1
Code indicating the sex of the individual

IMPLEMENTATION NAME: Patient Gender Code
F
Female
M
Male
U
Unknown
61
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
REF Property and Casualty Claim Number

0350
2010CA
Detail
Optional
1
Situational Rule: Required when the services included in this claim are to be considered
as part of a property and casualty claim. If not required by this implementation guide, do
not send.
TR3 Notes: 1. This is a property and casualty payer-assigned claim number. Providers
receive this number from the property and casualty payer during eligibility
determinations or some other communication with that payer. See Section 1.4.2, Property
and Casualty, for additional information about property and casualty claims.
2. This segment is not a HIPAA requirement as of this writing.
TR3 Example: REF*Y4*4445555~
Ref.
Des.
REF01
Data
Element
128
REF02
127
62
Base
User
Name
Attributes
Attributes
M
1 ID 2/3
M
Y4
Agency Claim Number
X
1 AN 1/50
M
IMPLEMENTATION NAME: Property Casualty Claim Number
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
REF Property and Casualty Patient Identifier

0375
2010CA
Detail
Optional
1
clearinghouse). If no required by this implementation guide, do not send.
Ref.
Des.
REF01
Data
Element
128
Base
User
Name
Attributes
Attributes
M
1 ID 2/3
M
1W
Unique identification number assigned to each member under a
subscriber's contract
This code designates a patient identification number used by the
destination payer identified in the Payer Name loop, Loop ID
2010BB, associated with this claim.
SY
would be valid, while sending "111-00-2222" would be invalid.
REF02
127
X
1 AN 1/50
M
Implementation Name: Property and Casualty Patient Identifier
63
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
CLM Claim information

1300
2300
Detail
Mandatory
1
To specify basic data about the claim
1
2
3
5
6
Comments:
Notes:
CLM02 is the total amount of all submitted charges of service segments for this
claim.
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.
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.
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.
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.
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.
TR3 Notes: 1. The developers of this implementation guide recommend that trading
partners limit the size of the transaction (ST-SE envelope) to a maximum of 5000 CLM
segments. There is no recommended limit to the number of ST-SE transactions within a
GS-GE or ISA-IEA. Willing trading partners can agree to set limits higher.
2. For purposes of this documentation, the claim detail information is presented only in
the dependent level. Specific claim detail information can be given in either the
subscriber or the dependent hierarchical level. Because of this, the claim information is
said to "float." Claim information is positioned in the same hierarchical level that
describes its owner-participant, either the subscriber or the dependent. In other words, the
claim information, Loop ID-2300, is placed following Loop ID-2010BB in the Subscriber
Hierarchical Level (HL) when patient information is sent in Loop ID-2010BA of the
Subscriber HL. Claim information is placed in the Patient HL when the patient
information is sent in Loop ID-2010CA of the Patient HL. When the patient is the
subscriber or is considered to be the subscriber, Loop ID-2000C and Loop ID-2010CA
are not sent. See Subscriber/Patient HL Segment explanation in section 1.4.3.2.2.1 for
details.
TR3 Example: CLM*12345656*500***11:A:7**A*N*I***********15~
Ref.
Des.
CLM
01
Data
Element
1028
Base
User
Attributes
Attributes
M 1
AN
M
1/38
Identifier used to track a claim from creation by the health care provider through
payment
IMPLEMENTATION NAME: Patient Control Number
Name
Claim Submitter's Identifier
The number that the submitter transmits in this position is echoed back to the submitter
in the 835 and other transactions. This permits the submitter to use the value in this
field as a key in the submitters system to match the claim to the payment information
returned in the 835 transaction. The two recommended identifiers are either the Patient
Account Number or the Claim Number in the billing submitters patient management
64
April 2014
005010X223A2 837
system. The developers of this implementation guide strongly recommend that

submitters use unique numbers for this field for each individual claim.
When Loop ID-2010AC is present, CLM01 represents the subrogated Medicaid
agencys claim number (ICN/DCN) from their original 835 CLP07 - Payer Claim
Control Number. See Section 1.4.1.4 of the front matter for a description of post
payment recovery claims for subrogated Medicaid agencies.
CLM
02
782
The maximum number of characters to be supported for this field is 20. Characters
beyond the maximum are not required to be stored nor returned by any 837-receiving
system.
Monetary Amount
O 1
R 1/18
M
Monetary amount
IMPLEMENTATION NAME: Total Claim Charge Amount
The Total Claim Charge Amount must be greater than or equal to zero.
CLM
05
CLM0
5-1
C023
The total claim charge amount must balance to the sum of all service line charge
amounts reported in the Institutional Service Line (SV2) segments for this claim.
Health Care Service Location Information
O 1
M
1331
To provide information that identifies the place of service or the type of bill related to
the location at which a health care service was rendered
Facility Code Value
M
AN 1/2
M
Code identifying where services were, or may be, performed; the first and second
positions of the Uniform Bill Type Code for Institutional Services or the Place of
Service Codes for Professional or Dental Services.
IMPLEMENTATION NAME: Facility Type Code
CLM0
5-2
CLM0
5-3
1332
Facility Code Qualifier
ID 1/2
1325
Code identifying the type of facility referenced

A
Uniform Billing Claim Form Bill Type
CODE SOURCE 236: Uniform Billing Claim Form Bill Type
Claim Frequency Type Code
O
ID 1/1
M
Code specifying the frequency of the claim; this is the third position of the Uniform
Billing Claim Form Bill Type
IMPLEMENTATION NAME: Claim Frequency Code
CODE SOURCE 235: Claim Frequency Type Code
1 or 7
1 = Original Entries.
CLM
07
1359
7 = Adjustments.
Provider Accept Assignment Code
ID 1/1
Code indicating whether the provider accepts assignment

IMPLEMENTATION NAME: Assignment or Plan Participation Code
Within this element the context of the word assignment is related to the relationship
65
April 2014
005010X223A2 837
CLM
08
1073
between the provider and the payer. This is NOT the field for reporting whether the
patient has or has not assigned benefits to the provider. The benefit assignment
indicator is in CLM08.
A
Assigned
B
Assignment Accepted on Clinical Lab Services Only
C
Not Assigned
Yes/No Condition or Response Code
O 1
ID 1/1
M
Code indicating a Yes or No condition or response
IMPLEMENTATION NAME: Benefits Assignment Certification Indicator
CLM
09
CLM
20
1363
This element answers the question whether or not the insured has authorized the plan
to remit payment directly to the provider.
N
No
W
Not Applicable
Use code W when the patient refuses to assign benefits.
Y
Yes
Release of Information Code
O 1
ID 1/1
M
1514
Code indicating whether the provider has on file a signed statement by the patient
authorizing the release of medical data to other organizations
The Release of Information response is limited to the information carried in this claim.
I
Informed Consent to Release Medical Information for
Conditions or Diagnoses Regulated by Federal Statutes
Required when the provider has not collected a signature AND
state or federal laws do not require a signature be collected.
Y
Yes, Provider has a Signed Statement Permitting Release of
Medical Billing Data Related to a Claim
Required when the provider has collected a signature.
OR
Required when state or federal laws require a signature be
collected.
Delay Reason Code
O 1
ID 1/2
O
Code indicating the reason why a request was delayed
SITUATIONAL RULE: Required when the claim is submitted late (past contracted
date of filing limitations). If not required by this implementation guide, do not send.
1
Proof of Eligibility Unknown or Unavailable
2
Litigation
3
Authorization Delays
4
Delay in Certifying Provider
5
Delay in Supplying Billing Forms
6
Delay in Delivery of Custom-made Appliances
7
Third Party Processing Delay
8
Delay in Eligibility Determination
9
Original Claim Rejected or Denied Due to a Reason Unrelated
to the Billing Limitation Rules
10
Administration Delay in the Prior Approval Process
11
Other
15
Natural Disaster
66
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
DTP Discharge Date/Hour

1350
2300
Detail
Optional
1
To specify any or all of a date, a time, or a time period
1
DTP02 is the date or time or period format that will appear in DTP03.
Situational Rule: Required on all final inpatient claims. If not required by this
TR3 Example: DTP*096*TM*1130~
Ref.
Des.
DTP0
1
DTP0
2
DTP0
3
67
Data
Element
374
1250
1251
Name
Date/Time Qualifier
Base
User
Attributes
Attributes
M 1
ID 3/3
M
Code specifying type of date or time, or both date and time

IMPLEMENTATION NAME: Date Time Qualifier
096
Discharge
M 1
ID 2/3
TM
Time Expressed in Format HHMM
Time expressed in the format HHMM where HH is the
numerical expression of hours in the day based on a twenty-four
hour clock and MM is the numerical expression of minutes
within an hour
Date Time Period
M 1
AN
M
1/35
IMPLEMENTATION NAME: Discharge Time
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
DTP Statement Dates

1350
2300
Detail
Mandatory
1
1
TR3 Example: DTP*434*RD8*20041209-20041214~

Ref.
Des.
DTP0
1
DTP0
2
DTP0
3
68
Data
Element
374
1250
1251
Name
Date/Time Qualifier
Base
User
Attributes
Attributes
M 1
ID 3/3
M

434
Statement
Date on which billing document was created
M 1
ID 2/3
RD8
Range of Dates Expressed in Format CCYYMMDDCCYYMMDD
A range of dates expressed in the format CCYYMMDDCCYYMMDD where CC is the first two digits of the calendar
year, YY is the last two digits of the calendar year, MM is the
month (01 to 12), and DD is the day in the month (01 to 31); the
first occurrence of CCYYMMDD is the beginning date and the
second occurrence is the ending date
Use RD8 to indicate the from and through date of the statement.
When the statement is for a single date of service, the from and
through date are the same.
Date Time Period
M 1
AN
M
1/35
IMPLEMENTATION NAME: Statement From or To Date
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
DTP Admission Date/Hour

1350
2300
Detail
Optional
1
1
Required on inpatient claims. If not required by this implementation guide, do not send.
TR3 Example: DTP*435*D8*200410131242~
Ref.
Des.
DTP0
1
DTP0
2
DTP0
3
69
Data
Element
374
1250
1251
Name
Date/Time Qualifier
Base
User
Attributes
Attributes
M 1
ID 3/3
M

435
Admission
Date of entrance to a health care establishment
M 1
ID 2/3
Selection of the appropriate qualifier is designated by the NUBC Billing Manual.
D8
D8
Required for home health and hospice.
Date Time Period
M 1
AN
M
1/35
IMPLEMENTATION NAME: Admission Date and Hour
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
DTP Date - Repricer Received Date

1350
2300
Detail
Optional
1
1
Required when a repricer is passing the claim onto the payer. If not required by this
TR3 Example: DTP*050*D8*20051030~
Ref.
Des.
DTP0
1
DTP0
2
DTP0
3
70
Data
Element
374
1250
1251
Name
Date/Time Qualifier
Base
User
Attributes
Attributes
M 1
ID 3/3
M

050
Received
M 1
ID 2/3
D8
Date Time Period
M 1
AN
1/35
IMPLEMENTATION NAME: Repricer Received Date
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
CL1 Institutional Claim Code

1400
2300
Detail
Mandatory
1
To supply information specific to hospital claims
TR3 Example: CL1*1*7*30~

Ref.
Des.
CL10
1
Data
Element
1315
Name
Admission Type Code
Base
User
Attributes
Attributes
O 1
ID 1/1
M
Code indicating the priority of this admission

SITUATIONAL RULE: Required when patient is being admitted for inpatient
services. If not required by this implementation guide, do not send.
CL10
2
1314
CODE SOURCE 231: Admission Type Code

Admission Source Code
ID 1/1
Code indicating the source of this admission

SITUATIONAL RULE: Required for all inpatient and outpatient services. If not
CL10
3
1352
CODE SOURCE 230: Admission Source Code

Patient Status Code
ID 1/2
Code indicating patient status as of the "statement covers through date"

CODE SOURCE 239: Patient Status Code
71
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
PWK Claim Supplemental Information

1550
2300
Detail
Mandatory
10
To identify the type or transmission or both of paperwork or supporting information
1 If either PWK05 or PWK06 is present, then the other is required.
1
2
PWK05 and PWK06 may be used to identify the addressee by a code number.
PWK07 may be used to indicate special information to be shown on the specified
report.
3 PWK08 may be used to indicate action pertaining to a report.
Situational Rule: Required when there is a paper attachment following this claim.
OR
Required when attachments are sent electronically (PWK02 = EL) but are transmitted in
another functional group (for example, 275) rather than by paper. PWK06 is then used to
identify the attached electronic documentation. The number in PWK06 is carried in the
TRN of the electronic attachment.
OR
Required when the provider deems it necessary to identify additional information that is
being held at the providers office and is available upon request by the payer (or
appropriate entity), but the information is not being submitted with the claim. Use the
value of "AA" in PWK02 to convey this specific use of the PWK segment.
TR3 Example: PWK*OZ*AA***AC*20700000007856936001~
Ref.
Des.
PWK01
PWK02
72
Data
Element
755
756
Base
User
Name
Attributes
Attributes
Report Type Code
M
1 ID 2/2
M
Code indicating the title or contents of a document, report or supporting item
IMPLEMENTATION NAME: Attachment Report Type Code
B3, CT, EB, NN, OB, OZ
Field indicating that an attachment was submitted with the claim
B3
Physician Order
CT
Certification
EB
Explanation of Benefits (Coordination of Benefits or Medicare
Secondary Payor)
Summary of benefits paid on the claim
NN
Nursing Notes
Notes kept by the nurse regarding a patient's physical and mental
condition, what medication the patient is on and when it should be
given
OB
Operative Note
Step-by-step notes of exactly what takes place during an operation
OZ
Support Data for Claim
Medical records that would support procedures performed; tests
given and necessary for a claim
Report Transmission Code
O
1 ID 1/2
M
April 2014
005010X223A2 837
PWK05
66
PWK06
67
Code defining timing, transmission method or format by which reports are to be sent
IMPLEMENTATION NAME: Attachment Transmission Code
AA
Available on Request at Provider Site
This means that the additional information is not being sent with the
claim at this time. Instead, it is available to the payer (or appropriate
entity) at their request.
BM
By Mail
EL
Electronically Only
Indicates that the attachment is being transmitted in a separate X12
functional group.
EM
E-Mail
FT
File Transfer
Required when the actual attachment is maintained by an attachment
warehouse or similar vendor.
FX
By Fax
X
1 ID 1/2
O
Code designating the system/method of code structure used for Identification Code (67)
SITUATIONAL RULE: Required when PWK02 = BM, EL, EM, FX or FT. If not required
AC
Attachment Control Number
Means of associating electronic claim with documentation forwarded
by other means
Identification Code
X
1 AN 2/80
O
SITUATIONAL RULE: Required when PWK02 = "BM", "EL", "EM", "FX" or "FT". If
IMPLEMENTATION NAME: Attachment Control Number
PWK06 is used to identify the attached electronic documentation. The number in PWK06
is carried in the TRN of the electronic attachment.
For the purpose of this implementation, the maximum field length is 50.
IRCN (Inquiry Record Claim Number)
Field Position:
01 - 17 = BCBSIL RCN number.
18 - 18 = Indicator that an original claim submission has been split into multiple claims.
The original will indicate zero.
19 - 20 = Indicates the number of adjustments on the claim.
73
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
CN1 Contract Information

1600
2300
Detail
Optional
1
To specify basic data about the contract or contract line item
1
2
3
4
CN102 is the contract amount.

CN103 is the allowance or charge percent.
CN104 is the contract code.
CN106 is an additional identifying number for the contract.
Situational Rule: Required when the submitter is contractually obligated to supply this
information on post-adjudicated claims. If not required by this implementation guide, do
not send.
TR3 Notes: 1. The developers of this implementation guide note that the CN1 segment is
for use only for post-adjudicated claims, which do not meet the definition of a health care
claim under HIPAA. Consequently, at the time of this writing, the CN1 segment is for
non-HIPAA use only.
TR3 Example: CN1*02*550~
Ref.
Des.
CN101
Data
Element
1166
CN102
782
Base
User
Name
Attributes
Attributes
Contract Type Code
M
1 ID 2/2
M
Code identifying a contract type
01
A patient classification scheme, which provides means of relating
the type of patients a hospital treats to the costs incurred by the
hospital, to determine quality of care and utilization of services in a
hospital setting
02
Per Diem
A contract which allows certain charges to be on a rate per day basis
03
Variable Per Diem
A contract which allows certain charges to be on a rate per day basis,
where the rate may not remain constant
04
Flat
A contract between the provider of service and the destination payor
whereby the flat rate charges may differ from the total itemized
charges
05
Capitated
A contract between the provider of service and the destination payor
which allows payment to the provider of service on a per member
per month basis
06
Percent
09
Other
Monetary Amount
O
1 R 1/18
O
Monetary amount
SITUATIONAL RULE: Required when the provider is required by contract to supply this
information on the claim. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Contract Amount
74
April 2014
005010X223A2 837
CN103
332
CN104
127
CN105
338
CN106
799
Percent, Decimal Format

O
1 R 1/6
O
Percent given in decimal format (e.g., 0.0 through 100.0 represents 0% through 100%)
IMPLEMENTATION NAME: Contract Percentage
O
1 AN 1/50
O
IMPLEMENTATION NAME: Contract Code
Terms Discount Percent
O
1 R 1/6
O
Terms discount percentage, expressed as a percent, available to the purchaser if an invoice
is paid on or before the Terms Discount Due Date
IMPLEMENTATION NAME: Terms Discount Percentage
Version Identifier
O
1 AN 1/30
O
Revision level of a particular format, program, technique or algorithm
IMPLEMENTATION NAME: Contract Version Identifier
75
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
AMT Patient Estimated Amount Due

1750
2300
Detail
Optional
1
To indicate the total monetary amount
Situational Rule: This segment is required when the Patient Responsibility Amount is
applicable to this claim. If not required by this implementation guide, do not send.
TR3 Example: AMT*F3*123~
Ref.
Des.
AMT01
Data
Element
522
AMT02
782
76
Base
User
Name
Attributes
Attributes
Amount Qualifier Code
M
1 ID 1/3
M
Code to qualify amount
F3
Patient Responsibility - Estimated
Approximate value one receiving medical care is obliged to pay
Monetary Amount
M
1 R 1/18
M
Monetary amount
IMPLEMENTATION NAME: Patient Responsibility Amount
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
REF Service Authorization Exception Code

1800
2300
Detail
Optional
1
Situational Rule: Required when mandated by government law or regulation to obtain
authorization for specific service(s) but, for the reasons listed in REF02, the service was
performed without obtaining the authorization. If not required by this implementation
guide, do not send.
TR3 Example: REF*4N*1~
Ref.
Des.
REF01
Data
Element
128
REF02
127
Base
User
Name
Attributes
Attributes
M
1 ID 2/3
M
4N
Special Payment Reference Number
X
1 AN 1/50
M
IMPLEMENTATION NAME: Service Authorization Exception Code
Allowable values for this element are:
1 Immediate/Urgent Care
2 Services Rendered in a Retroactive Period
3 Emergency Care
4 Client has Temporary Medicaid
5 Request from County for Second Opinion to Determine if Recipient Can Work
6 Request for Override Pending
7 Special Handling
1
Immediate/Urgent Care
2
Services Rendered in a Retroactive Period
3
Emergency Care
4
Client has Temporary Medicaid
5
Request from County for Second Opinion to Determine if Receipient
can Work
6
Request for Override Pending
7
Special Handling
77
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
REF Referral Number

1800
2300
Detail
Optional
1
Situational Rule: Required when a referral number is assigned by the payer or Utilization
Management Organization (UMO)
AND
a referral is involved.
TR3 Notes: 1. Numbers at this position apply to the entire claim unless they are
overridden in the REF segment in Loop ID-2400. A reference identification is considered
to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF
segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF
applies only to that specific line.
TR3 Example: REF*9F*12345~
Ref.
Des.
REF01
Data
Element
128
REF02
127
78
Base
User
Name
Attributes
Attributes
M
1 ID 2/3
M
9F
Referral Number
X
1 AN 1/50
M
IMPLEMENTATION NAME: Referral Number
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
REF Prior Authorization

1800
2300
Detail
Optional
1
Situational Rule: Required when an authorization number is assigned by the payer or
UMO
AND the services on this claim were preauthorized.
TR3 Notes: 1. Generally, preauthorization numbers are assigned by the payer or UMO to
authorize a service prior to its being performed. The UMO (Utilization Management
Organization) is generally the entity empowered to make a decision regarding the
outcome of a health services review or the owner of information. The prior authorization
number carried in this REF is specific to the destination payer reported in the Loop ID2010BB. If other payers have similar numbers for this claim, report that information in
the Loop ID-2330 loop REF which holds that payers information.
2. Numbers at this position apply to the entire claim unless they are overridden in the
REF segment in Loop ID-2400. A reference identification is considered to be overridden
if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop
ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific
line.
TR3 Example: REF*G1*Y~
Ref.
Des.
REF0
1
REF0
2
Data
Element
128
127
Name
Base
User
Attributes
Attributes
M 1
ID 2/3
M

G1
Prior Authorization Number
An authorization number acquired prior to the submission of a
claim
X 1
AN
M
1/50
IMPLEMENTATION NAME: Prior Authorization Number
Y or N
It indicates that all Medical Service Advisory requirements are met.
79
April 2014
005010X223A2 837
02005033146Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
REF Payer Claim Control Number

1800
2300
Detail
Optional
1
Situational Rule: Required when CLM05-3 (Claim Frequency Code) indicates this claim
is a replacement or void to a previously adjudicated claim. If not required by this
TR3 Notes: 1. This information is specific to the destination payer reported in Loop ID2010BB.
TR3 Example: REF*F8*0200503351423460CA20~
Ref.
Des.
REF0
1
REF0
2
Data
Element
128
127
Name
F8
Original Reference Number
Base
User
Attributes
Attributes
M 1
ID 2/3
M
AN
M
1/50
IMPLEMENTATION NAME: Payer Claim Control Number
This field will be supplied with Original Claim Document Control Number Field and
BlueChip Adjustment Reason Code.
Field Position:
01 - 17 = BCBSIL document control number
18 - 20 = BlueChip Adjustment Reason Code
80
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
REF Repriced Claim Number

1800
2300
Detail
Mandatory
1
Situational Rule: Required when this information is deemed necessary by the repricer.
The segment is not completed by providers. The information is completed by repricers
only. If not required by this implementation guide, do not send.
TR3 Notes: 1. This information is specific to the destination payer reported in the
2010BB loop.
TR3 Example: REF*9A*0200503351466360C02~
Ref.
Des.
REF0
1
REF0
2
Data
Element
128
127
Name
Base
User
Attributes
Attributes
M 1
ID 2/3
M

9A
Repriced Claim Reference Number
X
AN
M
1/50
IMPLEMENTATION NAME: Repriced Claim Reference Number
This field will be supplied with original claim Document Control Number and Claim
Adjustment Suffix.
Field Position:
01 - 17 = BCBSIL document control number
18 - 19 = Claim Adjustment Suffix
81
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
REF Adjusted Repriced Claim Number

1800
2300
Detail
Optional
1
TR3 Notes: 1. This information is specific to the destination payer reported in the
2010BB loop.
Shared Claims Processing Notes
TR3 Example: REF*9C*201~
Ref.
Des.
REF01
Data
Element
128
REF02
127
Base
User
Name
Attributes
Attributes
M
1 ID 2/3
M
9C
Adjusted Repriced Claim Reference Number
X
1 AN 1/50
M
IMPLEMENTATION NAME: Adjusted Repriced Claim Reference Number
Adjustment Reason Code (ANSI Code)
Indicates an adjustment made to the original entry. Please refer to Appendix for code value
conversion
82
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
REF Investigational Device Exemption Number

1800
2300
Detail
Optional
5
Situational Rule: Required when claim involves a Food and Drug Administration (FDA)
assigned investigational device exemption (IDE) number. When more than one IDE
applies, they must be split into separate claims. If not required by this implementation
guide, do not send.
TR3 Example: REF*LX*432907~
Ref.
Des.
REF01
Data
Element
128
REF02
127
83
Base
User
Name
Attributes
Attributes
M
1 ID 2/3
M
LX
Qualified Products List
X
1 AN 1/50
M
IMPLEMENTATION NAME: Investigational Device Exemption Identifier
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
REF Claim Identification For Transmission Intermediaries

1800
2300
Detail
Optional
1
Situational Rule: Required when this information is deemed necessary by transmission
intermediaries (Automated Clearinghouses, and others) who need to attach their own
unique claim number. If not required by this implementation guide, do not send.
TR3 Notes: 1. Although this REF is supplied for transmission intermediaries to attach
their own unique claim number to a claim, 837-recipients are not required under HIPAA
to return this number in any HIPAA transaction. Trading partners may voluntarily agree
to this interaction if they wish.
TR3 Example: REF*D9*0840179384759475~
Ref.
Des.
REF0
1
REF0
2
Data
Element
128
127
Name
Base
User
Attributes
Attributes
M 1
ID 2/3
M

Number assigned by clearinghouse, van, etc.
D9
Claim Number
Sequence number to track the number of claims opened within
a particular line of business
X 1
AN
M
1/50
IMPLEMENTATION NAME: Value Added Network Trace Number
The value carried in this element is limited to a maximum of 20 positions.
Unique control number assigned when a claim enter the ITS process.
84
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
REF Auto Accident State

1800
2300
Detail
Optional
1
Situational Rule: Required when the services reported on this claim are related to an auto
accident and the accident occurred in a country or location that has a state, province, or
sub-country code named in code source 22. If not required by this implementation guide,
do not send.
TR3 Example: REF*LU*MD~
Ref.
Des.
REF01
Data
Element
128
REF02
127
Base
User
Name
Attributes
Attributes
M
1 ID 2/3
M
LU
Location Number
X
1 AN 1/50
M
IMPLEMENTATION NAME: Auto Accident State or Province Code
Values in this field must be valid codes found in code source 22.
85
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
REF Medical Record Number

1800
2300
Detail
Optional
1
Situational Rule: Required when the provider needs to identify for future inquiries, the
actual medical record of the patient identified in either Loop ID - 2010BA or 2010CA for
this episode of care. If not required by this implementation guide, do not send.
TR3 Example: REF*EA*44444TH56~
Ref.
Des.
REF0
1
REF0
2
86
Data
Element
128
127
Name
Base
User
Attributes
Attributes
M 1
ID 2/3
M

EA
Medical Record Identification Number
A unique number assigned to each patient by the provider of
service (hospital) to assist in retrieval of medical records
X 1
AN
M
1/50
IMPLEMENTATION NAME: Medical Record Number
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
REF Demonstration Project Identifier

1800
2300
Detail
Optional
1
Situational Rule: Required when it is necessary to identify claims which are atypical in
ways such as content, purpose, and/or payment, as could be the case for a demonstration
or other special project, or a clinical trial. If not required by this implementation guide, do
not send.
TR3 Example: REF*P4*THJ1222~
Ref.
Des.
REF01
Data
Element
128
REF02
127
87
Base
User
Name
Attributes
Attributes
M
1 ID 2/3
M
P4
Project Code
X
1 AN 1/50
M
IMPLEMENTATION NAME: Demonstration Project Identifier
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
REF Peer Review Organization (PRO) Approval Number

1800
2300
Detail
Optional
1
Situational Rule: Required when an external Peer Review Organization assigns an
Approval Number to services deemed medically necessary by that organization. If not
Ref.
Des.
REF01
Data
Element
128
REF02
127
88
Base
User
Name
Attributes
Attributes
M
1 ID 2/3
M
G4
Peer Review Organization (PRO) Approval Number
An authorization number for certain surgical procedures and for an
assistant at cataract surgery
X
1 AN 1/50
M
IMPLEMENTATION NAME: Peer Review Authorization Number
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
K3 File Information
1850
2300
Detail
Mandatory
10
To transmit a fixed-format record or matrix contents
1 K303 identifies the value of the index.
1 The default for K302 is content.
Situational Rule: Required when ALL of the following conditions are met:
A regulatory agency concludes it must use the K3 to meet an emergency legislative
requirement;
The administering regulatory agency or other state organization has completed each one
of the following steps: contacted the X12N workgroup, requested a review of the K3 data
requirement to ensure there is not an existing method within the implementation guide to
meet this requirement
X12N determines that there is no method to meet the requirement. If not required by this
TR3 Notes: 1. At the time of publication of this implementation, K3 segments have no
specific use. The K3 segment is expected to be used only when necessary to meet the
unexpected data requirement of a legislative authority. Before this segment can be used :
- The X12N Health Care Claim workgroup must conclude there is no other available
option in the implementation guide to meet the emergency legislative requirement.
- The requestor must submit a proposal for approval accompanied by the relevant
business documentation to the X12N Health Care Claim workgroup chairs and receive
approval for the request. Upon review of the request, X12N will issue an approval or
denial decision to the requesting entity. Approved usage(s) of the K3 segment will be
reviewed by the X12N Health Care Claim workgroup to develop a permanent change to
include the business case in future transaction implementations.
2. Only when all of the requirements above have been met, may the regulatory agency
require the temporary use of the K3 segment.
3. X12N will submit the necessary data maintenance and refer the request to the
appropriate data content committee(s).
TR3 Example: K3*STATE DATA REQUIREMENT~
Ref.
Des.
K301
Data
Element
449
Base
User
Attributes
Attributes
M 1
AN
M
1/80
Data in fixed format agreed upon by sender and receiver
Refer to Appendix for fixed format claim level details.
Name
Fixed Format Information
The 837 format has a Claim Level File Information segment ("K3") and Claim Line
Level Supplemental Information segment ("PWK") which can be used for
communicating such information.
K3 and PWK segments repeat twice and contain information in fixed format. Detailed
89
April 2014
005010X223A2 837
information about each field has been described in Appendix
90
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
NTE Claim Note

1900
2300
Detail
Optional
10
To transmit information in a free-form format, if necessary, for comment or special
instruction
The NTE segment permits free-form information/data which, under ANSI X12
standard implementations, is not machine processible. The use of the NTE segment
should therefore be avoided, if at all possible, in an automated environment.
Situational Rule: Required when in the judgment of the provider, the information is
needed to substantiate the medical treatment and is not supported elsewhere within the
claim data set.
OR
Required when in the judgment of the provider, narrative information from the forms
"Home Health Certification and Plan of Treatment" or "Medical Update and Patient
Information" is needed to substantiate home health services.
TR3 Notes: 1. The developers of this implementation guide discourage using narrative
information within the 837. Trading partners who use narrative information with claims
are strongly encouraged to codify that information within the X12 environment.
TR3 Example: NTE*NTR*PATIENT REQUIRES TUBE FEEDING~
Ref.
Des.
NTE01
Data
Element
363
NTE02
352
91
Base
User
Name
Attributes
Attributes
Note Reference Code
O
1 ID 3/3
M
Code identifying the functional area or purpose for which the note applies
ALG
Allergies
DCP
Goals, Rehabilitation Potential, or Discharge Plans
DGN
Diagnosis Description
Verbal description of the condition involved
DME
Durable Medical Equipment (DME) and Supplies
MED
Medications
NTR
Nutritional Requirements
ODT
Orders for Disciplines and Treatments
RHB
Functional Limitations, Reason Homebound, or Both
RLH
Reasons Patient Leaves Home
RNH
Times and Reasons Patient Not at Home
SET
Unusual Home, Social Environment, or Both
SFM
Safety Measures
SPT
Supplementary Plan of Treatment
UPI
Updated Information
Description
M
1 AN 1/80
M
A free-form description to clarify the related data elements and their content
IMPLEMENTATION NAME: Claim Note Text
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
NTE Billing Note

1900
2300
Detail
Optional
1
instruction
Situational Rule: Required when in the judgment of the provider, the information is
needed to substantiate the medical treatment and is not supported elsewhere within the
claim data set.
TR3 Example: NTE*ADD*NO LIABILITY, PATIENT FELL AT HOME~
Ref.
Des.
NTE0
1
NTE0
2
92
Data
Element
363
352
Name
Note Reference Code
Base
User
Attributes
Attributes
O 1
ID 3/3
M
ADD
Additional Information
Description
M 1
AN
1/80
IMPLEMENTATION NAME: Billing Note Text
April 2014
005010X223A2 837
Segment:
HI Principal Diagnosis
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
2310
2300
Detail
Mandatory
1
To supply information related to the delivery of health care
2 Only one of C02208 or C02209 may be present.
TR3 Notes: 1. 1. Do not transmit the decimal point for ICD codes. The decimal point is
implied.
TR3 Example: HI*BK:9976~
TR3 Example: HI*ABK:T8731~
Ref.
Des.
HI01
Data
Element
C022
HI01-1
1270
93
Base
User
Name
Attributes
Attributes
Health Care Code Information
M
1
M
To send health care codes and their associated dates, amounts and quantities
Code List Qualifier Code
M
ID 1/3
M
Code identifying a specific industry code list
ABK
International Classification of Diseases Clinical Modification (ICD10-CM) Principal Diagnosis
This code set is not allowed for use under HIPAA at the time of this
writing. The qualifier can only be used:
If a new rule names the ICD-10-CM as an allowable code set under
HIPAA,
April 2014
005010X223A2 837
OR
The Secretary grants an exception to use the code set as a pilot
project as allowed under the law,
OR
For claims which are not covered under HIPAA.
HI01-2
1271
HI01-9
1073
CODE SOURCE 897: International Classification of Diseases, 10th

Revision, Clinical Modification (ICD-10-CM)
BK
International Classification of Diseases Clinical Modification (ICD9-CM) Principal Diagnosis
Industry Code
M
AN 1/30
M
Code indicating a code from a specific industry code list
IMPLEMENTATION NAME: Principal Diagnosis Code
X
ID 1/1
O
SITUATIONAL RULE: Required as directed by the NUBC billing manual.
IMPLEMENTATION NAME: Present on Admission Indicator
Refer to 005010X223A2 Data Element Dictionary for acceptable code values.
94
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
HI Admitting Diagnosis
2310
2300
Detail
Optional
1
Situational Rule: Required when claim involves an inpatient admission. If not required by
TR3 Notes: 1. Do not transmit the decimal point for ICD codes. The decimal point is
implied.
TR3 Example: HI*BJ:9976~
TR3 Example: HI*ABJ:T8741~
Ref.
Des.
HI01
Data
Element
C022
HI01-1
1270
95
Base
User
Name
Attributes
Attributes
M
1
M
M
ID 1/3
M
ABJ
International Classification of Diseases Clinical Modification (ICD10-CM) Admitting Diagnosis
HIPAA,
OR
April 2014
005010X223A2 837

OR
HI01-2
96
1271

BJ
International Classification of Diseases Clinical Modification (ICD9-CM) Admitting Diagnosis
Industry Code
M
AN 1/30
M
IMPLEMENTATION NAME: Admitting Diagnosis Code
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
HI Patient Reason For Visit

2310
2300
Detail
Optional
1
Situational Rule: Required when claim involves outpatient visits. If not required by this
implied.
TR3 Example: HI*PR:78701~
TR3 Example: HI*APR:R110~
Ref.
Des.
HI01
Data
Element
C022
HI01-1
1270
97
Base
User
Name
Attributes
Attributes
M
1
M
M
ID 1/3
M
APR
International Classification of Diseases Clinical Modification (ICD10-CM) Patient's Reason for Visit
HIPAA,
OR
April 2014
005010X223A2 837

OR
HI01-2
1271
HI02
C022
HI02-1
1270
HI02-2
1271
HI03
C022
HI03-1
1270
98

PR
Industry Code
M
AN 1/30
M
IMPLEMENTATION NAME: Patient Reason For Visit
O
1
O
SITUATIONAL RULE: Required when an additional Patients Reason for Visit must be
sent and the preceding HI data elements have been used to report other patients reason for
visit. If not required by this implementation guide, do not send.
M
ID 1/3
M
APR
HIPAA,
OR
OR
PR
Industry Code
M
AN 1/30
M
O
1
O
SITUATIONAL RULE: Required when an additional Patients Reason for Visit must be
sent and the preceding HI data elements have been used to report other patients reason for
visit. If not required by this implementation guide, do not send.
M
ID 1/3
M
APR
HIPAA,
April 2014
005010X223A2 837
OR
OR
HI03-2
99
1271

PR
Industry Code
M
AN 1/30
M
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
HI External Cause of Injury

2310
2300
Detail
Optional
1
Situational Rule: Required when an external Cause of Injury is needed to describe an

injury, poisoning, or adverse effect. If not required by this implementation guide, do not
send.
implied.
2. In order to fully describe an injury using ICD-10-CM, it will be necessary to report a
series of 3 external cause of injury codes.
TR3 Example: HI*BN:E8660~
TR3 Example: HI*ABN:T560X1~
Ref.
Des.
HI01
Data
Element
C022
HI01-1
1270
100
Base
User
Name
Attributes
Attributes
M
1
M
M
ID 1/3
M
ABN
International Classification of Diseases Clinical Modification (ICD10-CM) External Cause of Injury Code
April 2014
005010X223A2 837

HIPAA,
OR
OR
HI01-2
1271
HI01-9
1073
HI02
C022
HI02-1
1270
HI02-2
1271
HI02-9
1073
101

Revision, Clinical Modification (ICD-10-CM
BN
International Classification of Diseases Clinical Modification (ICD9-CM) External Cause of Injury Code (E-codes)
Industry Code
M
AN 1/30
M
IMPLEMENTATION NAME: External Cause of Injury Code
X
ID 1/1
O
O
1
O
SITUATIONAL RULE: Required when an additional External Cause of Injury must be
sent and the preceding HI data elements have been used to report other causes of injury. If
M
ID 1/3
M
ABN
HIPAA,
OR
OR
BN
Industry Code
M
AN 1/30
M
X
ID 1/1
O
April 2014
005010X223A2 837
HI03
C022
HI03-1
1270
HI03-2
1271
HI03-9
1073
HI04
C022
HI04-1
1270
102

O
1
O
M
ID 1/3
M
ABN
HIPAA,
OR
OR
BN
Industry Code
M
AN 1/30
M
X
ID 1/1
O
O
1
O
M
ID 1/3
M
ABN
HIPAA,
OR
OR
April 2014
005010X223A2 837
HI04-2
1271
HI04-9
1073
HI05
C022
HI05-1
1270
HI05-2
1271
HI05-9
1073
HI06
103
C022

BN
Industry Code
M
AN 1/30
M
X
ID 1/1
O
SITUATIONAL RULE: Required as directed by the NUBC billing
O
1
O
M
ID 1/3
M
ABN
HIPAA,
OR
OR
BN
Industry Code
M
AN 1/30
M
X
ID 1/1
O
O
1
O
April 2014
005010X223A2 837
HI06-1
1270
HI06-2
1271
HI06-9
1073
HI07
C022
HI07-1
1270

M
ID 1/3
M
ABN
HIPAA,
OR
OR
BN
Industry Code
M
AN 1/30
M
X
ID 1/1
O
O
1
O
M
ID 1/3
M
ABN
HIPAA,
OR
OR
BN
104

April 2014
005010X223A2 837
HI07-2
1271
HI07-9
1073
HI08
C022
HI08-1
1270
HI08-2
1271
HI08-9
1073
HI09
C022
HI09-1
1270
105
Industry Code
M
AN 1/30
X
ID 1/1

O
1
O
M
ID 1/3
M
ABN
HIPAA,
OR
OR
BN
Industry Code
M
AN 1/30
M
X
ID 1/1
O
O
1
O
M
ID 1/3
M
ABN
April 2014
005010X223A2 837

HIPAA,
OR
OR
HI09-2
1271
HI09-9
1073
HI10
C022
HI10-1
1270
HI10-2
1271
HI10-9
1073
106

BN
Industry Code
M
AN 1/30
M
X
ID 1/1
O
O
1
O
M
ID 1/3
M
ABN
HIPAA,
OR
OR
BN
Industry Code
M
AN 1/30
M
X
ID 1/1
O
April 2014
005010X223A2 837
HI11
C022
HI11-1
1270
HI11-2
1271
HI11-9
1073
HI12
C022
HI12-1
1270
107

O
1
O
M
ID 1/3
M
ABN
HIPAA,
OR
OR
BN
Industry Code
M
AN 1/30
M
X
ID 1/1
O
O
1
O
M
ID 1/3
M
ABN
HIPAA,
OR
OR
April 2014
005010X223A2 837
HI12-2
1271
HI12-9
1073

BN
Industry Code
M
AN 1/30
M
X
ID 1/1
O
108
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
HI Diagnosis Related Group (DRG) Information

2310
2300
Detail
Optional
1
Situational Rule: Required when an inpatient hospital is under DRG contract with a payer
and the contract requires the provider to identify the DRG to the payer. If not required by
TR3 Example: HI*DR:123~
Ref.
Des.
HI01
Data
Element
C022
HI01-1
1270
HI01-2
1271
109
Base
User
Name
Attributes
Attributes
M
1
M
M
ID 1/3
M
CODE SOURCE 229: Diagnosis Related Group Number (DRG)
DR
CODE SOURCE 229: Diagnosis Related Group Number (DRG)
Industry Code
M
AN 1/30
M
IMPLEMENTATION NAME: Diagnosis Related Group (DRG) Code
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
HI Other Diagnosis Information

2310
2300
Detail
Optional
2
Situational Rule: Required when other condition(s) coexist or develop(s) subsequently

during the patients treatment. If not required by this implementation guide, do not send.
implied.
TR3 Example: HI*BF:4821:::::::N*HI*BF:25000:::::::Y~
TR3 Example: HI*ABF:J151:::::::N*ABF:E119:::::::Y~
Ref.
Des.
HI01
Data
Element
C022
HI01-1
1270
110
Base
User
Name
Attributes
Attributes
M
1
M
M
ID 1/3
M
ABF
International Classification of Diseases Clinical Modification (ICD10-CM) Diagnosis
HIPAA,
OR
April 2014
005010X223A2 837

OR
HI01-2
1271
HI01-9
1073
HI02
C022
HI02-1
1270
HI02-2
1271
HI02-9
1073

BF
Industry Code
M
AN 1/30
M
IMPLEMENTATION NAME: Other Diagnosis
X
ID 1/1
O
O
1
O
SITUATIONAL RULE: Required when it is necessary to report an additional diagnoses
and the preceding HI data elements have been used to report other diagnoses. If not
M
ID 1/3
M
ABF
HIPAA,
OR
OR
BF
Industry Code
M
AN 1/30
M
X
ID 1/1
O
111
April 2014
005010X223A2 837
HI03
C022
HI03-1
1270
HI03-2
1271
HI03-9
1073
HI04
C022
HI04-1
1270

O
1
O
M
ID 1/3
M
ABF
HIPAA,
OR
OR
BF
Industry Code
M
AN 1/30
M
X
ID 1/1
O
O
1
O
M
ID 1/3
M
ABF
HIPAA,
OR
OR
112
April 2014
005010X223A2 837
BF
HI04-2
1271
HI04-9
1073
HI05
C022
HI05-1
1270
HI05-2
1271
HI05-9
1073
HI06
C022
HI06-1
1270
113

Industry Code
M
AN 1/30
M
X
ID 1/1
O
O
1
O
M
ID 1/3
M
ABF
HIPAA,
OR
OR
BF
Industry Code
M
AN 1/30
M
X
ID 1/1
O
O
1
O
M
ID 1/3
M
April 2014
005010X223A2 837
ABF
HI06-2
1271
HI06-9
1073
HI07
C022
HI07-1
1270
HI07-2
114
1271

HIPAA,
OR
OR

BF
Industry Code
M
AN 1/30
M
X
ID 1/1
O
O
1
O
M
ID 1/3
M
ABF
HIPAA,
OR
OR
BF
Industry Code
M
AN 1/30
M
April 2014
005010X223A2 837
HI07-9
1073
HI08
C022
HI08-1
1270
HI08-2
1271
HI08-9
1073
HI09
C022
HI09-1
1270
115

X
ID 1/1

O
1
O
M
ID 1/3
M
ABF
HIPAA,
OR
OR
BF
Industry Code
M
AN 1/30
M
X
ID 1/1
O
O
1
O
M
ID 1/3
M
ABF
HIPAA,
OR
April 2014
005010X223A2 837

OR
HI09-2
1271
HI09-9
1073
HI10
C022
HI10-1
1270
HI10-2
1271
HI10-9
1073

BF
Industry Code
M
AN 1/30
M
X
ID 1/1
O
O
1
O
M
ID 1/3
M
ABF
HIPAA,
OR
OR
BF
Industry Code
M
AN 1/30
M
X
ID 1/1
O
116
April 2014
005010X223A2 837
HI11
C022
HI11-1
1270
HI11-2
1271
HI11-9
1073
HI12
C022
HI12-1
1270

O
1
O
M
ID 1/3
M
ABF
HIPAA,
OR
OR
BF
Industry Code
M
AN 1/30
M
X
ID 1/1
O
O
1
O
M
ID 1/3
M
ABF
HIPAA,
OR
OR
117
April 2014
005010X223A2 837
BF
HI12-2
1271
HI12-9
1073

Industry Code
M
AN 1/30
M
X
ID 1/1
O
118
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
HI Principal Procedure Information

2310
2300
Detail
Optional
1
Situational Rule: Required on inpatient claims when a procedure was performed. If not
implied.
TR3 Example: HI*BR:3121:D8:20051119~
TR3 Example: HI*BBR:0B110F5:D8:20050321~
Ref.
Des.
HI01
Data
Element
C022
HI01-1
1270
119
Base
User
Name
Attributes
Attributes
M
1
M
M
ID 1/3
M
BBR
International Classification of Diseases Clinical Modification (ICD10-PCS) Principal Procedure Codes
If a new rule names the ICD-10-PCS as an allowable code set under
HIPAA,
OR
April 2014
005010X223A2 837

OR
HI01-2
1271
HI01-3
1250
HI01-4
1251
120

Revision, Procedure Coding System
BR
International Classification of Diseases Clinical Modification (ICD9-CM) Principal Procedure Codes
CAH
Advanced Billing Concepts (ABC) Codes
CODE SOURCE 843: Advanced Billing Concepts (ABC) Codes
Industry Code
M
AN 1/30
M
IMPLEMENTATION NAME: Principal Procedure Code
X
ID 2/3
M
D8
Date Time Period
X
AN 1/35
M
IMPLEMENTATION NAME: Principal Procedure Date
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
HI Other Procedure Information

2310
2300
Detail
Optional
2
Situational Rule: Required on inpatient claims when additional procedures must be

reported. If not required by this implementation guide, do not send.
implied.
TR3 Example: HI*BQ:3614:D8:20051117*BQ:3723:D8:20051119~
TR3 Example: HI*BBQ:02139Y3:D8:20050321*BBQ:4A025N8:D8:20050310~
Ref.
Des.
HI01
Data
Element
C022
HI01-1
1270
121
Base
User
Name
Attributes
Attributes
M
1
M
M
ID 1/3
M
BBQ
International Classification of Diseases Clinical Modification (ICD10-PCS) Other Procedure Codes
HIPAA,
OR
April 2014
005010X223A2 837

OR
HI01-2
1271
HI01-3
1250
HI01-4
1251
HI02
C022
HI02-1
1270
HI02-2
1271
HI02-3
1250
HI02-4
1251
122

BQ
International Classification of Diseases Clinical Modification (ICD9-CM) Other Procedure Codes
Industry Code
M
AN 1/30
M
IMPLEMENTATION NAME: Procedure Code
X
ID 2/3
M
D8
Date Time Period
X
AN 1/35
M
IMPLEMENTATION NAME: Procedure Date
O
1
O
SITUATIONAL RULE: Required when it is necessary to report an additional procedure
and the preceding HI data elements have been used to report other procedures. If not
M
ID 1/3
M
BBQ
HIPAA,
OR
OR
BQ
Industry Code
M
AN 1/30
M
X
ID 2/3
M
D8
Date Time Period
X
AN 1/35
M
April 2014
005010X223A2 837
HI03
C022
HI03-1
1270
HI03-2
1271
HI03-3
1250
HI03-4
1251
HI04
C022
HI04-1
1270
123

O
1
O
M
ID 1/3
M
BBQ
HIPAA,
OR
OR
BQ
Industry Code
M
AN 1/30
M
X
ID 2/3
M
D8
Date Time Period
X
AN 1/35
M
O
1
O
M
ID 1/3
M
BBQ
HIPAA,
OR
OR
April 2014
005010X223A2 837
HI04-2
1271
HI04-3
1250
HI04-4
1251
HI05
C022
HI05-1
1270
HI05-2
1271
HI05-3
1250
HI05-4
1251
HI06
C022
124

BQ
Industry Code
M
AN 1/30
M
X
ID 2/3
M
D8
Date Time Period
X
AN 1/35
M
O
1
O
M
ID 1/3
M
BBQ
HIPAA,
OR
OR
BQ
Industry Code
M
AN 1/30
M
X
ID 2/3
M
D8
Date Time Period
X
AN 1/35
M
O
1
O
April 2014
005010X223A2 837
HI06-1
1270
HI06-2
1271
HI06-3
1250
HI06-4
1251
HI07
C022
HI07-1
1270
125
M
ID 1/3
M
BBQ
HIPAA,
OR
OR
BQ
Industry Code
M
AN 1/30
M
X
ID 2/3
M
D8
Date Time Period
X
AN 1/35
M
O
1
O
M
ID 1/3
M
BBQ
HIPAA,
OR
OR
April 2014
005010X223A2 837
HI07-2
1271
HI07-3
1250
HI07-4
1251
HI08
C022
HI08-1
1270
HI08-2
1271
HI08-3
1250
HI08-4
1251
HI09
C022
126

BQ
Industry Code
M
AN 1/30
M
X
ID 2/3
M
D8
Date Time Period
X
AN 1/35
M
O
1
O
M
ID 1/3
M
BBQ
HIPAA,
OR
OR
BQ
Industry Code
M
AN 1/30
M
X
ID 2/3
M
D8
Date Time Period
X
AN 1/35
M
O
1
O
April 2014
005010X223A2 837
HI09-1
1270
HI09-2
1271
HI09-3
1250
HI09-4
1251
HI10
C022
HI10-1
1270

M
ID 1/3
M
BBQ
HIPAA,
OR
OR
BQ
Industry Code
M
AN 1/30
M
X
ID 2/3
M
D8
Date Time Period
X
AN 1/35
M
O
1
O
M
ID 1/3
M
BBQ
HIPAA,
OR
OR
BQ
127

April 2014
005010X223A2 837
HI10-2
1271
HI10-3
1250
HI10-4
1251
HI11
C022
HI11-1
1270
HI11-2
1271
HI11-3
1250
HI11-4
1251
HI12
C022
HI12-1
1270
128
Industry Code
M
AN 1/30
M
X
ID 2/3
M
D8
Date Time Period
X
AN 1/35
M
O
1
O
M
ID 1/3
M
BBQ
HIPAA,
OR
OR
BQ
Industry Code
M
AN 1/30
M
X
ID 2/3
M
D8
Date Time Period
X
AN 1/35
M
O
1
O
M
ID 1/3
M
BBQ
April 2014
005010X223A2 837
HIPAA,
OR
OR
HI12-2
1271
HI12-3
1250
HI12-4
1251
129

BQ
Industry Code
M
AN 1/30
M
X
ID 2/3
M
D8
Date Time Period
X
AN 1/35
M
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
HI Occurrence Span Information

2310
2300
Detail
Optional
2
Situational Rule: Required when there is an Occurrence Span Code that applies to this
claim. If not required by this implementation guide, do not send.
TR3 Example: HI*BI:70:RD8:20051202-20051212*BI:74:RD8:20051214-20051216~
Ref.
Des.
HI01
HI011
Data
Element
C022
1270
HI012
1271
HI013
1250
130
Name
Base
Attributes
M 1
User
Attributes
M
M
ID 1/3

BI
Occurrence Span
CODE SOURCE 132: National Uniform Billing Committee
(NUBC) Codes
Industry Code
M
AN
M
1/30
IMPLEMENTATION NAME: Occurrence Span Code
X
ID 2/3
M
April 2014
005010X223A2 837
HI014
1251
HI02
C022
RD8
Date Time Period
X
AN
M
1/35
IMPLEMENTATION NAME: Occurrence Span Code Date
O 1
M
1270
SITUATIONAL RULE: Required when it is necessary to report an additional
occurrence span code and the preceding HI data elements have been used to report
other occurrence span codes. If not required by this implementation guide, do not send.
M
ID 1/3
M
HI021
HI022
1271
HI023
1250

BI
Occurrence Span
(NUBC) Codes
Industry Code
M
AN
M
1/30
X
ID 2/3
M
HI024
1251
HI03
C022
RD8
Date Time Period
X
AN
M
1/35
O 1
O
1270
M
ID 1/3
M
HI031

BI
Occurrence Span
131
April 2014
005010X223A2 837
HI032
1271
HI033
1250

(NUBC) Codes
Industry Code
M
AN
M
1/30
X
ID 2/3
M
HI034
1251
HI04
C022
RD8
Date Time Period
X
AN
M
1/35
O 1
O
1270
M
ID 1/3
M
HI041
HI042
1271
HI043
1250
HI044
1251
HI05
C022

BI
Occurrence Span
(NUBC) Codes
Industry Code
M
AN
M
1/30
X
ID 2/3
M
RD8
Date Time Period
X
AN
M
1/35
O 1
O
132
April 2014
005010X223A2 837
HI051
1270
HI052
1271
HI053
1250

M
ID 1/3
M
BI
Occurrence Span
(NUBC) Codes
Industry Code
M
AN
M
1/30
X
ID 2/3
M
HI054
1251
HI06
C022
RD8
Date Time Period
X
AN
M
1/35
O 1
O
1270
M
ID 1/3
M
HI061
HI062
1271
HI063
1250

BI
Occurrence Span
(NUBC) Codes
Industry Code
M
AN
M
1/30
X
ID 2/3
M
RD8
133
April 2014
005010X223A2 837
HI064
1251
HI07
C022
AN
1/35
O 1
1270
M
ID 1/3
M
HI071
HI072
1271
HI073
1250
Date Time Period

BI
Occurrence Span
(NUBC) Codes
Industry Code
M
AN
M
1/30
X
ID 2/3
M
HI074
1251
HI08
C022
RD8
Date Time Period
X
AN
M
1/35
O 1
O
1270
M
ID 1/3
M
HI081
HI082
1271
HI083
1250

BI
Occurrence Span
(NUBC) Codes
Industry Code
M
AN
M
1/30
X
ID 2/3
M
134
April 2014
005010X223A2 837
RD8
HI084
1251
HI09
C022

Date Time Period
X
AN
M
1/35
O 1
O
1270
M
ID 1/3
M
HI091
HI092
1271
HI093
1250

BI
Occurrence Span
(NUBC) Codes
Industry Code
M
AN
M
1/30
X
ID 2/3
M
HI094
1251
HI10
C022
RD8
Date Time Period
X
AN
M
1/35
O 1
O
1270
M
ID 1/3
M
HI101

BI
Occurrence Span
(NUBC) Codes
135
April 2014
005010X223A2 837
HI102
HI103
1271
Industry Code
1250

X
AN
1/30
ID 2/3
HI104
1251
HI11
C022
RD8
Date Time Period
X
AN
M
1/35
O 1
O
1270
M
ID 1/3
M
HI111
HI112
1271
HI113
1250
HI114
1251
HI12
C022

BI
Occurrence Span
(NUBC) Codes
Industry Code
M
AN
M
1/30
X
ID 2/3
M
RD8
Date Time Period
X
AN
M
1/35
O 1
O
136
April 2014
005010X223A2 837
HI121
1270
HI122
1271
HI123
1250
HI124
137
1251
M
ID 1/3
M
BI
Occurrence Span
(NUBC) Codes
Industry Code
M
AN
M
1/30
X
ID 2/3
M
RD8
Date Time Period
X
AN
M
1/35
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
HI Occurrence Information
2310
2300
Detail
Optional
2
Situational Rule: Required when there is a Occurrence Code that applies to this claim. If
TR3 Example: HI*BH:42:D8:20051208*BH:A3:D8:20051203~
Ref.
Des.
HI01
HI011
Data
Element
C022
1270
HI012
1271
HI013
1250
138
Name
Base
Attributes
M 1
User
Attributes
M
M
ID 1/3
M
BH
Occurrence
(NUBC) Codes
Industry Code
M
AN
M
1/30
IMPLEMENTATION NAME: Occurrence Code
X
ID 2/3
M
April 2014
005010X223A2 837
HI014
1251
HI02
C022
D8
Date Time Period
X
AN
1/35
IMPLEMENTATION NAME: Occurrence Code Date
O 1
1270
occurrence code and the preceding HI data elements have been used to report other
occurrence codes. If not required by this implementation guide, do not send.
M
ID 1/3
M
HI021
HI022
1271
HI023
1250

BH
Occurrence
(NUBC) Codes
Industry Code
M
AN
M
1/30
X
ID 2/3
M
HI024
1251
HI03
C022
D8
Date Time Period
X
AN
1/35
O 1
1270
M
ID 1/3
M
HI031
HI032
1271
HI033
1250
HI034
139
1251

BH
Occurrence
(NUBC) Codes
Industry Code
M
AN
M
1/30
X
ID 2/3
M
D8
Date Time Period
X
AN
1/35
April 2014
005010X223A2 837
HI04
HI041
C022

O
1270
M
ID 1/3
M
HI042
1271
HI043
1250

BH
Occurrence
(NUBC) Codes
Industry Code
M
AN
M
1/30
X
ID 2/3
M
HI044
1251
HI05
C022
D8
Date Time Period
X
AN
1/35
O 1
1270
M
ID 1/3
M
HI051
HI052
1271
HI053
1250
HI054
1251
HI06
C022

BH
Occurrence
(NUBC) Codes
Industry Code
M
AN
M
1/30
X
ID 2/3
M
D8
Date Time Period
X
AN
1/35
O 1
140
April 2014
005010X223A2 837
HI061
1270
HI062
1271
HI063
1250
M
ID 1/3
M
BH
Occurrence
(NUBC) Codes
Industry Code
M
AN
M
1/30
X
ID 2/3
M
HI064
1251
HI07
C022
D8
Date Time Period
X
AN
1/35
O 1
1270
M
ID 1/3
M
HI071
HI072
1271
HI073
1250

BH
Occurrence
(NUBC) Codes
Industry Code
M
AN
M
1/30
X
ID 2/3
M
HI074
1251
HI08
C022
D8
Date Time Period
X
AN
1/35
O 1
1270
M
ID 1/3
M
HI081
141
April 2014
005010X223A2 837
BH
HI082
1271
HI083
1250
Occurrence
(NUBC) Codes
Industry Code
M
AN
M
1/30
X
ID 2/3
M
HI084
1251
HI09
C022
D8
Date Time Period
X
AN
1/35
O 1
1270
M
ID 1/3
M
HI091
- HI09-
1271
HI093
1250

BH
Occurrence
(NUBC) Codes
Industry Code
M
AN
M
1/30
X
ID 2/3
M
HI094
1251
HI10
C022
D8
Date Time Period
X
AN
1/35
O 1
1270
M
ID 1/3
M
HI101
HI102
142
1271

BH
Occurrence
(NUBC) Codes
Industry Code
M
AN
M
1/30
April 2014
005010X223A2 837
HI103
1250

X
ID 2/3
HI104
1251
HI11
C022
D8
Date Time Period
X
AN
1/35
O 1
1270
M
ID 1/3
M
HI111
HI112
1271
HI113
1250

BH
Occurrence
(NUBC) Codes
Industry Code
M
AN
M
1/30
X
ID 2/3
M
HI114
1251
HI12
C022
D8
Date Time Period
X
AN
1/35
O 1
1270
M
ID 1/3
M
HI121
HI122
1271
HI123
1250

BH
Occurrence
(NUBC) Codes
Industry Code
M
AN
M
1/30
X
ID 2/3
M
143
April 2014
005010X223A2 837
HI124
144
1251
D8
Date Time Period

X
AN
1/35
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
HI Value Information
2310
2300
Detail
Optional
2
Situational Rule: Required when there is a Value Code that applies to this claim. If not
TR3 Example: HI*BE:08:::1740*BE:A7:::940~
Ref.
Des.
HI01
HI011
Data
Element
C022
1270
HI012
1271
HI015
782
145
Name
Base
Attributes
M 1
User
Attributes
M
M
ID 1/3

BE
Value
(NUBC) Codes
Industry Code
M
AN
M
1/30
IMPLEMENTATION NAME: Value Code
Monetary Amount
O
R 1/18
M
April 2014
005010X223A2 837
HI02
HI021
C022
Monetary amount
IMPLEMENTATION NAME: Value Code Amount
1270
SITUATIONAL RULE: Required when it is necessary to report an additional value
code and the preceding HI data elements have been used to report other value codes. If
M
ID 1/3
M
HI022
1271
HI025
782
HI03
HI031

BE
Value
(NUBC) Codes
Industry Code
M
AN
M
1/30
Monetary Amount
O
R 1/18
M
C022
1270
M
ID 1/3
M
1271
HI035
782
HI041
Monetary amount
HI032
HI04

BE
Value
(NUBC) Codes
Industry Code
M
AN
M
1/30
Monetary Amount
O
R 1/18
M
C022
Monetary amount
1270
M
ID 1/3
M

BE
Value
146
April 2014
005010X223A2 837
(NUBC) Codes
HI042
HI045
HI05
HI051
1271
Industry Code
782

Monetary Amount
O
R 1/18
1270
M
ID 1/3
M
HI055
782

BE
Value
(NUBC) Codes
Industry Code
M
AN
M
1/30
Monetary Amount
O
R 1/18
M
C022
Monetary amount
1270
M
ID 1/3
M
HI062
1271
HI065
782
HI07
C022
1271
HI061
AN
1/30
Monetary amount
HI052
HI06
C022

BE
Value
(NUBC) Codes
Industry Code
M
AN
M
1/30
Monetary Amount
O
R 1/18
M
Monetary amount
147
April 2014
005010X223A2 837
HI071
1270
HI072
1271
HI075
782
HI08
HI081
C022
1270
M
ID 1/3
M
1271
HI085
782
HI091

BE
Value
(NUBC) Codes
Industry Code
M
AN
M
1/30
Monetary Amount
O
R 1/18
M
C022
Monetary amount
1270
M
ID 1/3
M
HI092
1271
HI095
782
148

BE
Value
(NUBC) Codes
Industry Code
M
AN
M
1/30
Monetary Amount
O
R 1/18
M
Monetary amount
HI082
HI09
M
ID 1/3
M

BE
Value
(NUBC) Codes
Industry Code
M
AN
M
1/30
Monetary Amount
O
R 1/18
M
April 2014
005010X223A2 837
HI10
HI101
C022
Monetary amount
1270
M
ID 1/3
M
HI102
1271
HI105
782
HI11
HI111

BE
Value
(NUBC) Codes
Industry Code
M
AN
M
1/30
Monetary Amount
O
R 1/18
M
C022
1270
M
ID 1/3
M
1271
HI115
782
HI121
Monetary amount
HI112
HI12

BE
Value
(NUBC) Codes
Industry Code
M
AN
M
1/30
Monetary Amount
O
R 1/18
M
C022
Monetary amount
1270
M
ID 1/3
M

BE
Value
149
April 2014
005010X223A2 837
(NUBC) Codes
HI122
HI125
1271
Industry Code
782

Monetary Amount
O
AN
1/30
R 1/18
Monetary amount
150
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
HI Condition Information
2310
2300
Detail
Optional
2
Situational Rule: Required when there is a Condition Code that applies to this claim. If
TR3 Example: HI*BG:17*BG:67~
Ref.
Des.
HI01
HI011
Data
Element
C022
1270
Name
Base
Attributes
M 1
User
Attributes
M
M
ID 1/3

BG
Condition
(NUBC) Codes
HI012
HI02
151
1271
Industry Code
C022

IMPLEMENTATION NAME: Condition Code
O
AN
1/30
M
April 2014
005010X223A2 837
HI021
1270
condition code and the preceding HI data elements have been used to report other
condition codes. If not required by this implementation guide, do not send.
M
ID 1/3
M
BG
Condition
(NUBC) Codes
HI022
HI03
HI031
1271
Industry Code
AN
1/30
C022

O
1270
M
ID 1/3
M

BG
Condition
(NUBC) Codes
HI032
HI04
HI041
1271
Industry Code
AN
1/30
C022

O
1270
M
ID 1/3
M

BG
Condition
(NUBC) Codes
HI042
HI05
1271
Industry Code
C022

O
AN
1/30
152
April 2014
005010X223A2 837
HI051
1270

M
ID 1/3
M
BG
Condition
(NUBC) Codes
HI052
HI06
HI061
1271
Industry Code
AN
1/30
C022

O
1270
M
ID 1/3
M

BG
Condition
(NUBC) Codes
HI062
HI07
HI071
1271
Industry Code
AN
1/30
C022

O
1270
M
ID 1/3
M

BG
Condition
(NUBC) Codes
HI072
HI08
1271
Industry Code
C022

O
AN
1/30
153
April 2014
005010X223A2 837
HI081
1270
ID 1/3

BG
Condition
(NUBC) Codes
HI082
HI09
HI091
1271
Industry Code
AN
1/30
C022

O
1270
M
ID 1/3
M

BG
Condition
(NUBC) Codes
HI092
HI10
HI101
1271
Industry Code
AN
1/30
C022

O
1270
M
ID 1/3
M

BG
Condition
(NUBC) Codes
HI102
HI11
HI111
1271
Industry Code
AN
1/30
C022

O
1270
M
ID 1/3
M

154
April 2014
005010X223A2 837
BG
HI112
HI12
HI121
Condition
(NUBC) Codes
1271
Industry Code
AN
1/30
C022

O
1270
M
ID 1/3
M

BG
Condition
(NUBC) Codes
HI122
1271
Industry Code
AN
1/30

155
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
HI Treatment Code Information

2310
2300
Detail
Optional
2
Situational Rule: Required when Home Health Agencies need to report Plan of Treatment
information under various payer contracts. If not required by this implementation guide,
do not send.
TR3 Example: HI*TC:A01~
Ref.
Des.
HI01
Data
Element
C022
HI01-1
1270
Base
User
Name
Attributes
Attributes
M
1
M
M
ID 1/3
M
Treatment Codes
HI01-2
1271
HI02
C022
156
Industry Code
M
AN 1/30
M
IMPLEMENTATION NAME: Treatment Code
O
1
O
SITUATIONAL RULE: Required when it is necessary to report an additional treatment
code and the preceding HI data elements have been used to report other treatment codes. If
April 2014
005010X223A2 837
HI02-1
1270
HI02-2
1271
HI03
C022
HI03-1
1270

M
ID 1/3
M
TC
Treatment Codes
CODE SOURCE 359: Treatment Codes
Industry Code
M
AN 1/30
M
O
1
O
M
ID 1/3
M
Treatment Codes
HI03-2
1271
HI04
C022
HI04-1
1270
Industry Code
M
AN 1/30
M
O
1
O
M
ID 1/3
M
Treatment Codes
HI04-2
1271
HI05
C022
HI05-1
1270
Industry Code
M
AN 1/30
M
O
1
O
M
ID 1/3
M
Treatment Codes
HI05-2
1271
HI06
C022
HI06-1
1270
157
Industry Code
M
AN 1/30
M
O
1
O
M
ID 1/3
M
April 2014
005010X223A2 837
Treatment Codes
HI06-2
1271
HI07
C022
HI07-1
1270
Industry Code
M
AN 1/30
M
O
1
O
M
ID 1/3
M
Treatment Codes
HI07-2
1271
HI08
C022
HI08-1
1270
Industry Code
M
AN 1/30
M
O
1
O
M
ID 1/3
M
Treatment Codes
HI08-2
1271
HI09
C022
HI09-1
1270
Industry Code
M
AN 1/30
M
O
1
O
M
ID 1/3
M
Treatment Codes
HI09-2
1271
HI10
C022
HI10-1
1270
Industry Code
M
AN 1/30
M
O
1
O
M
ID 1/3
M
Treatment Codes
158
April 2014
005010X223A2 837
HI10-2
1271
HI11
C022
HI11-1
1270
Industry Code
M
AN 1/30
M
O
1
O
M
ID 1/3
M
Treatment Codes
HI11-2
1271
HI12
C022
HI12-1
1270
HI12-2
1271
159
Industry Code
M
AN 1/30
M
O
1
O
M
ID 1/3
M
TC
Treatment Codes
CODE SOURCE 359: Treatment Codes
Industry Code
M
AN 1/30
M
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
HCP Claim Pricing/Repricing Information

2410
2300
Detail
Mandatory
1
To specify pricing or repricing information about a health care claim or line item
1 At least one of HCP01 or HCP13 is required.
2 If either HCP09 or HCP10 is present, then the other is required.
1 HCP02 is the allowed amount.
2 HCP03 is the savings amount.
3 HCP04 is the repricing organization identification number.
4 HCP05 is the pricing rate associated with per diem or flat rate repricing.
5 HCP06 is the approved DRG code.
6 HCP07 is the approved DRG amount.
7 HCP08 is the approved revenue code.
8 HCP10 is the approved procedure code.
9 HCP12 is the approved service units or inpatient days.
10 HCP13 is the rejection message returned from the third party organization.
11 HCP15 is the exception reason generated by a third party organization.
1 HCP06, HCP07, HCP08, HCP10, and HCP12 are fields that will contain different
values from the original submitted values.
2. For capitated encounters, pricing or repricing information usually is not applicable and
is provided to qualify other information within the claim.
TR3 Example: HCP*00*100*10*9~
Ref.
Des.
HCP0
1
HCP0
2
Data
Element
1473
782
Name
Pricing Methodology
Base
User
Attributes
Attributes
X 1
ID 2/2
M
Code specifying pricing methodology at which the claim or line item has been priced
or repriced
Specific code use is determined by Trading Partner Agreement due to the variances in
contracting policies in the industry.
00 - Non Participating
02 - Participating
00
Zero Pricing (Not Covered Under Contract)
02
Priced at the Standard Fee Schedule
Monetary Amount
O 1
R 1/18
M
Monetary amount
IMPLEMENTATION NAME: Repriced Allowed Amount
Eligible amount is the amount of the provider charge that is covered under groups
160
April 2014
005010X223A2 837
HCP0
3
782
contract and eligible for payment

Monetary Amount
R 1/18
Monetary amount
repricer. The segment is not completed by providers. The information is completed by
repricers only. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Repriced Saving Amount
HCP0
4
127
This information is specific to the destination payer reported in Loop ID-2010BB.

Ineligible amount is the amount of provider charges considered not covered under
groups contract.
O 1
AN
O
1/50
IMPLEMENTATION NAME: Repricing Organization Identifier
This field will be supplied with provider PPO status identifier.
HCP0
5
118
O - Out of State
Y - Yes
N - No
0 - Veteran's Administration Facility - Non - Participating
1 - Participating Provider
2 - Non-Participating Provider
3 - POS Participating Provider, Preferred Provider
9 - Unsolicited Provider
J AltNet Network Provider Preferred Provider
P Custom Network Provider - Participating
Rate
O
R 1/9
Rate expressed in the standard monetary denomination for the currency specified
IMPLEMENTATION NAME: Repricing Per Diem or Flat Rate Amount
HCP0
6
161
127

O 1
AN
O
1/50
April 2014
005010X223A2 837
IMPLEMENTATION NAME: Repriced Approved DRG Code
HCP0
7
782

Monetary Amount
O 1
R 1/18
O
Monetary amount
IMPLEMENTATION NAME: Repriced Approved Amount
HCP0
8
234

Product/Service ID
O 1
AN
O
1/48
Identifying number for a product or service
IMPLEMENTATION NAME: Repriced Approved Revenue Code
HCP1
1
HCP1
2
355

Unit or Basis for Measurement Code
X 1
ID 2/2
O
380
Code specifying the units in which a value is being expressed, or manner in which a
measurement has been taken
SITUATIONAL RULE: Required when HCP12 exists. If not required by this
DA
Days
UN
Unit
Quantity
X 1
R 1/15
O
Numeric value of quantity
IMPLEMENTATION NAME: Repriced Approved Service Unit Count
HCP1
3
901
The maximum length for this field is 8 digits excluding the decimal.
When a decimal is used, the maximum number of digits allowed to
the right of the decimal is three.
Reject Reason Code
X 1
ID 2/2
Code assigned by issuer to identify reason for rejection

T1
Cannot Identify Provider as TPO (Third Party Organization)
Participant
162
April 2014
005010X223A2 837
T2
HCP1
4
1526
Cannot Identify Payer as TPO (Third Party Organization)

Participant
T3
Cannot Identify Insured as TPO (Third Party Organization)
Participant
T4
Payer Name or Identifier Missing
T5
Certification Information Missing
T6
Claim does not contain enough information for re-pricing
Policy Compliance Code
O 1
ID 1/2
O
Code specifying policy compliance
HCP1
5
1527

1
Procedure Followed (Compliance)
2
Not Followed - Call Not Made (Non-Compliance Call Not
Made)
3
Not Medically Necessary (Non-Compliance Non-Medically
Necessary)
4
Not Followed Other (Non-Compliance Other)
5
Emergency Admit to Non-Network Hospital
Exception Code
O 1
ID 1/2
O
Code specifying the exception reason for consideration of out-of-network health care
services
1
Non-Network Professional Provider in Network Hospital
2
Emergency Care
3
Services or Specialist not in Network
4
Out-of-Service Area
5
State Mandates
6
Other
163
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
NM1 Attending Provider Name

2500
2310A
Detail
Optional
1
Situational Rule: Required when the claim contains any services other than nonscheduled transportation claims. If not required by this implementation guide, do not
send.
TR3 Notes: 1. The Attending Provider is the individual who has overall responsibility for
the patients medical care and treatment reported in this claim.
TR3 Example: NM1*71*1*JONES*JOHN****XX*1234567891~
Ref.
Des.
NM10
1
NM10
2
NM10
3
NM10
4
Data
Element
98
Name
Base
User
Attributes
Attributes
M 1
ID 2/3
M
1065

71
Attending Physician
Physician present when medical services are performed
When used, the term physician is any type of provider filling
this role.
M 1
ID 1/1
M
1035

1
Person
1036

IMPLEMENTATION NAME: Attending Provider Last Name
Name First
O 1
AN
1/60
AN
1/35

SITUATIONAL RULE: Required when the person has a first name. If not required by
NM10
5
1037
IMPLEMENTATION NAME: Attending Provider First Name

Name Middle
O 1
AN
1/25

SITUATIONAL RULE: Required when the middle name/initial is needed to identify
the individual. If not required by this implementation guide, do not send.
NM10
164
1039
IMPLEMENTATION NAME: Attending Provider Middle Name or Initial

Name Suffix
O 1
AN
O
April 2014
005010X223A2 837
NM10
8
NM10
9
1/10
individual. not required by this implementation guide, do not send.
66
67
IMPLEMENTATION NAME: Attending Provider Name Suffix

X 1
ID 1/2
(67)
OR
OR
XX
Identifier
Services National Provider Identifier
Identification Code
X 1
AN
O
2/80
OR
OR
IMPLEMENTATION NAME: Attending Provider Primary Identifier
165
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
PRV Provider Information

2550
2310A
Detail
Optional
1
To specify the identifying characteristics of a provider
1 If either PRV02 or PRV03 is present, then the other is required.
Situational Rule: Required when adjudication of the destination payer, or any subsequent
payer listed on this claim, is known to be impacted by the attending provider taxonomy
code. If not required by this implementation guide, do not send.
TR3 Example: PRV*AT*PXC*208D00000X~
Ref.
Des.
PRV01
Data
Element
1221
PRV02
128
PRV03
127
166
Base
User
Name
Attributes
Attributes
Provider Code
M
1 ID 1/3
M
Code identifying the type of provider
AT
Attending
X
1 ID 2/3
M
PXC
Health Care Provider Taxonomy Code
CODE SOURCE 682: Health Care Provider Taxonomy
X
1 AN 1/50
M
IMPLEMENTATION NAME: Provider Taxonomy Code
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
REF Attending Provider Secondary Identification

2710
2310A
Detail
Optional
4
Situational Rule: Required prior to the mandated HIPAA National Provider Identifier
(NPI) implementation date when an identification number other than the NPI is necessary
for the receiver to identify the provider.
OR
Required on or after the mandated NPI Implementation Date when NM109 in this loop is
not used and an identification number other than the NPI is necessary for the receiver to
identify the provider. If not required by this implementation guide, do not send.
TR3 Example: REF*1G*A12345~
Ref.
Des.
REF01
Data
Element
128
REF02
127
167
Base
User
Name
Attributes
Attributes
M
1 ID 2/3
M
0B
State License Number
1G
Provider UPIN Number
UPINs must be formatted as either X99999 or XXX999.
G2
LU
Location Number
X
1 AN 1/50
M
IMPLEMENTATION NAME: Attending Provider Secondary Identifier
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
NM1 Operating Physician Name

2500
2310B
Detail
Optional
1
Situational Rule: Required when a surgical procedure code is listed on this claim. If not
TR3 Notes: 1. The Operating Physician is the individual with primary responsibility for
performing the surgical procedure(s).
2. Information in Loop ID-2310 applies to the entire claim unless it is overridden on a
service line by the presence of Loop ID-2420 with the same value in NM101.
TR3 Example: NM1*72*1*MEYERS*JANE****XX.1234567891~
Ref.
Des.
NM101
Data
Element
98
NM102
1065
NM103
1035
NM104
1036
NM105
1037
NM107
1039
168
Base
User
Name
Attributes
Attributes
M
1 ID 2/3
M
72
Operating Physician
Doctor who performs a surgical procedure
M
1 ID 1/1
M
1
Person
X
1 AN 1/60
M
IMPLEMENTATION NAME: Operating Physician Last Name
Name First
O
1 AN 1/35
O
SITUATIONAL RULE: Required when the person has a first name. If not required by this
IMPLEMENTATION NAME: Operating Physician First Name
Name Middle
O
1 AN 1/25
O
SITUATIONAL RULE: Required when the middle name or initial of the person is needed
to identify the individual. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Operating Physician Middle Name or Initial
Name Suffix
O
1 AN 1/10
O
April 2014
005010X223A2 837
NM108
66
NM109
67
IMPLEMENTATION NAME: Operating Physician Name Suffix

X
1 ID 1/2
O
SITUATIONAL RULE: Required for providers in the United States or its territories on or
after the mandated HIPAA National Provider Identifier (NPI) implementation date when
the provider is eligible to receive an NPI.
OR
Required for providers not in the United States or its territories on or after the mandated
HIPAA National Provider Identifier (NPI) implementation date when the provider has
received an NPI.
OR
Required for providers prior to the mandated NPI implementation date when the provider
has received an NPI and the submitter has the capability to send it. If not required by this
XX
Identifier
CODE SOURCE 537: Centers for Medicare and Medicaid Services
National Provider Identifier
Identification Code
X
1 AN 2/80
O
OR
received an NPI.
OR
IMPLEMENTATION NAME: Operating Physician Primary Identifier
169
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
REF Operating Physician Secondary Identification

2710
2310B
Detail
Optional
4
OR
Ref.
Des.
REF01
Data
Element
128
REF02
127
170
Base
User
Name
Attributes
Attributes
M
1 ID 2/3
M
0B
1G
G2
LU
Location Number
X
1 AN 1/50
M
IMPLEMENTATION NAME: Operating Physician Secondary Identifier
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
NM1 Other Operating Physician Name

2500
2310C
Detail
Optional
1
Situational Rule: Required when another Operating Physician is involved. If not required
by the implementation guide, do not send.
TR3 Notes: 1. The Other Operating Physician is the individual performing a secondary
surgical procedure or assisting the Operating Physician.
2. This Other Operating Physician segment can only be used when Operating Physician
information (Loop ID - 2310B) is also sent on this claim.
TR3 Example: NM1*ZZ*1*DOE*JOHN*A***XX*1234567891~
Ref.
Des.
NM101
Data
Element
98
NM102
1065
NM103
1035
NM104
1036
NM105
1037
NM107
1039
171
Base
User
Name
Attributes
Attributes
M
1 ID 2/3
M
ZZ
Mutually Defined
ZZ is used to indicate Other Operating Physician.
M
1 ID 1/1
M
1
Person
X
1 AN 1/60
M
IMPLEMENTATION NAME: Other Operating Physician Last Name
Name First
O
1 AN 1/35
O
IMPLEMENTATION NAME: Other Operating Physician First Name
Name Middle
O
1 AN 1/25
O
IMPLEMENTATION NAME: Other Operating Physician Middle Name or Initial
Name Suffix
O
1 AN 1/10
O
April 2014
005010X223A2 837
NM108
66
NM109
67
IMPLEMENTATION NAME: Other Operating Physician Name Suffix

X
1 ID 1/2
O
OR
received an NPI.
OR
XX
Identifier
Identification Code
X
1 AN 2/80
O
OR
received an NPI.
OR
IMPLEMENTATION NAME: Other Operating Physician Identifier
172
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
REF Other Operating Physician Secondary Identification

2710
2310C
Detail
Optional
4
OR
Ref.
Des.
REF01
Data
Element
128
REF02
127
173
Base
User
Name
Attributes
Attributes
M
1 ID 2/3
M
0B
1G
G2
LU
Location Number
X
1 AN 1/50
M
IMPLEMENTATION NAME: Other Provider Secondary Identifier
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
NM1 Rendering Provider Name

2500
2310D
Detail
Optional
1
Situational Rule: Required when the Rendering Provider is different than the Attending
Provider reported in Loop ID-2310A of this claim.
AND
When state or federal regulatory requirements call for a "combined claim", that is, a
claim that includes both facility and professional components (for example, a Medicaid
clinic bill or Critical Access Hospital Claim.) If not required by this implementation
guide, do not send.
TR3 Notes: 1. The Rendering Provider is the health care professional who delivers or
completes a particular medical service or non-surgical procedure.
TR3 Example: NM1*82*1*DOE*JANE*C***XX*1234567804~
Ref.
Des.
NM101
Data
Element
98
NM102
1065
NM103
1035
NM104
1036
NM105
1037
NM107
1039
174
Base
User
Name
Attributes
Attributes
M
1 ID 2/3
M
82
Rendering Provider
M
1 ID 1/1
M
1
Person
X
1 AN 1/60
M
IMPLEMENTATION NAME: Rendering Provider Last
Name First
O
1 AN 1/35
O
IMPLEMENTATION NAME: Rendering Provider First Name
Name Middle
O
1 AN 1/25
O
IMPLEMENTATION NAME: Rendering Provider Middle Name or Initial
Name Suffix
O
1 AN 1/10
April 2014
005010X223A2 837
NM108
66
NM109
67
IMPLEMENTATION NAME: Rendering Provider Name Suffix

X
1 ID 1/2
O
OR
received an NPI.
OR
XX
Identifier
Identification Code
X
1 AN 2/80
O
OR
received an NPI.
OR
IMPLEMENTATION NAME: Rendering Provider Identifier
175
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
REF Rendering Provider Secondary Identification

2710
2310D
Detail
Optional
4
OR
Ref.
Des.
REF01
Data
Element
128
REF02
127
176
Base
User
Name
Attributes
Attributes
M
1 ID 2/3
M
0B
1G
G2
LU
Location Number
X
1 AN 1/50
M
IMPLEMENTATION NAME: Rendering Provider Secondary Identifier
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
NM1 Service Facility Location Name

2500
2310E
Detail
Optional
1
Situational Rule: Required when the location of health care service is different than that
carried in Loop ID-2010AA (Billing Provider). If not required by this implementation
guide, do not send.
TR3 Notes: 1. When an organization health care providers NPI is provided to identify
the Service Location, the organization health care provider must be external to the entity
identified as the Billing Provider (for example, reference lab). It is not permissible to
report an organization health care provider NPI as the Service Location if the entity being
identified is a component (for example, subpart) of the Billing Provider. In that case, the
subpart must be the Billing Provider.
TR3 Example: NM1*77*2*ABC CLINIC*****XX*1234567891~
Ref.
Des.
NM101
Data
Element
98
NM102
1065
NM103
1035
NM108
66
NM109
67
Base
User
Name
Attributes
Attributes
M
1 ID 2/3
M
77
Service Location
M
1 ID 1/1
M
2
Non-Person Entity
X
1 AN 1/60
M
IMPLEMENTATION NAME: Laboratory or Facility Name
X
1 ID 1/2
O
SITUATIONAL RULE: Required when the service location to be identified has an NPI
and is not a component or subpart of the Billing Provider entity. If not required by this
XX
Identifier
Identification Code
X
1 AN 2/80
O
SITUATIONAL RULE: Required when the service location to be identified has an NPI
and is not a component or subpart of the Billing Provider entity. If not required by this
IMPLEMENTATION NAME: Laboratory or Facility Primary Identifier
177
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
N3 Service Facility Location Address

2650
2310E
Detail
Optional
1
TR3 Notes: 1. If service facility location is in an area where there are no street addresses,
enter a description of where the service was rendered (for example, "crossroad of State
Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".)
Ref.
Des.
N301
Data
Element
166
N302
166
Base
User
Name
Attributes
Attributes
Address Information
M
1 AN 1/55
M
Address information
IMPLEMENTATION NAME: Laboratory or Facility Address Line
Address Information
O
1 AN 1/55
O
Address information
IMPLEMENTATION NAME: Laboratory or Facility Address Line
178
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
N4 Service Facility Location City, State, ZIP Code

2700
2310E
Detail
Optional
1
1
specify a location.
Ref.
Des.
N401
Data
Element
19
N402
156
Base
User
Name
Attributes
Attributes
City Name
O
1 AN 2/30
M
IMPLEMENTATION NAME: Laboratory or Facility City Name
X
1 ID 2/2
O
send.
IMPLEMENTATION NAME: Laboratory or Facility State or Province Code
N403
116

Postal Code
O
1 ID 3/15
O
for United States)
IMPLEMENTATION NAME: Laboratory or Facility Postal Zone or ZIP Code
N404
26
When reporting the ZIP code for U.S. addresses, the full nine digit ZIP code must be
provided.
Country Code
X
1 ID 2/3
O
N407
179
1715

X
1 ID 1/3
April 2014
005010X223A2 837
180
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
REF Service Facility Location Secondary Identification

2710
2310E
Detail
Optional
3
OR
Required on or after the mandated NPI implementation date when the entity is not a
Health Care provider (a.k.a. an atypical provider), and an identifier is necessary for the
claims processor to identify the entity. If not required by this implementation guide, do
not send.
Ref.
Des.
REF01
Data
Element
128
REF02
127
181
Base
User
Name
Attributes
Attributes
M
1 ID 2/3
M
0B
G2
LU
Location Number
X
1 AN 1/50
M
IMPLEMENTATION NAME: Laboratory or Facility Secondary Identifier
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
NM1 Referring Provider Name

2500
2310F
Detail
Optional
1
Situational Rule: Required on an outpatient claim when the Referring Provider is
different than the Attending Provider. If not required by this implementation guide, do
not send.
TR3 Notes: 1. The Referring Provider is provider who sends the patient to another
provider for services.
TR3 Example: NM1*DN*1*WELBY*MARCUS*W**JR*XX*1234567891~
Ref.
Des.
NM101
Data
Element
98
NM102
1065
NM103
1035
NM104
1036
NM105
1037
NM107
1039
Base
User
Name
Attributes
Attributes
M
1 ID 2/3
M
DN
Referring Provider
M
1 ID 1/1
M
1
Person
X
1 AN 1/60
M
IMPLEMENTATION NAME: Referring Provider Last Name
Name First
O
1 AN 1/35
O
IMPLEMENTATION NAME: Referring Provider First Name
Name Middle
O
1 AN 1/25
O
IMPLEMENTATION NAME: Referring Provider Middle Name or Initial
Name Suffix
O
1 AN 1/10
O
IMPLEMENTATION NAME: Referring Provider Name Suffix
182
April 2014
005010X223A2 837
NM108
66
NM109
67

X
1 ID 1/2
O
SITUATIONAL RULE: Required for providers on or after the mandated HIPAA National
Provider Identifier (NPI) implementation date when the provider has received an NPI and
the NPI is available to the submitter.
OR
Required for providers prior to the mandated HIPAA NPI implementation date when the
provider has received an NPI and the submitter has the capability to send it. If not required
XX
Identifier
Identification Code
X
1 AN 2/80
O
OR
IMPLEMENTATION NAME: Referring Provider Identifier
183
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
REF Referring Provider Secondary Identification

2710
2310F
Detail
Optional
3
OR
TR3 Notes: 1. The REF segment in Loop ID-2310 applies to the entire claim unless
overridden on the service line level by the presence of a REF segment with the same
value in REF01.
Ref.
Des.
REF01
Data
Element
128
REF02
127
184
Base
User
Name
Attributes
Attributes
M
1 ID 2/3
M
0B
1G
G2
X
1 AN 1/50
M
IMPLEMENTATION NAME: Referring Provider Secondary Identifier
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
SBR Other Subscriber Information

2900
2320
Detail
Optional
1
To record information specific to the primary insured and the insurance carrier for that
insured
1
2
3
4
SBR02 specifies the relationship to the person insured.

SBR03 is policy or group number.
SBR04 is plan name.
SBR07 is destination payer code. A "Y" value indicates the payer is the destination
payer; an "N" value indicates the payer is not the destination payer.
Situational Rule: Required when other payers are known to potentially be involved in
paying on this claim. If not required by this implementation guide, do not send.
TR3 Notes: 1. All information contained in Loop ID-2320 applies only to the payer
identified in Loop ID-2330B of this iteration of Loop ID-2320. It is specific only to that
payer. If information for an additional payer is necessary, repeat Loop ID-2320 with its
respective 2330 Loops.
2. See Crosswalking COB Data Elements section for more information on handling COB
in the 837.
TR3 Example: SBR*S*01*GR0786******13~
Ref.
Des.
SBR01
Data
Element
1138
SBR02
1069
185
Base
User
Name
Attributes
Attributes
Payer Responsibility Sequence Number Code
M
1 ID 1/1
M
Code identifying the insurance carrier's level of responsibility for a payment of a claim
Within a given claim, the various values for the Payer Responsibility Sequence Number
Code (other than value "U") may occur no more than once.
A
Payer Responsibility Four
B
Payer Responsibility Five
C
Payer Responsibility Six
D
Payer Responsibility Seven
E
Payer Responsibility Eight
F
Payer Responsibility Nine
G
Payer Responsibility Ten
H
Payer Responsibility Eleven
P
Primary
S
Secondary
T
Tertiary
U
Unknown
This code may only be used in payer to payer COB claims when the
original payer determined the presence of this coverage from
eligibility files received from this payer or when the original claim
did not provide the responsibility sequence for this payer.
O
1 ID 2/2
M
01
Spouse
April 2014
005010X223A2 837
18
19
SBR03
127
Self
Child
Dependent between the ages of 0 and 19; age qualifications may
vary depending on policy
20
Employee
21
Unknown
39
Organ Donor
Individual receiving medical service in order to donate organs for a
transplant
40
Cadaver Donor
Deceased individual donating body to be used for research or
transplants
53
Life Partner
G8
Other Relationship
O
1 AN 1/50
O
SITUATIONAL RULE: Required when the subscribers identification card for the nondestination payer identified in Loop ID-2330B of this iteration of Loop ID-2320 shows a
group number. If not required by this implemetation guide, do not send.
IMPLEMENTATION NAME: Insured Group or Policy Number
SBR04
93
SBR09
1032
186
This is not the number uniquely identifying the subscriber. The unique subscriber number
is submitted in Loop 2330A-NM109 for this iteration of Loop ID-2320.
Name
O
1 AN 1/60
O
Free-form name
SITUATIONAL RULE: Required when SBR03 is not used and the group name is
available. If not required by this implementation guide, do not send.
IMPLEMENTATION NAME: Other Insured Group Name
Claim Filing Indicator Code
O
1 ID 1/2
M
Code identifying type of claim
SITUATIONAL RULE: Required prior to mandated use of the HIPAA National Plan ID. If
11
Other Non-Federal Programs
12
Preferred Provider Organization (PPO)
13
Point of Service (POS)
14
Exclusive Provider Organization (EPO)
15
Indemnity Insurance
16
Health Maintenance Organization (HMO) Medicare Risk
17
Dental Maintenance Organization
AM
Automobile Medical
BL
Blue Cross/Blue Shield
CH
Champus
CI
Commercial Insurance Co.
DS
Disability
FI
Federal Employees Program
HM
Health Maintenance Organization
LM
Liability Medical
MA
Medicare Part A
MB
Medicare Part B
April 2014
005010X223A2 837
MC
OF
TV
VA
WC
ZZ
187
Medicaid
Other Federal Program
Use code OF when submitting Medicare Part D claims.
Title V
Veterans Affairs Plan
Workers' Compensation Health Claim
Mutually Defined
Use Code ZZ when Type of Insurance is not known.
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
CAS Claim Level Adjustments

2950
2320
Detail
Optional
5
To supply adjustment reason codes and amounts as needed for an entire claim or for a
particular service within the claim being paid
1 If CAS05 is present, then at least one of CAS06 or CAS07 is required.
2 If CAS06 is present, then CAS05 is required.
1 CAS03 is the amount of adjustment.
2 CAS04 is the units of service being adjusted.
3 CAS06 is the amount of the adjustment.
1 Adjustment information is intended to help the provider balance the remittance
information. Adjustment amounts should fully explain the difference between
submitted charges and the amount paid.
Situational Rule: Required when the claim has been adjudicated by the payer identified in
this loop, and the claim has claim level adjustment information. If not required by this
TR3 Notes: 1. Submitters must use this CAS segment to report prior payers claim level
adjustments that cause the amount paid to differ from the amount originally charged.
2. Only one Group Code is allowed per CAS. If it is necessary to send more than one
Group Code at the claim level, repeat the CAS segment again.
3. Codes and associated amounts must come from either paper remittance advice or 835s
(Electronic Remittance Advice) received on the claim. When the information originates
from a paper remittance advice that does not use the standard Claim Adjustment Reason
Codes, the paper values must be converted to standard Claim Adjustment Reason Codes.
4. A single CAS segment contains six repetitions of the "adjustment trio" composed of
adjustment reason code, adjustment amount, and adjustment quantity. These six
adjustment trios are used to report up to six adjustments related to a particular Claim
Adjustment Group
188
April 2014
005010X223A2 837
Code (CAS01). The first adjustment is reported in the first adjustment trio (CAS02CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment
trio CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19).
TR3 Example: CAS*PR*1*7*93~
TR3 Example: CAS*OA*93*15*06~
Ref.
Des.
CAS0
1
CAS0
2
Data
Element
1033
1034
Name
Claim Adjustment Group Code
Base
User
Attributes
Attributes
M 1
ID 1/2
M
Code identifying the general category of payment adjustment

CO, OA, PR
CO
Contractual Obligations
OA
Other adjustments
PR
Patient Responsibility
Claim Adjustment Reason Code
M 1
ID 1/5
Code identifying the detailed reason the adjustment was made

IMPLEMENTATION NAME: Adjustment Reason Code
CODE SOURCE 139: Claim Adjustment Reason Code
See CODE SOURCE 139: Claim Adjustment Reason Code
01-Deductible: Total amount determined by the other carrier or Medicare which must
be paid by the insured toward his own medical expenses before benefit under his
contract will be paid
02-Coinsurance: Total other carrier or Medicare coinsurance expenses that the

member is liable to pay under his contract
03-Copay: Medical expenses before Medicare or other insurance
187- Personal Saving Amt: Consumer Spending Account payments (includes but is
not limited to Flexible Spending Account, Health Savings Account, Health
Reimbursement Account, etc
96- Non Covered Amt: Total other carrier or Medicare amount determined to be not
covered under the member's contract
45-Held Harmless Amt: Total amount determined by the other carrier or Medicare
that the member is not responsible to pay
CAS0
3
782
For a complete list of Adjustment Reason Codes please reference Washington

Publishing
Monetary Amount
M 1
R 1/18
M
Monetary amount
189
April 2014
005010X223A2 837
CAS0
4
380
Quantity
R 1/15

SITUATIONAL RULE: Required when the number of service units has being
adjusted. If not required by this implementation guide, do not send.
CAS0
5
1034
IMPLEMENTATION NAME: Adjustment Quantity

ID 1/5

SITUATIONAL RULE: Required when it is necessary to report an additional non-zero
adjustment, beyond what has already been supplied, to this claim for the Claim
Adjustment Group Code reported in CAS01. If not required by this implementation
guide, do not send.
CAS0
6
782

Monetary Amount
X
R 1/18
Monetary amount
SITUATIONAL RULE: Required when CAS05 is present. If not required by this
CAS0
7
380
IMPLEMENTATION NAME: Adjustment Amount

Quantity
R 1/15

SITUATIONAL RULE: Required when CAS05 is present and is related to a units of
service adjustment. If not required by this implementation guide, do not send.
CAS0
8
1034

ID 1/5

guide, do not send.
CAS0
9
782

Monetary Amount
X
R 1/18
Monetary amount
CAS1
0
380

Quantity
R 1/15

190
April 2014
005010X223A2 837
CAS1
1
1034

ID 1/5

guide, do not send.
CAS1
2
782

Monetary Amount
X
R 1/18
Monetary amount
CAS1
3
380

Quantity
R 1/15

CAS1
4
1034

ID 1/5

guide, do not send.
CAS1
5
782

Monetary Amount
X
R 1/18
Monetary amount
CAS1
6
380

Quantity
R 1/15

CAS1
7
1034

ID 1/5

191
April 2014
005010X223A2 837

guide, do not send.
CAS1
8
782

Monetary Amount
X
R 1/18
Monetary amount
CAS1
9
380

Quantity
R 1/15

192
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
AMT Coordination of Benefits (COB) Payer Paid Amount

3000
2320
Detail
Optional
1
Situational Rule: Required when the claim has been adjudicated by the payer identified in
Loop ID-2330B of this loop.
OR
Required when Loop ID-2010AC is present. In this case, the claim is a post payment
recovery claim submitted by a subrogated Medicaid agency. If not required by this
TR3 Example: AMT*D*411~
Ref.
Des.
AMT
01
AMT
02
Data
Element
522
782
Name
D
Payor Amount Paid
Monetary Amount
Base
User
Attributes
Attributes
M 1
ID 1/3
M
R 1/18
Monetary amount
IMPLEMENTATION NAME: Payer Paid Amount
It is acceptable to show "0" as the amount paid.
When Loop ID-2010AC is present, this is the amount the Medicaid agency actually
paid.
193
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
AMT Remaining Patient Liability

3000
2320
Detail
Optional
1
Situational Rule: Required when the Other Payer identified in Loop ID-2330B (of this
iteration of Loop ID-2320) has adjudicated this claim and provided claim level
information only.
OR
Required when the Other Payer identified in Loop ID-2330B (of this iteration of Loop
ID-2320) has adjudicated this claim and the provider received a paper remittance advice
and the provider does not have the ability to report line item information. If not required
TR3 Notes: 1. In the judgment of the provider, this is the remaining amount to be paid
after adjudication by the Other Payer identified in Loop ID-2330B of this iteration of
Loop ID-2320.
2. This segment is only used in provider submitted claims. It is not used in Payer-toPayer Coordination of Benefits (COB).
3. This segment is not used if the line level (Loop ID-2430) Remaining Patient Liability
AMT segment is used for this Other Payer.
TR3 Example: AMT*EAF*75~
Ref.
Des.
AMT
01
AMT
02
Data
Element
522
782
Name
EAF
Amount Owed
Monetary Amount
Base
User
Attributes
Attributes
M 1
ID 1/3
M
R 1/18
Monetary amount
IMPLEMENTATION NAME: Remaining Patient Liability
194
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
AMT Coordination of Benefits (COB) Total Non-covered Amount

3000
2320
Detail
Optional
1
Situational Rule: Required when state Medicaid cost avoidance policy allows providers
to bypass claim submission to the otherwise prior payer identified in Loop ID 2330B. If
TR3 Notes: 1. When this segment is used, the amount reported in AMT02 must equal
the total claim charge amount reported in CLM02. Neither the prior payer paid AMT, nor
any CAS segments are used as this claim has not been adjudicated by this payer.
TR3 Example: AMT*A8*273~
Ref.
Des.
AMT01
Data
Element
522
AMT02
782
195
Base
User
Name
Attributes
Attributes
M
1 ID 1/3
M
A8
Noncovered Charges - Actual
Calculated value not covered by the benefit plan
Monetary Amount
M
1 R 1/18
M
Monetary amount
IMPLEMENTATION NAME: Non-Covered Charge Amount
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
OI Other Insurance Coverage Information

3100
2320
Detail
Mandatory
1
To specify information associated with other health insurance coverage
1
OI03 is the 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.
TR3 Notes: 1. All information contained in the OI segment applies only to the payer
who is identified in the 2330B loop of this iteration of the 2320 loop.
TR3 Example: OI***Y*B**Y~
Ref.
Des.
OI03
Data
Element
1073
Base
User
Name
Attributes
Attributes
O
1 ID 1/1
M
IMPLEMENTATION NAME: Benefits Assignment Certification Indicator
This is a crosswalk from CLM08 when doing COB.
OI06
1363
This element answers the question whether or not the insured has authorized the plan to
remit payment directly to the provider.
N
No
W
Not Applicable
Use code W when the patient refuses to assign benefits.
Y
Yes
Release of Information Code
O
1 ID 1/1
M
Code indicating whether the provider has on file a signed statement by the patient
authorizing the release of medical data to other organizations
This is a crosswalk from CLM09 when doing COB.
The Release of Information response is limited to the information carried in this claim.
I
Informed Consent to Release Medical Information for Conditions or
Diagnoses Regulated by Federal Statutes
Required when the provider has not collected a signature AND state
or federal laws do not require a signature be collected.
Y
Yes, Provider has a Signed Statement Permitting Release of Medical
Billing Data Related to a Claim
Required when the provider has collected a signature.
OR
Required when state or federal laws require a signature be collected.
196
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
MIA Inpatient Adjudication Information

3150
2320
Detail
Optional
1
To provide claim-level data related to the adjudication of Medicare inpatient claims
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
Comments:
Notes:
MIA01 is the covered days.

MIA02 is the Prospective Payment System (PPS) Operating Outlier amount.
MIA03 is the lifetime psychiatric days.
MIA04 is the Diagnosis Related Group (DRG) amount.
MIA05 is the Claim Payment Remark Code. See Code Source 411.
MIA06 is the disproportionate share amount.
MIA07 is the Medicare Secondary Payer (MSP) pass-through amount.
MIA08 is the total Prospective Payment System (PPS) capital amount.
MIA09 is the Prospective Payment System (PPS) capital, federal specific portion,
Diagnosis Related Group (DRG) amount.
MIA10 is the Prospective Payment System (PPS) capital, hospital specific portion,
Diagnosis Related Group (DRG), amount.
MIA11 is the Prospective Payment System (PPS) capital, disproportionate share,
hospital Diagnosis Related Group (DRG) amount.
MIA12 is the old capital amount.
MIA13 is the Prospective Payment System (PPS) capital indirect medical education
claim amount.
MIA14 is hospital specific Diagnosis Related Group (DRG) Amount.
MIA15 is the cost report days.
MIA16 is the federal specific Diagnosis Related Group (DRG) amount.
MIA17 is the Prospective Payment System (PPS) Capital Outlier amount.
MIA18 is the indirect teaching amount.
MIA19 is the professional component amount billed but not payable.
MIA24 is the capital exception amount.
Situational Rule: Required when inpatient adjudication information is reported in the

remittance advice.
OR
Required when it is necessary to report remark codes. If not required by this
TR3 Example: MIA*1***3568*98*MA01***************21***MA25~
Ref.
Des.
MIA01
Data
Element
380
MIA03
380
Base
User
Name
Attributes
Attributes
Quantity
M
1 R 1/15
M
IMPLEMENTATION NAME: Covered Days or Visits Count
Quantity
O
1 R 1/15
O
SITUATIONAL RULE: Required when returned in the remittance advice. If not required
IMPLEMENTATION NAME: Lifetime Psychiatric Days Count
197
April 2014
005010X223A2 837
MIA04
782
MIA05
127
MIA06
782
MIA07
782
MIA08
782
MIA09
782
MIA10
782
MIA11
782
MIA12
782
198
Monetary Amount
O
1 R 1/18
O
Monetary amount
IMPLEMENTATION NAME: Claim DRG Amount
O
1 AN 1/50
O
IMPLEMENTATION NAME: Claim Payment Remark Code
Monetary Amount
O
1 R 1/18
O
Monetary amount
IMPLEMENTATION NAME: Claim Disproportionate Share Amount
Monetary Amount
O
1 R 1/18
O
Monetary amount
IMPLEMENTATION NAME: Claim MSP Pass-through Amount
Monetary Amount
O
1 R 1/18
O
Monetary amount
IMPLEMENTATION NAME: Claim PPS Capital Amount
Monetary Amount
O
1 R 1/18
O
Monetary amount
IMPLEMENTATION NAME: PPS-Capital FSP DRG Amount
Monetary Amount
O
1 R 1/18
O
Monetary amount
IMPLEMENTATION NAME: PPS-Capital HSP DRG Amount
Monetary Amount
O
1 R 1/18
O
Monetary amount
IMPLEMENTATION NAME: PPS-Capital DSH DRG Amount
Monetary Amount
O
1 R 1/18
O
Monetary amount
April 2014
005010X223A2 837
MIA13
782
MIA14
782
MIA15
380
MIA16
782
MIA17
782
MIA18
782
MIA19
782
MIA20
127
MIA21
127
199
IMPLEMENTATION NAME: Old Capital Amount

Monetary Amount
O
1 R 1/18
O
Monetary amount
IMPLEMENTATION NAME: PPS-Capital IME amount
Monetary Amount
O
1 R 1/18
O
Monetary amount
IMPLEMENTATION NAME: PPS-Operating Hospital Specific DRG Amount
Quantity
O
1 R 1/15
O
IMPLEMENTATION NAME: Cost Report Day Count
Monetary Amount
O
1 R 1/18
O
Monetary amount
IMPLEMENTATION NAME: PPS-Operating Federal Specific DRG Amount
Monetary Amount
O
1 R 1/18
O
Monetary amount
IMPLEMENTATION NAME: Claim PPS Capital Outlier Amount
Monetary Amount
O
1 R 1/18
O
Monetary amount
IMPLEMENTATION NAME: Claim Indirect Teaching Amount
Monetary Amount
O
1 R 1/18
O
Monetary amount
IMPLEMENTATION NAME: Nonpayable Professional Component Amount
O
1 AN 1/50
O
O
1 AN 1/50
O
April 2014
005010X223A2 837
MIA22
127
MIA23
127
MIA24
782

O
1 AN 1/50
O
O
1 AN 1/50
O
Monetary Amount
O
1 R 1/18
O
Monetary amount
IMPLEMENTATION NAME: PPS-Capital Exception Amount
200
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
MOA Outpatient Adjudication Information

3200
2320
Detail
Optional
1
To convey claim-level data related to the adjudication of Medicare claims not related to
an inpatient setting
1
2
3
4
5
6
7
8
9
Comments:
Notes:
MOA01 is the reimbursement rate.

MOA02 is the claim Health Care Financing Administration Common Procedural
Coding System (HCPCS) payable amount.
MOA03 is the Claim Payment Remark Code. See Code Source 411.
MOA08 is the End Stage Renal Disease (ESRD) payment amount.
MOA09 is the professional component amount billed but not payable.
Situational Rule: Required when outpatient adjudication information is reported in the

remittance advice
OR
Required when it is necessary to report remark codes. If not required by this
TR3 Example: MOA***A4~
Ref.
Des.
MOA01
Data
Element
954
MOA02
782
MOA03
127
MOA04
127
201
Base
User
Name
Attributes
Attributes
Percentage as Decimal
O
1 R 1/10
O
Percentage expressed as a decimal (e.g., 0.0 through 1.0 represents 0% through 100%)
IMPLEMENTATION NAME: Reimbursement Rate
Monetary Amount
O
1 R 1/18
O
Monetary amount
IMPLEMENTATION NAME: HCPCS Payable Amount
O
1 AN 1/50
O
O
1 AN 1/50
O
April 2014
005010X223A2 837
MOA05
127
MOA06
127
MOA07
127
MOA08
782
MOA09
782

O
1 AN 1/50
O
O
1 AN 1/50
O
O
1 AN 1/50
O
Monetary Amount
O
1 R 1/18
O
Monetary amount
IMPLEMENTATION NAME: End Stage Renal Disease Payment Amount
Monetary Amount
O
1 R 1/18
O
Monetary amount
IMPLEMENTATION NAME: Nonpayable Professional Component Amount
202
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
NM1 Other Subscriber Name

3250
2330A
Detail
Mandatory
1
TR3 Notes: 1. If the patient can be uniquely identified to the Other Payer indicated in this
iteration of Loop ID-2320 by a unique Member Identification Number, then the patient is
the subscriber or is considered to be the subscriber and is identified in this Other
Subscribers Name Loop ID-2330A.
2. If the patient is a dependent of the subscriber for this other coverage and cannot be
uniquely identified to the Other Payer indicated in this iteration of Loop ID-2320 by a
unique Member Identification Number, then the subscriber for this other coverage is
identified in this Other Subscribers Name Loop ID-2330A.
in the 837.
TR3 Example: NM1*IL*1*DOE*JOHN*T**JR*MI*123456~
Ref.
Des.
NM101
Data
Element
98
NM102
1065
NM103
1035
NM104
1036
NM105
1037
NM107
1039
203
Base
User
Name
Attributes
Attributes
M
1 ID 2/3
M
IL
Insured or Subscriber
M
1 ID 1/1
M
1
Person
2
Non-Person Entity
X
1 AN 1/60
M
IMPLEMENTATION NAME: Other Insured Last Name
Name First
O
1 AN 1/35
O
IMPLEMENTATION NAME: Other Insured First Name
Name Middle
O
1 AN 1/25
O
SITUATIONAL RULE: Required when NM102 = 1 (person) and the middle name or
initial of the person is needed to identify the individual. If not required by this
IMPLEMENTATION NAME: Other Insured Middle Name
Name Suffix
O
1 AN 1/10
O
April 2014
005010X223A2 837

SITUATIONAL RULE: Required when NM102 = 1 (person) and the name suffix of the
person is needed to identify the individual. If not required by this implementation guide, do
not send.
NM108
66
IMPLEMENTATION NAME: Other Insured Name Suffix

X
1 ID 1/2
M
II
Standard Unique Health Identifier for each Individual in the United
States
Required if the HIPAA Individual Patient Identifier is mandated use.
If not required, use value MI instead.
MI
The code MI is intended to be the subscribers identification number
as assigned by the payer. (For example, Insureds ID, Subscribers
ID, Health Insurance Claim Number (HIC), etc.)
MI is also intended to be used in claims submitted to the Indian
Health Service/Contract Health Services (IHS/CHS) Fiscal
Intermediary for the purpose of reporting the Tribe Residency Code
(Tribe County State). In the event that a Social Security Number
(SSN) is also available on an IHS/CHS claim, put the SSN in
REF02.
NM109
204
67
When sending the Social Security Number as the Member ID, it

must be a string of exactly nine
would be valid, while sending "111-00- 2222" would be invalid.
Identification Code
X
1 AN 2/80
M
IMPLEMENTATION NAME: Other Insured Identifier
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
N3 Other Subscriber Address

3320
2330A
Detail
Optional
1
Situational Rule: Required when the information is available. If not required by this
Ref.
Des.
N301
Data
Element
166
N302
166
Base
User
Name
Attributes
Attributes
Address Information
M
1 AN 1/55
M
Address information
IMPLEMENTATION NAME: Other Insured Address Line
Address Information
O
1 AN 1/55
O
Address information
IMPLEMENTATION NAME: Other Insured Address Line
205
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
N4 Other Subscriber City/State/ZIP Code

3400
2330A
Detail
Optional
1
1
specify a location.
Situational Rule: Required when the information is available. If not required by this
Ref.
Des.
N401
Data
Element
19
N402
156
Base
User
Name
Attributes
Attributes
City Name
O
1 AN 2/30
M
IMPLEMENTATION NAME: Other Insured City Name
X
1 ID 2/2
O
send.
IMPLEMENTATION NAME: Other Insured State Code
N403
116

Postal Code
O
1 ID 3/15
O
for United States)
IMPLEMENTATION NAME: Other Insured Postal Zone or ZIP Code
N404
26

Country Code
X
1 ID 2/3
O
N407
206
1715

X
1 ID 1/3
April 2014
005010X223A2 837
207
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
REF Other Subscriber Secondary Information

3550
2330A
Detail
Optional
2
Situational Rule: Required when an additional identification number to that provided in
Ref.
Des.
REF01
Data
Element
128
REF02
127
208
Base
User
Name
Attributes
Attributes
M
1 ID 2/3
M
SY
numbers with no separators. For
example, sending "111002222" would be valid, while sending "11100-2222" would be invalid.
X
1 AN 1/50
M
IMPLEMENTATION NAME: Other Insured Additional Identifier
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
NM1 Other Payer Name

3250
2330B
Detail
Mandatory
1
TR3 Notes: 1. See Crosswalking COB Data Elements section for more information on
handling COB in the 837.
TR3 Example: NM1*PR*2*ABC INSURANCE CO*****PI*11122333~
Ref.
Des.
NM10
1
NM10
2
NM10
3
NM10
8
Data
Element
98
Name
Base
User
Attributes
Attributes
M 1
ID 2/3
M
1065

PR
Payer
M 1
ID 1/1
M
1035

2
Non-Person Entity
66
AN
1/60

IMPLEMENTATION NAME: Other Payer Last or Organization Name
X 1
ID 1/2
(67)
On or after the mandated implementation date for the HIPAA National Plan Identifier
(National Plan ID), XV must be sent. Prior to the mandated implementation date and
prior to any phase-in period identified by Federal regulation, PI must be sent.
If a phase-in period is designated, PI must be sent unless:
1. Both the sender and receiver agree to use the National Plan ID,
2. The receiver has a National Plan ID, and
3. The sender has the capability to send the National Plan ID.
NM10
9
209
67
If all of the above conditions are true, XV must be sent. In this case the Payer
Identification Number that would have been sent using qualifier PI can be sent in the
corresponding REF segment using qualifier 2U.
PI
Payor Identification
XV
Centers for Medicare and Medicaid Services PlanID
Services PlanID
Identification Code
X 1
AN
M
2/80
April 2014
005010X223A2 837

IMPLEMENTATION NAME: Other Payer Primary Identifier
When sending Line Adjudication Information for this payer, the identifier sent in
SVD01 (Payer Identifier) and in Loop ID-2430 (Line Adjudication Information) must
match this value.
210
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
N3 Other Payer Address

3320
2330B
Detail
Optional
1
clearinghouse).
Ref.
Des.
N301
N302
Data
Element
166
166
Name
Address Information
Base
User
Attributes
Attributes
M 1
AN
M
1/55
Address information
IMPLEMENTATION NAME: Other Payer Address Line
Address Information
O
AN
1/55
Address information
IMPLEMENTATION NAME: Other Payer Address Line
211
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
N4 Other Payer City/State/ZIP Code

3400
2330B
Detail
Optional
1
1
specify a location.
clearinghouse). If not required by this implementation guide, do not send.
Ref.
Des.
N401
N402
Data
Element
19
156
Name
City Name
Base
User
Attributes
Attributes
O 1
AN
M
2/30

IMPLEMENTATION NAME: Other Payer City Name
X
ID 2/2

America, including its territories, or Canada. If not required by this implementation
guide, do not send.
IMPLEMENTATION NAME: Other Payer State Code
N403
116

Postal Code
ID
O
3/15
IMPLEMENTATION NAME: Other Payer Postal Zone or ZIP Code
N404
26

Country Code
ID 2/3

212
April 2014
005010X223A2 837
N407
1715

X
ID 1/3

213
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
DTP Claim Check or Remittance Date

3500
2330B
Detail
Optional
1
1
Situational Rule: Required when the payer identified in this loop has previously
adjudicated the claim and Loop ID-2430, Line Check or Remittance Date, is not used. If
TR3 Example: DTP*573*D8*20040203~
Ref.
Des.
DTP01
Data
Element
374
DTP02
1250
DTP03
1251
214
Base
User
Name
Attributes
Attributes
Date/Time Qualifier
M
1 ID 3/3
M
573
Date Claim Paid
M
1 ID 2/3
M
D8
Date Time Period
M
1 AN 1/35
M
IMPLEMENTATION NAME: Adjudication or Payment Date
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
REF Other Payer Secondary Identifier

3550
2330B
Detail
Optional
2
Situational Rule: Required prior to the mandated implementation date for the HIPAA
National Plan Identifier when an additional identification number to that provided in the
TR3 Example: REF*2U*98765~
Ref.
Des.
REF01
REF02
215
Data
Element
128
127
Base
User
Name
Attributes
Attributes
M
1 ID 2/3
M
2U
EI
The Employers Identification Number must be a string of exactly
nine numbers with no separators.
For example, "001122333" would be valid, while sending "001-122333" or "00-1122333" would be invalid.
FY
Claim Office Number
The identification of the specific payer's location designated as
responsible for the submitted claim
NF
National Association of Insurance Commissioners (NAIC) Code
A unique number assigned to each insurance company
CODE SOURCE 245: National Association of Insurance
Commissioners (NAIC) Code
X
1 AN 1/50
M
IMPLEMENTATION NAME: Other Payer Secondary Identifier
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
REF Other Payer Prior Authorization Number

3550
2330B
Detail
Optional
1
Situational Rule: Required when the payer identified in this loop has assigned a prior
authorization number to this claim. If not required by this implementation guide, do not
send.
TR3 Example: REF*G1*AB333-Y5~
Ref.
Des.
REF01
Data
Element
128
REF02
127
216
Base
User
Name
Attributes
Attributes
M
1 ID 2/3
M
G1
Prior Authorization Number
An authorization number acquired prior to the submission of a claim
X
1 AN 1/50
M
IMPLEMENTATION NAME: Other Payer Prior Authorization Number
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
REF Other Payer Referral Number

3550
2330B
Detail
Optional
1
Situational Rule: Required when the payer identified in this loop has assigned a referral
number to this claim. If not required by this implementation guide, do not send.
TR3 Example: REF*9F*12345~
Ref.
Des.
REF01
Data
Element
128
REF02
127
217
Base
User
Name
Attributes
Attributes
M
1 ID 2/3
M
9F
Referral Number
X
1 AN 1/50
M
IMPLEMENTATION NAME: Other Payer Prior Authorization or Referral Number
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
REF Other Payer Claim Adjustment Indicator

3550
2330B
Detail
Optional
1
Situational Rule: Required when the claim is being sent in the payer-to-payer COB model
AND
the destination payer is secondary to the payer identified in this 2330B loop
AND
the payer identified in this 2330B loop has re-adjudicated the claim. If not required, then
do not send.
TR3 Example: REF*T4*Y~
Ref.
Des.
REF01
Data
Element
128
REF02
127
Base
User
Name
Attributes
Attributes
M
1 ID 2/3
M
T4
Signal Code
Defense Fuel Supply Center to bill back fuel purchases to the
appropriate service or agency account fund
X
1 AN 1/50
M
IMPLEMENTATION NAME: Other Payer Claim Adjustment Indicator
Only allowed value is "Y".
218
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
REF Other Payer Claim Control Number

3550
2330B
Detail
Optional
1
Situational Rule: Required when it is necessary to identify the Other Payers Claim
Control Number in a payer-to-payer COB situation.
OR
Required when the Other Payers Claim Control Number is available. If not required by
TR3 Example: REF*F8*R555588~
Ref.
Des.
REF01
Data
Element
128
REF02
127
219
Base
User
Name
Attributes
Attributes
M
1 ID 2/3
M
F8
Original Reference Number
This is the payers internal Claim Control Number for this claim for
the payer identified in this iteration of Loop ID-2330. This value is
typically used in payer-to-payer COB situations only.
X
1 AN 1/50
M
IMPLEMENTATION NAME: Other Payers Claim Control Number
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
NM1 Other Payer Attending Provider

3250
2330C
Detail
Optional
1
Situational Rule: Required prior to the mandated implementation of the HIPAA National
Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is
sent and one or more additional payer-specific provider identification numbers are
required by this non-destination payer (Loop ID- 2330B) to identify the provider.
OR
Required after the mandated implementation of the NPI rule for providers who are not
Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and
one or more additional payer-specific provider identification numbers are required by this
non-destination payer (Loop ID-2330B) to identify the provider. If not required by this
Ref.
Des.
NM101
Data
Element
98
NM102
1065
220
Base
User
Name
Attributes
Attributes
M
1 ID 2/3
M
71
Attending Physician
Physician present when medical services are performed
M
1 ID 1/1
M
1
Person
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
REF Other Payer Attending Provider Secondary Identification

3550
2330C
Detail
Mandatory
4
TR3 Notes: 1. Non-destination (COB) payers provider identification number(s).
in the 837.
Ref.
Des.
REF01
Data
Element
128
REF02
127
221
Base
User
Name
Attributes
Attributes
M
1 ID 2/3
M
0B
1G
G2
This code designates a proprietary provider number for the nondestination payer identified in the Other Payer Name Loop ID2330B for this iteration of Loop ID-2320. This is true regardless of
whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield
plan, a commercial plan, or any other health plan.
LU
Location Number
X
1 AN 1/50
M
IMPLEMENTATION NAME: Other Payer Attending Provider Secondary Identifier
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
NM1 Other Payer Operating Physician

3250
2330D
Detail
Optional
1
OR
Ref.
Des.
NM101
Data
Element
98
NM102
1065
222
Base
User
Name
Attributes
Attributes
M
1 ID 2/3
M
72
Operating Physician
M
1 ID 1/1
M
1
Person
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
REF Other Payer Operating Physician Secondary Identification

3550
2330D
Detail
Mandatory
4
in the 837.
TR3 Example: REF.*G2*12345~
Ref.
Des.
REF01
Data
Element
128
REF02
127
223
Base
User
Name
Attributes
Attributes
M
1 ID 2/3
M
0B
1G
G2
LU
Location Number
X
1 AN 1/50
M
IMPLEMENTATION NAME: Other Payer Operating Provider Secondary Identifier
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
NM1 Other Payer Other Operating Physician

3250
2330E
Detail
Optional
1
OR
TR3 Example: NM1*ZZ*1~
Ref.
Des.
NM101
Data
Element
98
NM102
1065
224
Base
User
Name
Attributes
Attributes
M
1 ID 2/3
M
ZZ
Mutually Defined
M
1 ID 1/1
M
1
Person
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
REF Other Payer Other Operating Physician Secondary Identification

3550
2330E
Detail
Mandatory
4
in the 837.
Ref.
Des.
REF01
Data
Element
128
REF02
127
225
Base
User
Name
Attributes
Attributes
M
1 ID 2/3
M
0B
1G
G2
LU
Location Number
X
1 AN 1/50
M
IMPLEMENTATION NAME: Other Payer Other Operating Physician Secondary
Identifier
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
NM1 Other Payer Service Facility Location

3250
2330F
Detail
Optional
1
OR
TR3 Notes: 1. See Crosswalking COB Data Elements section for more information
on handling COB in the 837.
Ref.
Des.
NM101
Data
Element
98
NM102
1065
226
Base
User
Name
Attributes
Attributes
M
1 ID 2/3
M
77
Service Location
M
1 ID 1/1
M
2
Non-Person Entity
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
REF Other Payer Service Facility Location Identification

3550
2330F
Detail
Mandatory
3
in the 837.
Ref.
Des.
REF01
Data
Element
128
REF02
127
227
Base
User
Name
Attributes
Attributes
M
1 ID 2/3
M
0B
G2
LU
Location Number
X
1 AN 1/50
M
IMPLEMENTATION NAME: Other Payer Service Facility Location Identifier
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
NM1 Other Payer Rendering Provider Name

3250
2330G
Detail
Optional
1
OR
Ref.
Des.
NM101
Data
Element
98
NM102
1065
228
Base
User
Name
Attributes
Attributes
M
1 ID 2/3
M
82
Rendering Provider
M
1 ID 1/1
M
1
Person
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
REF Other Payer Rendering Provider Secondary Identification

3550
2330G
Detail
Mandatory
4
in the 837.
Ref.
Des.
REF01
Data
Element
128
REF02
127
229
Base
User
Name
Attributes
Attributes
M
1 ID 2/3
M
0B
1G
G2
LU
Location Number
X
1 AN 1/50
M
IMPLEMENTATION NAME: Other Payer Rendering Provider Secondary Identifier
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
NM1 Other Payer Referring Provider

3250
2330H
Detail
Optional
1
OR
TR3 Example: NM1*DN*1~
Ref.
Des.
NM101
Data
Element
98
NM102
1065
230
Base
User
Name
Attributes
Attributes
M
1 ID 2/3
M
DN
Referring Provider
M
1 ID 1/1
M
1
Person
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
REF Other Payer Referring Provider Secondary Identification

3550
2330H
Detail
Mandatory
3
in the 837.
Ref.
Des.
REF01
Data
Element
128
REF02
127
231
Base
User
Name
Attributes
Attributes
M
1 ID 2/3
M
0B
1G
G2
X
1 AN 1/50
M
IMPLEMENTATION NAME: Other Payer Referring Provider Identifier
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
NM1 Other Payer Billing Provider

3250
2330I
Detail
Optional
1
OR
Ref.
Des.
NM101
Data
Element
98
NM102
1065
232
Base
User
Name
Attributes
Attributes
M
1 ID 2/3
M
85
Billing Provider
M
1 ID 1/1
M
2
Non-Person Entity
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
REF Other Payer Billing Provider Secondary Identification

3550
2330I
Detail
Mandatory
2
TR3 Notes: 1. See Crosswalking COB Data Elements section for more information
on handling COB in the 837.
Ref.
Des.
REF01
Data
Element
128
REF02
127
233
Base
User
Name
Attributes
Attributes
M
1 ID 2/3
M
G2
LU
Location Number
X
1 AN 1/50
M
IMPLEMENTATION NAME: Other Payer Billing Provider Identifier
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
LX Service Line Number

3650
2400
Detail
Mandatory
1
To reference a line number in a transaction set
TR3 Notes: 1. The LX functions as a line counter.

2. The Service Line LX segment must begin with one and is incremented by one for each
additional service line of a claim.
3. LX01 is used to indicate bundling in SVD06 in the Line Item Adjudication loop. See
Section 1.4.1.2 for more information on bundling and unbundling.
TR3 Example: LX*1~
Ref.
Des.
LX01
Data
Element
554
Name
Assigned Number
Base
User
Attributes
Attributes
M 1
N0 1/6
M
Number assigned for differentiation within a transaction set
234
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
SV2 Institutional Service Line

3750
2400
Detail
Mandatory
1
To specify the service line item detail for a health care institution
1 At least one of SV201 or SV202 is required.
2 If either SV204 or SV205 is present, then the other is required.
1 SV201 is the revenue code.
2 SV203 is the submitted service line item amount.
3 SV207 is a non-covered service amount.
4 SV208 is the detail service line indicator. A "Y" value indicates a detail service line;
an "N" value indicates a summary service line.
TR3 Example: SV2*0300*HC:81099*73.42*UN*81~
TR3 Example: SV2*0120**1500*DA*5~
Ref.
Des.
SV20
1
Data
Element
234
Name
Product/Service ID
Base
User
Attributes
Attributes
X 1
AN
M
1/48

IMPLEMENTATION NAME: Service Line Revenue Code
SV20
2
SV20
2-1
C003
235
See Code Source 132: National Uniform Billing Committee (NUBC) Codes.
Composite Medical Procedure Identifier
X 1
O
To identify a medical procedure by its standardized codes and applicable modifiers
SITUATIONAL RULE: Required for outpatient claims when an appropriate HCPCS
or HIPPS code exists for this service line item.
OR
Required for inpatient claims when an appropriate HCPCS (drugs and/or biologics
only) or HIPPS code exists for this service line item.
Product/Service ID Qualifier
M
ID 2/2
M
Code identifying the type/source of the descriptive number used in Product/Service ID
(234)
IMPLEMENTATION NAME: Product or Service ID Qualifier
ER
Jurisdiction Specific Procedure and Supply Codes
This code set is not allowed for use under HIPAA at the time of
this writing. The qualifier can only be used:
If a new rule names the Jurisdiction Specific Procedure and
Supply Codes as an allowable code set under HIPAA,
OR
OR
235
April 2014
005010X223A2 837
HC
HP
IV
WK
SV20
2-2
234
SV20
2-3
1339
CODE SOURCE 576: Workers Compensation Specific

Procedure and Supply Codes
Health Care Financing Administration Common Procedural
Coding System (HCPCS) Codes
HCFA coding scheme to group procedure(s) performed on an
outpatient basis for payment to hospital under Medicare;
primarily used for ambulatory surgical and other diagnostic
departments
Because the AMAs CPT codes are also level 1 HCPCS codes,
they are reported under HC.
CODE SOURCE 130: Healthcare Common Procedural Coding
System
Health Insurance Prospective Payment System (HIPPS) Skilled
Nursing Facility Rate Code
CODE SOURCE 716: Health Insurance Prospective Payment
System (HIPPS) Rate Code for Skilled Nursing Facilities
Home Infusion EDI Coalition (HIEC) Product/Service Code
If a new rule names the Home Infusion EDI Coalition (HIEC)
Product/Service Codes as an allowable code set under HIPAA,
OR
OR
CODE SOURCE 513: Home Infusion EDI Coalition (HIEC)
Product/Service Code List
At the time of this writing, this code set has been approved by
the Secretary of HHS as a pilot project allowed under HIPAA
law. The qualifier may only be used in transactions covered
under HIPAA; By parties registered in the pilot project and the
ir
trading partners,
OR
If a new rule names the Complementary, Alternative, or
Holistic Procedure Codes as an allowable code set under
HIPAA,
OR
CODE SOURCE 843: Advanced Billing Concepts (ABC)

Codes
Product/Service ID
M
AN
M
1/48
Procedure Modifier
O
AN 2/2
O
This identifies special circumstances related to the performance of the service, as
defined by trading partners
SITUATIONAL RULE: Required when a modifier clarifies or improves the reporting
accuracy of the associated procedure code. This is the first procedure code modifier. If
236
April 2014
005010X223A2 837
SV20
2-4
SV20
2-5
SV20
2-6
1339
Procedure Modifier
1339

SITUATIONAL RULE: Required when a second modifier clarifies or improves the
reporting accuracy of the associated procedure code. If not required by this
Procedure Modifier
O
AN 2/2
O
1339

SITUATIONAL RULE: Required when a third modifier clarifies or improves the
implementation
guide, do not send.
Procedure Modifier
O
AN 2/2
O
SV20
2-7
352
SV20
3
782
AN 2/2

SITUATIONAL RULE: Required when a fourth modifier clarifies or improves the
Description
O
AN
O
1/80
SITUATIONAL RULE: Required when, in the judgment of the submitter, the
Procedure Code does not definitively describe the service/product/supply and Loop
ID-2410 is not used.
OR
Required when SV202-2 is a non-specific Procedure Code. Non-specific codes may
include in their descriptors terms such as: Not Otherwise Classified (NOC); Unlisted;
Unspecified; Unclassified; Other; Miscellaneous; Prescription Drug, Generic; or
Prescription Drug, Brand
Name. If not required by this implementation guide, do not send.
Monetary Amount
O 1
R 1/18
M
Monetary amount
IMPLEMENTATION NAME: Line Item Charge Amount
This is the total charge amount for this service line. The amount is inclusive of the
providers base charge and any applicable tax amounts reported within this lines AMT
segments.
SV20
4
SV20
5
237
355
Zero "0" is an acceptable value for this element.

380
The following fixed value(s) will be populated for this element:
DA
UN
DA
Days
UN
Unit
Quantity
X 1
R 1/15
M
ID 2/2
April 2014
005010X223A2 837

IMPLEMENTATION NAME: Service Unit Count
SV20
6
1371
The maximum length for this field is 8 digits excluding the decimal. When a decimal
is used, the maximum number of digits allowed to the right of the decimal is three.
Unit Rate
X 1
R 1/10
M
The rate per unit of associate revenue for hospital accommodation
SITUATIONAL RULE: Required when the rate is HCPCS/HIPPS.
OR
Required when the charges for this line are associated with an accomodations revenue
code.
If not required this implementation guide, do not send.
SV20
7
782
IMPLEMENTATION NAME: Service Line Rate

Accommodation Rate
Monetary Amount
R 1/18
Monetary amount
SITUATIONAL RULE: Required if needed to report line specific noncovered charge
amount. If not required this implementation guide, do not send.
IMPLEMENTATION NAME: Line Item Denied Charge or Non-Covered Charge
Amount
238
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
PWK Line Supplemental Information

4200
2400
Detail
Mandatory
10
To identify the type or transmission or both of paperwork or supporting information
1 If either PWK05 or PWK06 is present, then the other is required.
1
2
PWK05 and PWK06 may be used to identify the addressee by a code number.
PWK07 may be used to indicate special information to be shown on the specified
report.
3 PWK08 may be used to indicate action pertaining to a report.
Required when there is a paper attachment following this claim.
OR
Required when attachments are sent electronically (PWK02 = EL) but are transmitted in
another functional group (for example, 275) rather than by paper. PWK06 is then used to
identify the attached electronic documentation. The number in PWK06 is carried in the
TRN of the electronic attachment.
OR
Required when the provider deems it necessary to identify additional information that is
being held at the providers office and is available upon request by the payer (or
appropriate entity), but the information is not being submitted with the claim. Use the
value of "AA" in PWK02 to convey this specific use of the PWK segment. If not required
TR3 Example: PWK*OZ*BM***AC*DMN0012~
Ref.
Des.
PWK01
239
Data
Element
755
Base
User
Name
Attributes
Attributes
Report Type Code
M
1 ID 2/2
M
Code indicating the title or contents of a document, report or supporting item
IMPLEMENTATION NAME: Attachment Report Type Code
03
Report Justifying Treatment Beyond Utilization Guidelines
04
Drugs Administered
05
Treatment Diagnosis
06
Initial Assessment
07
Functional Goals
Expected outcomes of rehabilitative services
08
Plan of Treatment
09
Progress Report
10
Continued Treatment
11
Chemical Analysis
13
Certified Test Report
15
Justification for Admission
21
Recovery Plan
A3
Allergies/Sensitivities Document
A4
Autopsy Report
AM
Ambulance Certification
Information to support necessity of ambulance trip
AS
Admission Summary
A brief patient summary; it lists the patient's chief complaints and
April 2014
005010X223A2 837
B2
B3
B4
BR
BS
BT
CB
CK
CT
D2
DA
DB
DG
DJ
DS
EB
HC
HR
I5
IR
LA
M1
MT
NN
OB
OC
OD
OE
OX
OZ
P4
240
the reasons for admitting the patient to the hospital

Prescription
Physician Order
Referral Form
Benchmark Testing Results
Baseline
Blanket Test Results
Chiropractic Justification
Lists the reasons chiropractic is just and appropriate treatment
Consent Form(s)
Certification
Drug Profile Document
Dental Models
Cast of the teeth; they are usually taken before partial dentures or
braces are placed
Durable Medical Equipment Prescription
Prescription describing the need for durable medical equipment; it
usually includes the diagnosis and possible time period the
equipment will be needed
Diagnostic Report
Report describing the results of lab tests x-rays or radiology films
Discharge Monitoring Report
Discharge Summary
Report listing the condition of the patient upon release from the
hospital; it usually lists where the patient is being released to, what
medication the patient is taking and when to follow-up with the
doctor
Explanation of Benefits (Coordination of Benefits or Medicare
Secondary Payor)
Summary of benefits paid on the claim
Health Certificate
Health Clinic Records
Immunization Record
State School Immunization Records
Laboratory Results
Medical Record Attachment
Models
Nursing Notes
Notes kept by the nurse regarding a patient's physical and mental
condition, what medication the patient is on and when it should be
given
Operative Note
Step-by-step notes of exactly what takes place during an operation
Oxygen Content Averaging Report
Orders and Treatments Document
Objective Physical Examination (including vital signs) Document
Oxygen Therapy Certification
Medical records that would support procedures performed; tests
given and necessary for a claim
Pathology Report
April 2014
005010X223A2 837
P5
PE
PN
PO
PQ
PY
PZ
RB
PWK02
756
PWK05
66
PWK06
67
Patient Medical History Document

Parenteral or Enteral Certification
Physical Therapy Notes
Prosthetics or Orthotic Certification
Paramedical Results
Physician's Report
Physical Therapy Certification
Radiology Films
X-rays, videos, and other radiology diagnostic tests
RR
Radiology Reports
Reports prepared by a radiologists after the films or x-rays have been
reviewed
RT
Report of Tests and Analysis Report
RX
Renewable Oxygen Content Averaging Report
SG
Symptoms Document
V5
Death Notification
XP
Photographs
Report Transmission Code
O
1 ID 1/2
M
Code defining timing, transmission method or format by which reports are to be sent
IMPLEMENTATION NAME: Attachment Transmission Code
AA
Available on Request at Provider Site
This means that the additional information is not being sent with the
claim at this time. Instead, it is available to the payer (or appropriate
entity) at their request.
BM
By Mail
EL
Electronically Only
Indicates that the attachment is being transmitted in a separate X12
functional group.
EM
E-Mail
FT
File Transfer
Required when the actual attachment is maintained by an attachment
warehouse or similar vendor.
FX
By Fax
X
1 ID 1/2
O
SITUATIONAL RULE: Required if PWK02 = "BM", "EL", "EM" "FX" or "FT". If not
AC
Attachment Control Number
Means of associating electronic claim with documentation forwarded
by other means
Identification Code
X
1 AN 2/80
O
SITUATIONAL RULE: Required if PWK02 = BM, EL, EM FX or FT. If not required by
IMPLEMENTATION NAME: Attachment Control Number
PWK06 is used to identify the attached electronic documentation. The number in PWK06
is carried in the TRN of the electronic attachment.
For the purpose of this implementation, the maximum field length is 50.
241
April 2014
005010X223A2 837
Refer to Appendix for fixed format claim level details.

The 837 format has a Claim Level File Information segment ("K3") and Claim Line Level
Supplemental Information segment ("PWK") which can be used for communicating such
information. The table in Appendix shows how SCP communicates this information in the
K3 and PWK Segment.
K3 and PWK segments repeat twice and contain information in fixed format. Detailed
information about each field has been described in Appendix.
242
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
DTP Date - Service Date

4550
2400
Detail
Mandatory
1
1
Situational Rule: Required on outpatient service lines where a drug is not being billed and
the Statement Covers Period is greater than one day.
OR
Required on service lines where a drug is being billed and the payers adjudication is
known to be impacted by the drug duration or the date the prescription was written. If not
TR3 Notes: 1. In cases where a drug is being billed on a service line, date range may be
used to indicate drug duration for which the drug supply will be used by the patient. The
difference in dates, including both the begin and end dates, are the days supply of the
drug. Example: 20000101 - 20000107 (1/1/00 to 1/7/00) is used for a 7 day supply where
the first day of the drug used by the patient is 1/1/00. In the event a drug is administered
on less than a daily basis (for example, every other day) the date range would include the
entire period during which the drug was supplied, including the last day the drug was
used. Example: 20000101 - 20000108 (1/1/00 to 1/8/00) is used for an 8 days supply
where the prescription is written for Q48 (every 48 hours), four doses of the drug are
dispensed and the first dose is used on 1/1/00.
2. In cases where a drug is being billed on a service line, a single date may be used to
indicate the date the prescription was written (or otherwise communicated by the
prescriber if not written).
TR3 Example: DTP*472*RD8*20060108~
Ref.
Des.
DTP0
1
DTP0
2
Data
Element
374
1250
Name
Date/Time Qualifier
Base
User
Attributes
Attributes
M 1
ID 3/3
M

472
Service
Begin and end dates of the service being rendered
M 1
ID 2/3
RD8 is required only when the "To and From" dates are different. However, at the
discretion of the submitter, RD8 can also be used when the "To and From" dates are
the same.
RD8
RD8
243
April 2014
005010X223A2 837
DTP0
3
244
1251

Date Time Period
M 1
AN
M
1/35
IMPLEMENTATION NAME: Service Date
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
REF Line Item Control Number

4700
2400
Detail
Optional
1
Situational Rule: Required when the submitter needs a line item control number for
subsequent communications to or from the payer. If not required by this implementation
guide, do not send.
TR3 Notes: 1. The line item control number must be unique within a patient control
number (CLM01). Payers are required to return this number in the remittance advice
transaction (835) if the provider sends it to them in the 837 and adjudication is based
upon line item detail regardless of whether bundling or unbundling has occurred.
2. Submitters are STRONGLY encouraged to routinely send a unique line item control
number on all service lines, particularly if the submitter automatically posts their
remittance advice. Submitting a unique line item control number allows the capability to
automatically post by
service line.
TR3 Example: REF*6R*54321~
Ref.
Des.
REF01
Data
Element
128
REF02
127
Base
User
Name
Attributes
Attributes
M
1 ID 2/3
M
6R
Provider Control Number
Number assigned by information provider company for tracking and
billing purposes
X
1 AN 1/50
M
IMPLEMENTATION NAME: Line Item Control Number
The maximum number of characters to be supported for this field is 30. A submitter may
submit fewer characters depending upon their needs. However, the HIPAA maximum
requirement to be supported by any responding system is 30. Characters beyond 30 are
not required to be stored nor returned by any 837-receiving system.
245
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
REF Repriced Line Item Reference Number

4700
2400
Detail
Optional
1
Situational Rule: Required when a repricing (pricing) organization needs to have an
identifying number on the service line in their submission to their payer organization.
This segment is not completed by providers. If not required by this implementation guide,
do not send.
TR3 Example: REF*9B*444444~
Ref.
Des.
REF01
Data
Element
128
REF02
127
246
Base
User
Name
Attributes
Attributes
M
1 ID 2/3
M
9B
Repriced Line Item Reference Number
X
1 AN 1/50
M
IMPLEMENTATION NAME: Repriced Line Item Reference Number
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
REF Adjusted Repriced Line Item Reference Number

4700
2400
Detail
Optional
1
Situational Rule: Required when a repricing (pricing) organization needs to have an
identifying number on an adjusted service line in their submission to their payer
organization. This segment is not completed by providers. If not required by this
TR3 Example: REF*9D*444444~
Ref.
Des.
REF01
Data
Element
128
REF02
127
247
Base
User
Name
Attributes
Attributes
M
1 ID 2/3
M
9D
Adjusted Repriced Line Item Reference Number
X
1 AN 1/50
M
IMPLEMENTATION NAME: Adjusted Repriced Line Item Reference Number
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
AMT Service Tax Amount

4750
2400
Detail
Optional
1
Situational Rule: Required when a service tax or surcharge applies to the service being
reported in SV201 and the submitter is required to report that information to the receiver.
TR3 Notes: 1. When reporting the Service Tax Amount (AMT02), the amount reported in
the Line Item Charge Amount (SV203) for this service line must include the amount
reported in the Service Tax Amount.
TR3 Example: AMT*GT*15~
Ref.
Des.
AMT01
Data
Element
522
AMT02
782
248
Name
GT
Goods and Services Tax
Canadian value-added tax
Monetary Amount
Monetary amount
IMPLEMENTATION NAME: Service Tax Amount
Base
User
Attributes
Attributes
M
1 ID 1/3
M
1 R 1/18
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
AMT Facility Tax Amount

4750
2400
Detail
Optional
1
Situational Rule: Required when a facility tax or surcharge applies to the service being
reported in SV201 and the submitter is required to report that information to the receiver.
TR3 Notes: 1. When reporting the Facility Tax Amount (AMT02), the amount reported
in the Line Item Charge Amount (SV203) for this service line must include the amount
reported in the Facility Tax Amount.
TR3 Example: AMT*N8*22~
Ref.
Des.
AMT01
Data
Element
522
AMT02
782
249
Name
N8
Miscellaneous Taxes
Monetary Amount
Monetary amount
IMPLEMENTATION NAME: Facility Tax Amount
Base
User
Attributes
Attributes
M
1 ID 1/3
M
1 R 1/18
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
NTE Third Party Organization Notes

4850
2400
Detail
Optional
1
instruction
Situational Rule: Required when the TPO/repricer needs to forward additional
information to the payer. This segment is not completed by providers. If not required by
TR3 Example: NTE*TPO*state regulation 123 was applied during the pricing of this
claim~
Ref.
Des.
NTE01
Data
Element
363
NTE02
352
250
Base
User
Name
Attributes
Attributes
Note Reference Code
O
1 ID 3/3
M
TPO
Third Party Organization Notes
Description
M
1 AN 1/80
M
IMPLEMENTATION NAME: Line Note Text
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
HCP Line Pricing/Repricing Information

4920
2400
Detail
Mandatory
1
To specify pricing or repricing information about a health care claim or line item
1 At least one of HCP01 or HCP13 is required.
1 HCP02 is the allowed amount.
2 HCP03 is the savings amount.
3 HCP04 is the repricing organization identification number.
4 HCP05 is the pricing rate associated with per diem or flat rate repricing.
5 HCP06 is the approved DRG code.
6 HCP07 is the approved DRG amount.
7 HCP08 is the approved revenue code.
8 HCP10 is the approved procedure code.
9 HCP12 is the approved service units or inpatient days.
10 HCP13 is the rejection message returned from the third party organization.
11 HCP15 is the exception reason generated by a third party organization.
1 HCP06, HCP07, HCP08, HCP10, and HCP12 are fields that will contain different
values from the original submitted values.
2. For capitated encounters, pricing or repricing information usually is not applicable and
is provided to qualify other information within the claim.
TR3 Example: HCP*02*100*10*******DA*4~
Ref.
Des.
HCP0
1
Data
Element
1473
Name
Pricing Methodology
Base
User
Attributes
Attributes
X 1
ID 2/2
M
Code specifying pricing methodology at which the claim or line item has been priced
or repriced
Specific code use is determined by Trading Partner Agreement due to the variances in
contracting policies in the industry.
00, 02
HCP0
2
782
00 - Non Participating Provider

02 - Participating Provider
00
Zero Pricing (Not Covered Under Contract)
02
Priced at the Standard Fee Schedule
Monetary Amount
O 1
R 1/18
Monetary amount
251
April 2014
005010X223A2 837
HCP0
3
782
Eligible amount is the amount of the provider charge that is covered under groups
contract and eligible for payment
Monetary Amount
O 1
R 1/18
O
Monetary amount
HCP0
4
127
HCP0
5
118

Ineligible amount is the amount of provider charges considered not covered under
groups contract.
O 1
AN
O
1/50
Rate
O 1
R 1/9
O
Rate expressed in the standard monetary denomination for the currency specified
HCP0
6
127
HCP0
7
782

Most Common Semi Private Room Rate
O 1
AN
O
1/50
Monetary Amount
O 1
R 1/18
O
Monetary amount
HCP0
8
252
234

Product/Service ID
O 1
AN
O
1/48
April 2014
005010X223A2 837
IMPLEMENTATION NAME: Product or Service ID
HCP0
9
235

X 1
ID 2/2
O
(234)
SITUATIONAL RULE: Required when HCP10 exists. If not required by this
ER
If a new rule names the Jurisdiction Specific Procedure and
Supply Codes as an allowable code set under HIPAA,
OR
OR
HC
HP
IV
WK
253

departments
CODE SOURCE 130: Health Care Financing Administration
Common Procedural Coding System
If a new rule names the Home Infusion EDI Coalition (HIEC)
Product/Service Codes as an allowable code set under HIPAA,
OR
OR
law. The qualifier may only be used in transactions
April 2014
005010X223A2 837
covered under HIPAA; By parties registered in the pilot project

and their trading partners,
OR
HIPAA,
OR
HCP1
0
234

Codes
Product/Service ID
X 1
AN
O
1/48
IMPLEMENTATION NAME: Repriced Approved HCPCS Code
HCP1
1
HCP1
2
355

X 1
ID 2/2
O
380
DA
DA
Days
Quantity
X 1
R 1/15
O
HCP1
3
901
The maximum length for this field is 8 digits excluding the decimal. When a decimal is
used, the maximum number of digits allowed to the right of the decimal is three.
Reject Reason Code
X 1
ID 2/2
O
Code assigned by issuer to identify reason for rejection
T1
Cannot Identify Provider as TPO (Third Party Organization)
Participant
T2
Cannot Identify Payer as TPO (Third Party Organization)
Participant
T3
Cannot Identify Insured as TPO (Third Party Organization)
254
April 2014
005010X223A2 837
HCP1
4
1526
Participant
T4
Payer Name or Identifier Missing
T5
Certification Information Missing
T6
Claim does not contain enough information for re-pricing
Policy Compliance Code
O 1
ID 1/2
O
Code specifying policy compliance
HCP1
5
1527

1
Procedure Followed (Compliance)
2
Not Followed - Call Not Made (Non-Compliance Call Not
Made)
3
Not Medically Necessary (Non-Compliance Non-Medically
Necessary)
4
Not Followed Other (Non-Compliance Other)
5
Emergency Admit to Non-Network Hospital
Exception Code
O 1
ID 1/2
O
Code specifying the exception reason for consideration of out-of-network health care
services
1
Non-Network Professional Provider in Network Hospital
2
Emergency Care
3
Services or Specialist not in Network
4
Out-of-Service Area
5
State Mandates
6
Other
255
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
LIN Drug Identification

4930
2410
Detail
Optional
1
To specify basic item identification data
1 If either LIN04 or LIN05 is present, then the other is required.
1 LIN01 is the line item identification
1 See the Data Dictionary for a complete list of IDs.
2 LIN02 through LIN31 provides for fifteen different product/service IDs for each
item. For example: Case, Color, Drawing No., U.P.C. No., ISBN No., Model No., or
SKU.
Situational Rule: Required when government regulation mandates that prescribed drugs
and biologics are reported with NDC numbers.
OR
Required when the provider or submitter chooses to report NDC numbers to enhance the
claim reporting or adjudication processes. If not required by this implementation guide,
do not send.
TR3 Notes: 1. Drugs and biologics reported in this segment are a further specification of
service(s) described in the SV2 segment of this Service Line Loop ID-2400.
TR3 Example: LIN**N4*01234567891~
Ref.
Des.
LIN02
Data
Element
235
LIN03
234
256
Base
User
Name
Attributes
Attributes
M
1 ID 2/2
M
(234)
N4
National Drug Code in 5-4-2 Format
5-digit manufacturer ID, 4-digit product ID, 2-digit trade package
size
CODE SOURCE 240: National Drug Code by Format
Product/Service ID
M
1 AN 1/48
M
IMPLEMENTATION NAME: National Drug Code
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
CTP Drug Quantity

4940
2410
Detail
Mandatory
1
To specify pricing information
1 If either CTP04 or CTP05 is present, then the other is required.
2 If CTP06 is present, then CTP07 is required.
1 CTP07 is a multiplier factor to arrive at a final discounted price. A multiplier of .90
would be the factor if a 10% discount is given.
2 CTP08 is the rebate amount.
1 See Figures Appendix for an example detailing the use of CTP03 and CTP04.
See Figures Appendix for an example detailing the use of CTP03, CTP04 and
CTP07.
TR3 Example: CTP****2*UN~
Ref.
Des.
CTP04
Data
Element
380
CTP05
C001
C00101
355
257
Base
User
Name
Attributes
Attributes
Quantity
X
1 R 1/15
M
IMPLEMENTATION NAME: National Drug Unit Count
Composite Unit of Measure
X
1
M
To identify a composite unit of measure (See Figures Appendix for examples of use)
IMPLEMENTATION NAME: Code Qualifier
M
ID 2/2
M
F2
International Unit
A unit accepted by an international agency; potency of a
drug/vitamin based on a specific weight of that drug/vitamin
GR
Gram
ME
Milligram
ML
Milliliter
UN
Unit
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
REF Prescription or Compound Drug Association Number

4950
2410
Detail
Optional
1
Situational Rule: Required when dispensing of the drug has been done with an assigned
prescription number.
OR
Required when the provided medication involves the compounding of two or more drugs
being reported and there is no prescription number. If not required by this implementation
guide, do not send.
TR3 Notes: 1. In cases where a compound drug is being billed, the components of the
compound will all have the same prescription number. Payers receiving the claim can
relate all the components by matching the prescription number.
2. For cases where the drug is provided without a prescription (for example, from a
physicians office), the value provided in this segment is a "link sequence number". The
link sequence number is a provider assigned number that is unique to this claim. Its
purpose is to enable the receiver to piece together the components of the compound.
TR3 Example: REF*XZ*123456~
Ref.
Des.
REF01
Data
Element
128
REF02
127
258
Base
User
Name
Attributes
Attributes
M
1 ID 2/3
M
VY
Link Sequence Number
XZ
Pharmacy Prescription Number
X
1 AN 1/50
M
IMPLEMENTATION NAME: Prescription Number
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
NM1 Operating Physician Name

5000
2420A
Detail
Optional
1
Situational Rule: Required when a surgical procedure code is listed on this claim.
AND
The Operating Physician for this line is different than the Operating Physician reported in
Loop ID - 2310B (claim level). If not required by this implementation guide, do not send.
TR3 Notes: 1. The Operating Physician is the individual with primary responsibility for
performing the surgical procedure(s).
TR3 Example: NM1*72*1*MEYERS*JANE****XX*1234567891~
Ref.
Des.
NM101
Data
Element
98
NM102
1065
NM103
1035
NM104
1036
NM105
1037
NM107
1039
Base
User
Name
Attributes
Attributes
M
1 ID 2/3
M
72
Operating Physician
M
1 ID 1/1
M
1
Person
X
1 AN 1/60
M
IMPLEMENTATION NAME: Operating Physician Last Name
Name First
O
1 AN 1/35
O
IMPLEMENTATION NAME: Operating Physician First Name
Name Middle
O
1 AN 1/25
O
IMPLEMENTATION NAME: Operating Physician Middle Name or Initial
Name Suffix
O
1 AN 1/10
O
IMPLEMENTATION NAME: Operating Physician Name Suffix
259
April 2014
005010X223A2 837
NM108
66
NM109
67

X
1 ID 1/2
O
OR
received an NPI.
OR
XX
Identifier
Identification Code
X
1 AN 2/80
O
Required for providers in the United States or its territories on or after the mandated
HIPAA National Provider Identifier (NPI) implementation date when the provider is
eligible to receive an NPI.
OR
received an NPI.
OR
IMPLEMENTATION NAME: Operating Physician Primary Identifier
260
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
REF Operating Physician Secondary Identification

5250
2420A
Detail
Optional
20
OR
TR3 Notes: 1. When it is necessary to report one or more non-destination payer
Secondary Identifiers, the composite data element in REF04 is used to identify the payer
who assigned this identifier.
Ref.
Des.
REF01
Data
Element
128
REF02
127
REF04
C040
REF04-1
128
261
Base
User
Name
Attributes
Attributes
M
1 ID 2/3
M
0B
1G
G2
LU
Location Number
X
1 AN 1/50
M
IMPLEMENTATION NAME: Operating Physician Secondary Identifier
Reference Identifier
O
1
O
To identify one or more reference numbers or identification numbers as specified by the
Reference Qualifier
SITUATIONAL RULE: Required when the identifier reported in REF02 of this segment is
for a non-destination payer.
Do not use this composite when the value reported in REF01 is either 0B or 1G.
M
ID 2/3
M
2U
April 2014
005010X223A2 837
REF04-2
127
M
AN 1/50
M
The payer identifier reported in this field must match the corresponding payer identifier
reported in Loop ID-2330B NM109.
262
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
NM1 Other Operating Physician Name

5000
2420B
Detail
Optional
1
Situational Rule: Required when another Operating Physician is involved.
AND
The Other Operating Physician for this line is different than the Other Operating
Physician reported in Loop ID 2310C (claim level).
If not required by the implementation guide, do not send.
TR3 Example: NM1*ZZ*1*JONES*JOHN***SR*XX*1234567891~
Ref.
Des.
NM101
Data
Element
98
NM102
1065
NM103
1035
NM104
1036
NM105
1037
NM107
1039
NM108
66
263
Base
User
Name
Attributes
Attributes
M
1 ID 2/3
M
ZZ
Mutually Defined
M
1 ID 1/1
M
1
Person
X
1 AN 1/60
M
IMPLEMENTATION NAME: Other Operating Physician Last Name
Name First
O
1 AN 1/35
O
IMPLEMENTATION NAME: Other Operating Physician First Name
Name Middle
O
1 AN 1/25
O
IMPLEMENTATION NAME: Other Operating Physician Middle Name or Initial
Name Suffix
O
1 AN 1/10
O
IMPLEMENTATION NAME: Other Operating Physician Name Suffix
X
1 ID 1/2
O
April 2014
005010X223A2 837
NM109
67
OR
received an NPI.
OR
XX
Identifier
Identification Code
X
1 AN 2/80
O
OR
received an NPI.
OR
IMPLEMENTATION NAME: Other Operating Physician Identifier
264
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
REF Other Operating Physician Secondary Identification

5250
2420B
Detail
Optional
20
OR
Ref.
Des.
REF01
Data
Element
128
REF02
127
REF04
C040
REF04-1
128
265
Base
User
Name
Attributes
Attributes
M
1 ID 2/3
M
0B
1G
G2
LU
Location Number
X
1 AN 1/50
M
IMPLEMENTATION NAME: Other Provider Secondary Identifier
O
1
O
Reference Qualifier
M
ID 2/3
M
2U
April 2014
005010X223A2 837
REF04-2
127
M
AN 1/50
M
266
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
NM1 Rendering Provider Name

5000
2420C
Detail
Optional
1
Situational Rule: Required when Rendering Provider is different than the Attending
Provider reported in the 2310A loop of this claim.
AND
State or federal regulatory requirements call for a "combined claim", that is, a claim that
includes both facility and professional components (for example, a Medicaid clinic bill or
Critical Access Hospital Hospital Claim.)
AND
The Rendering Provider for this line is different than the Rendering Provider reported in
Loop ID 2310D (claim level).
TR3 Notes: 1. The Rendering Provider is the health care professional who delivers or
completes a particular medical service or non-surgical procedure.
TR3 Example: NM1*82*1*MEYERS*JANE*C***XX*1234567804~
Ref.
Des.
NM101
Data
Element
98
NM102
1065
NM103
1035
NM104
1036
NM105
1037
NM107
1039
267
Base
User
Name
Attributes
Attributes
M
1 ID 2/3
M
82
Rendering Provider
M
1 ID 1/1
M
1
Person
X
1 AN 1/60
M
IMPLEMENTATION NAME: Rendering Provider Last Name
Name First
O
1 AN 1/35
O
IMPLEMENTATION NAME: Rendering Provider First Name
Name Middle
O
1 AN 1/25
O
IMPLEMENTATION NAME: Rendering Provider Middle Name or Initial
Name Suffix
O
1 AN 1/10
April 2014
005010X223A2 837
NM108
66
NM109
67
IMPLEMENTATION NAME: Rendering Provider Name Suffix

X
1 ID 1/2
O
OR
received an NPI.
OR
XX
Identifier
Identification Code
X
1 AN 2/80
O
OR
received an NPI.
OR
IMPLEMENTATION NAME: Rendering Provider Identifier
268
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
REF Rendering Provider Secondary Identification

5250
2420C
Detail
Optional
20
OR
Ref.
Des.
REF01
Data
Element
128
REF02
127
REF04
C040
REF04-1
128
269
Base
User
Name
Attributes
Attributes
M
1 ID 2/3
M
0B
1G
G2
LU
Location Number
X
1 AN 1/50
M
IMPLEMENTATION NAME: Rendering Provider Secondary Identifier
O
1
O
Reference Qualifier
M
ID 2/3
M
2U
April 2014
005010X223A2 837
REF04-2
127
M
AN 1/50
M
270
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
NM1 Referring Provider Name

5000
2420D
Detail
Optional
1
Situational Rule: Required on an outpatient claim when the Referring Provider is
different than the Attending Provider.
AND
The Referring Provider for this line is different than the Referring Provider reported in
Loop ID 2310F (claim level). If not required by this implementation guide, do not send.
TR3 Notes: 1. The Referring Provider is provider who sends the patient to another
provider for services.
TR3 Example: NM1*DN*1*SMITH*JANE****XX*1234567890~
Ref.
Des.
NM101
Data
Element
98
NM102
1065
NM103
1035
NM104
1036
NM105
1037
NM107
1039
Base
User
Name
Attributes
Attributes
M
1 ID 2/3
M
DN
Referring Provider
M
1 ID 1/1
M
1
Person
X
1 AN 1/60
M
IMPLEMENTATION NAME: Referring Provider Last Name
Name First
O
1 AN 1/35
O
IMPLEMENTATION NAME: Referring Provider First Name
Name Middle
O
1 AN 1/25
O
IMPLEMENTATION NAME: Referring Provider Middle Name or Initial
Name Suffix
O
1 AN 1/10
O
IMPLEMENTATION NAME: Referring Provider Name Suffix
271
April 2014
005010X223A2 837
NM108
66
NM109
67

X
1 ID 1/2
O
OR
XX
Identifier
Identification Code
X
1 AN 2/80
O
OR
IMPLEMENTATION NAME: Referring Provider Identifier
272
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
REF Referring Provider Secondary Identification

5250
2420D
Detail
Optional
20
OR
Ref.
Des.
REF01
Data
Element
128
REF02
127
REF04
C040
REF04-1
128
REF04-2
127
273
Base
User
Name
Attributes
Attributes
M
1 ID 2/3
M
0B
1G
G2
X
1 AN 1/50
O
IMPLEMENTATION NAME: Referring Provider Secondary Identifier
O
1
O
Reference Qualifier
M
ID 2/3
M
2U
M
AN 1/50
M
April 2014
005010X223A2 837

274
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
SVD Line Adjudication Information

5400
2430
Detail
Optional
1
To convey service line adjudication information for coordination of benefits between the
initial payers of a health care claim and all subsequent payers
1
2
3
4
1
SVD01 is the payer identification code.

SVD02 is the amount paid for this service line.
SVD04 is the revenue code.
SVD05 is the paid units of service.
SVD03 represents the medical procedure code upon which adjudication of this
service line was based. This may be different than the submitted medical procedure
code.
2 SVD06 is only used for bundling of service lines. It references the LX Assigned
Number of the service line into which this service line was bundled.
Situational Rule: Required when the claim has been previously adjudicated by payer
identified in Loop ID-2330B and this service line has payments and/or adjustments
applied to it. If not required by this implementation guide, do not send.
TR3 Notes: 1. To show unbundled lines: If, in the original claim, line 3 is unbundled into
(for example) 2 additional lines, then the SVD for line 3 is used 3 times: once for the
original adjustment to line 3 and then two more times for the additional unbundled lines.
TR3 Example: SVD*43*55*HC:84550**3~
Ref.
Des.
SVD0
1
Data
Element
67
Name
Identification Code
Base
User
Attributes
Attributes
M 1
AN
M
2/80

This identifier indicates the payer responsible for the reimbursement described in this
iteration of the 2430 loop. The identifier indicates the Other Payer by matching the
appropriate Other Payer Primary Identifier (Loop ID-2330B, element NM109).
SVD0
2
782
Monetary Amount
R 1/18
Monetary amount
IMPLEMENTATION NAME: Service Line Paid Amount
SVD0
3
SVD0
3-1
C003
235
Zero "0" is an acceptable value for this element.

Composite Medical Procedure Identifier
To identify a medical procedure by its standardized codes and applicable modifiers

This element contains the procedure code that was used to pay this service line.
M
ID 2/2
M
(234)
ER
275
April 2014
005010X223A2 837
HC
HP
IV
WK
SVD0
3-2
234
SVD0
3-3
1339

departments
CODE SOURCE 130: Health Care Financing Administration
Common Procedural Coding System
If a new rule names the Home Infusion EDI Coalition Codes as
an allowable code set under HIPAA,
OR
OR
law.
The qualifier may only be used in transactions covered under
HIPAA; By parties registered in the pilot project and their
trading partners,
OR
HIPAA,
OR

Codes
Product/Service ID
M
AN
M
1/48
Procedure Modifier
O
AN 2/2
O
SITUATIONAL RULE: Required when a modifier clarifies or improves the reporting
accuracy of the associated procedure code. This is the first procedure code modifier. If
276
April 2014
005010X223A2 837
SVD0
3-4
SVD0
3-5
SVD0
3-6
1339
Procedure Modifier
AN 2/2
1339

SITUATIONAL RULE: Required when a second modifier clarifies or improves the
Procedure Modifier
O
AN 2/2
O
1339

SITUATIONAL RULE: Required when a third modifier clarifies or improves the
Procedure Modifier
O
AN 2/2
O
SITUATIONAL RULE: Required when a fourth modifier clarifies or improves the
Description
O
AN
O
1/80
SITUATIONAL RULE: Required when SVC01-7 was returned in the 835 transaction.
SVD0
3-7
352
SVD0
4
SVD0
5
234
IMPLEMENTATION NAME: Procedure Code Description

Product/Service ID
M 1
380
Quantity
AN
1/48
R 1/15
M
M

IMPLEMENTATION NAME: Paid Service Unit Count
This is the number of paid units from the remittance advice. When paid units are not
present on the remittance advice, use the original billed units.
SVD0
6
554
The maximum length for this field is 8 digits excluding the decimal. When a decimal
is used, the maximum number of digits allowed to the right of the decimal is three.
Assigned Number
O 1
N0 1/6
O
Number assigned for differentiation within a transaction set
SITUATIONAL RULE: Required when payer bundled this service line. If not required
IMPLEMENTATION NAME: Bundled line Number
277
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
CAS Line Adjustment

5450
2430
Detail
Optional
5
To supply adjustment reason codes and amounts as needed for an entire claim or for a
particular service within the claim being paid
1 CAS03 is the amount of adjustment.
1 Adjustment information is intended to help the provider balance the remittance
information. Adjustment amounts should fully explain the difference between
submitted charges and the amount paid.
Situational Rule: Required when the payer identified in Loop 2330B made line level
adjustments which caused the amount paid to differ from the amount originally charged.
TR3 Notes: 1. A single CAS segment contains six repetitions of the "adjustment trio"
composed of adjustment reason code, adjustment amount, and adjustment quantity. These
six adjustment trios are used to report up to six adjustments related to a particular Claim
Adjustment Group Code (CAS01). The first adjustment is reported in the first adjustment
trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the
second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio
(CAS17-CAS19).
TR3 Example: CAS*PR*1*7.93~
Ref.
Des.
CAS01
278
Data
Element
1033
Base
User
Name
Attributes
Attributes
Claim Adjustment Group Code
M
1 ID 1/2
M
Code identifying the general category of payment adjustment
April 2014
005010X223A2 837
CAS02
1034

CO, OA, PR
CO
Contractual Obligations
OA
Other adjustments
PR
Patient Responsibility
M
1 ID 1/5

01-Deductible: Total amount determined by the other carrier or Medicare which must be
paid by the insured toward his own medical expenses before benefit under his contract will
be paid
02-Coinsurance: Total other carrier or Medicare coinsurance expenses that the member is
liable to pay under his contract
03-Copay: Medical expenses before Medicare or other insurance
187- Personal Saving Amt: Consumer Spending Account payments (includes but is not
limited to Flexible Spending Account, Health Savings Account, Health Reimbursement
Account, etc
96- Non Covered Amt: Total other carrier or Medicare amount determined to be not
covered under the member's contract
45-Held Harmless Amt: Total amount determined by the other carrier or Medicare that the
member is not responsible to pay
For a complete list of Adjustment Reason Codes please reference Washington Publishing
CAS03
782
CAS04
380
CAS05
1034
Monetary Amount
M
1 R 1/18
M
Monetary amount
Quantity
O
1 R 1/15
O
SITUATIONAL RULE: Required when the units of service are being adjusted. If not
X
1 ID 1/5
O
adjustment, beyond what has already been supplied, to this service line for the Claim
Adjustment Group Code reported in CAS01. If not required by this implementation guide,
do not send.
279
April 2014
005010X223A2 837
CAS06
782
CAS07
380
CAS08
1034
Monetary Amount
X
1 R 1/18
O
Monetary amount
Quantity
X
1 R 1/15
O
X
1 ID 1/5
O
do not send.
CAS09
782
CAS10
380
CAS11
1034
Monetary Amount
X
1 R 1/18
O
Monetary amount
Quantity
X
1 R 1/15
O
X
1 ID 1/5
O
do not send.
280
April 2014
005010X223A2 837
CAS12
782
CAS13
380
CAS14
1034
Monetary Amount
X
1 R 1/18
O
Monetary amount
Quantity
X
1 R 1/15
O
X
1 ID 1/5
O
do not send.
CAS15
782
CAS16
380
CAS17
1034
Monetary Amount
X
1 R 1/18
O
Monetary amount
Quantity
X
1 R 1/15
O
X
1 ID 1/5
O
do not send.
CAS18
281
782

Monetary Amount
X
1 R 1/18
O
Monetary amount
April 2014
005010X223A2 837
CAS19
380

Quantity
X
1 R 1/15
O
282
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
DTP Line Check or Remittance Date

5500
2430
l
Detail
Mandatory
1
1
TR3 Example: DTP*573*D8*20040203~

Ref.
Des.
DTP01
Data
Element
374
DTP02
1250
DTP03
1251
283
Base
User
Name
Attributes
Attributes
Date/Time Qualifier
M
1 ID 3/3
M
573
Date Claim Paid
M
1 ID 2/3
M
D8
Date Time Period
M
1 AN 1/35
M
IMPLEMENTATION NAME: Adjudication or Payment Date
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
AMT Remaining Patient Liability

5505
2430
Detail
Optional
1
Situational Rule: Required when the Other Payer referenced in SVD01 of this iteration of
Loop ID 2430 has adjudicated this claim, provided line level information, and the
provider has the ability to report line item information. If not required by this
TR3 Notes: 1. In the judgment of the provider, this is the remaining amount to be paid
after adjudication by the Other Payer referenced in SVD01 of this iteration of Loop ID2430.
2. This segment is only used in provider submitted claims; it is not used in Payer-toPayer Coordination of Benefits (COB).
3. This segment is not used if the claim level (Loop ID 2320) Remaining Patient Liability
AMT segment is used for this Other Payer.
TR3 Example: AMT*EAF*75~
Ref.
Des.
AMT01
Data
Element
522
AMT02
782
284
Base
User
Name
Attributes
Attributes
M
1 ID 1/3
M
EAF
Amount Owed
Monetary Amount
M
1 R 1/18
M
Monetary amount
IMPLEMENTATION NAME: Remaining Patient Liability
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Notes:
SE Transaction Set Trailer

5550
Detail
Mandatory
1
To indicate the end of the transaction set and provide the count of the transmitted
segments (including the beginning (ST) and ending (SE) segments)
1 SE is the last segment of each transaction set.

TR3 Example: SE*1230*987654~
Ref.
Des.
SE01
Data
Element
96
SE02
329
285
Base
User
Name
Attributes
Attributes
Number of Included Segments
M
1 N0 1/10
M
Total number of segments included in a transaction set including ST and SE segments
IMPLEMENTATION NAME: Transaction Segment Count
Transaction Set Control Number
M
1 AN 4/9
M
Identifying control number that must be unique within the transaction set functional group
assigned by the originator for a transaction set
The Transaction Set Control Number in ST02 and SE02 must be identical. The number
must be unique within a specific interchange (ISA-IEA), but can repeat in other
interchanges.
April 2014
005010X223A2 837
EDI Control Directory
Control Segments
ISA
Interchange Control Header Segment
GS
Functional Group Header Segment
GE
Functional Group Trailer Segment
IEA
Interchange Control Trailer Segment
286
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
ISA Interchange Control Header

0010
Mandatory
1
To start and identify an interchange of zero or more functional groups and
interchange-related control segments
Syntax Notes:
Semantic Notes:
Comments:
Ref.
Des.
ISA01
ISA02
ISA03
ISA04
ISA05
ISA06
ISA07
287

Data
Base
User
Element Name
Attributes
Attributes
I01
Authorization Information Qualifier
M
1 ID 2/2
M
Code identifying the type of information in the Authorization Information
00
Refer to 005010 Data Element Dictionary for acceptable code values.
I02
Authorization Information
M
1 AN 10/10 M
Information used for additional identification or authorization of the interchange
sender or the data in the interchange; the type of information is set by the
Authorization Information Qualifier (I01)
I03
Security Information Qualifier
M
1 ID 2/2
M
Code identifying the type of information in the Security Information
00
I04
Security Information
M
1 AN 10/10 M
This is used for identifying the security information about the interchange sender or
the data in the interchange; the type of information is set by the Security
Information Qualifier (I03)
I05
Interchange ID Qualifier
M
1 ID 2/2
M
Code indicating the system/method of code structure used to designate the sender
or receiver ID element being qualified
ZZ
I06
Interchange Sender ID
M
1 AN 15/15 M
Identification code published by the sender for other parties to use as the receiver
ID to route data to them; the sender always codes this value in the sender ID
element
I05

HCSCLABOR
Interchange ID Qualifier
M
1 ID 2/2
M
Code indicating the system/method of code structure used to designate the sender
April 2014
005010X223A2 837
ISA08
I07
ISA09
I08
ISA10
I09
ISA11
I65
ISA12
I11
ISA13
I12
ISA14
I13
ISA15
I14
ISA16
I15
288
or receiver ID element being qualified

ZZ
Interchange Receiver ID
M
1 AN 15/15 M
Identification code published by the receiver of the data; When sending, it is used
by the sender as their sending ID, thus other parties sending to them will use this
as a receiving ID to route data to them
Account Adjudication Identification Number Assigned to group.
Interchange Date
M
1 DT 6/6
M
Date of the interchange
Interchange Time
M
1 TM 4/4
M
Time of the interchange
Repetition Separator
M
1 AN 1/1
M
Type is not applicable; the repetition separator is a delimiter and not a data
element; this field provides the delimiter used to separate repeated occurrences of
a simple data element or a composite data structure; this value must be different
than the data element separator, component element separator, and the segment
terminator
The following character, caret, will be populated for this element:
^
Interchange Control Version Number
M
1 ID 5/5
M
Code specifying the version number of the interchange control segments
00501
Interchange Control Number
M
1 N0 9/9
M
A control number assigned by the interchange sender
Unique Control Number
Acknowledgment Requested
M
1 ID 1/1
M
Code indicating sender's request for an interchange acknowledgment
0
Interchange Usage Indicator
M
1 ID 1/1
M
Code indicating whether data enclosed by this interchange envelope is test,
production or information
Component Element Separator
M
1 AN 1/1
M
Type is not applicable; the component element separator is a delimiter and not a
data element; this field provides the delimiter used to separate component data
elements within a composite data structure; this value must be different than the
data element separator and the segment terminator
The following character, colon, will be populated for this element:
:
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Ref.
Des.
GS01
GS Functional Group Header

0020
Mandatory
1
To indicate the beginning of a functional group and to provide control information
1
2
3
1
GS04 is the group date.

GS05 is the group time.
The data interchange control number GS06 in this header must be identical
to the same data element in the associated functional group trailer, GE02.
A functional group of related transaction sets, within the scope of X12
standards, consists of a collection of similar transaction sets enclosed by a
functional group header and a functional group trailer.

Data
Element Name
479
Functional Identifier Code
Base
User
Attributes
Attributes
M 1
ID 2/2
M
GS02
142
GS03
124
GS04
373
Code identifying a group of application related transaction sets

HC
Application Sender's Code
M 1
AN
M
2/15
Code identifying party sending transmission; codes agreed to by trading
partners
HCSCLABOR
Application Receiver's Code
M 1
AN
M
2/15
Code identifying party receiving transmission; codes agreed to by trading
partners
Account Adjudication Identification Number Assigned to Group.
Date
M 1
DT 8/8
M
337
Date expressed as CCYYMMDD where CC represents the first two digits of

the calendar year
The following format will be populated for this element:
CCYYMMDD
Time
M 1
TM 4/8
M
GS05
Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or

HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59),
S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are
expressed as follows: D = tenths (0-9) and DD = hundredths (00-99)
289
April 2014
005010X223A2 837
GS06
GS07
GS08
290
28
The following format will be populated for this element:

HHMMSSDD
Group Control Number
M 1
N0 1/9
455
Assigned number originated and maintained by the sender

Unique Group Control Number
Responsible Agency Code
M 1
ID 1/2
480
Code identifying the issuer of the standard; this code is used in conjunction
with Data Element 480
X
Version / Release / Industry Identifier
M 1
AN
M
Code
1/12
Code indicating the version, release, subrelease, and industry identifier of the
EDI standard being used, including the GS and GE segments; if code in
DE455 in GS segment is X, then in DE 480 positions 1-3 are the version
number; positions 4-6 are the release and subrelease, level of the version; and
positions 7-12 are the industry or trade association identifiers (optionally
assigned by user); if code in DE455 in GS segment is T, then other formats
are allowed
005010X223A1
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
Syntax Notes:
Semantic Notes:
Comments:
Ref.
Des.
GE01
GE02
291
GE Functional Group Trailer

0030
Mandatory
1
To indicate the end of a functional group and to provide control information
1
1
The data interchange control number GE02 in this trailer must be identical to
the same data element in the associated functional group header, GS06.
The use of identical data interchange control numbers in the associated
functional group header and trailer is designed to maximize functional group
integrity. The control number is the same as that used in the corresponding
header.

Data
Base
User
Element Name
Attributes
Attributes
97
Number of Transaction Sets Included
M
1 N0 1/6
M
Total number of transaction sets included in the functional group or interchange
(transmission) group terminated by the trailer containing this data element
28
Group Control Number
M
1 N0 1/9
M
Assigned number originated and maintained by the sender
April 2014
005010X223A2 837
Segment:
Position:
Loop:
Level:
Usage:
Max Use:
Purpose:
IEA Interchange Control Trailer

0040
Mandatory
1
To define the end of an interchange of zero or more functional groups and
interchange-related control segments
Syntax Notes:
Semantic Notes:
Comments:
Ref.
Des.
IEA01
IEA02
292

Data
Base
User
Element Name
Attributes
Attributes
I16
Number of Included Functional Groups
M
1 N0 1/5
M
A count of the number of functional groups included in an interchange
I12
Interchange Control Number
M
1 N0 9/9
M
A control number assigned by the interchange sender
April 2014
005010X223A2 837
APPENDIX:
A. K301 Fix Format Field Specifications
Fixed
Field
Field
Format
Justify
Default Bytes
Position Usage
Information
Comments
Provider IRS Withhold

Indicator
N/A
Spaces
Provider 835 Indicator
N/A
Spaces
Member-Record Edit
N/A
N/A
Claim Status
Left
4-5
Spaces
Status of HCSC claim
Medicare Case No
Left
6-16
Spaces
11
17
Spaces
Number that Medicare assigns to a

claim
A value of Y will be populated to
indicate that this is a prompt
payment provider. If the field is left
blank, there is no prompt payment
requirement.
R05 up-front credits, this Field will
contain the amount of the fund
upfront credit.
Code transmitted by host plan to
identify the availability of their
discount on the secondary
payments.
Prior Paid amount on the claim
Prompt Pay Indicator
Indicates that the status of the

provider requires further
investigation and that the payee
code has been changed from 0 or
pay provider to 1 or pay subscriber
when it has a value of H. Otherwise,
the field is left blank
This field indicates whether or not an
835 electronic remittance advice is
required
Field indicates the results of Soft
Edits
Claim Upfront Credit

Amt/Adjustment amt
Right
18-25
Zeroes
Claim Secondary Pay
N/A
26
Spaces
Claim Prior Paid Amt
Right
27-37
Req. on
Adjustment
Zeroes
11
Claim Discount
Amount/Repriced
savings amt
Right
38-48
Req. on
Adjustment
Zeroes
11
Informational Field for use in

adjustment processing
Claim SF Message
Codes
Left
49-52
Spaces
Claim SF Message
Codes
Left
53-56
Spaces
Claim SF Message
Codes
Left
57-60
Spaces
Claim SF Message
Codes
Left
61-64
Spaces
Claim SF Message
Codes
Left
65-68
Spaces
Claim Status Reason

Code
Left
69-71
Spaces
Code transmitted by the host plan to

identify any situation that the
processing site needs to consider in
the adjudication of the claim
Field contains the BCBSIL status
reason code
293
April 2014
005010X223A2 837
Claim Specialty Days
Left
72-74
Spaces
The total number of days associated

with prompt payment
Member - P- F- Name UPD
N/A
75
Spaces
Member - P- L- Name UPD
N/A
76
Spaces
Member - P- M- Name UPD
N/A
77
Spaces
Member - P- Sex - UPD
N/A
78
Spaces
Member - P- DOB UPD
N/A
79
Spaces
Indicator informing accounts that this

field has been updated through the
soft edit process
soft edit process
soft edit process
soft edit process
soft edit process
Member - P-SUBID UPD
N/A
80
Spaces

soft edit process
2300
Segment
Repeats
Number assigned to the provider for
EMC Identification purposes by the
payer receiver
Field indicating the category of a
provider
A code which further describes the
provider type
File
Information
Provider Number
1-10
10
Provider Type
11-12
Provider Specialty Code
13-15
ITS- Provider Number
16-28
Spaces
13
Claim (BDC) SF Msg

Codes - 1
29-32
Spaces
Claim (BDC) SF Msg

Codes 2
33-36
Spaces
Claim (BDC) SF Msg

Codes 3
37-40
Spaces
Claim (BDC) SF Msg

Codes 4
41-44
Spaces
Claim (BDC) SF Msg

Codes - 5
45-48
Spaces
FSS Returned Amt
49-59
Zeroes
11
Claim Process Due Date
60-67
Zeroes
Actual date when Disposition Record

must be processed via HPA or ALIM
Medicare paid Amount
68-78
Zeros
11
Medicare payment as reflected on

the EOB
2300
Segment
Repeats
File
Information
294
This provider number is assigned by

the host BCBS Plan. Plans may
utilize the same provider number for
different local provider, although
should be unique within that
particular plan
Provider Returned Amount
April 2014
005010X223A2 837
BDIS Indicator
1-5
IHS Provider Indicator
295
Spaces
Indicator that signals that the

services on the claim are Blue
Distinction Center Program-related.
See appendix sec. F
Indicator used to identify certain
providers that use the IHS special
pricing
April 2014
005010X223A2 837
B. PWK06 Fix Format Field Specifications

PWK06
Fixed
Justify Field
Field Initial Bytes
File
Format
Position Usage
Description
Information
PWK06
Provision Identifier
Left
1-4
Spaces
BCBSIL Internal
Provision ID
PWK06
Service Discount Percent
Right
5-8
Zeroes
Discount Percentage
applied to each line of
service
PWK06
SF Message Code 1
Left
9-12
Spaces
PWK06
SF Message Code 2
Left
13-16
Spaces
PWK06
SF Message Code 3
Left
17-20
Spaces
PWK06
SF Message Code 4
Left
21-24
Spaces
PWK06
SF Message Code 5
Left
25-28
Spaces
PWK06
Service Basic Ineligible

Reason Code 1
Left
29-31
Spaces
Code transmitted by the

HOST plan to identify
any special situation that
the process site needs
to consider in the
adjudication process
to consider in the
to consider in the
to consider in the
to consider in the
Used to describe why a
service is ineligible
PWK06
Service Basic Ineligible

Reason Code 2
Left
32-34
Spaces
Used to describe why a

service is ineligible
PWK06
Service OI Allowed
Amount
Right
35-45
Zeroes
11
Amount covered under

the other carrier or
Medicare contract for
payment
296
April 2014
005010X223A2 837
PWK
Claim
Justify
Supplemental
Information
Field
Position
2400
Segment
Repeat twice
if applicable
PWK06
Service OI Paid Amount
Right
1-11
Zeroes
11
PWK06
PWK06
Service OI Copay
Amount
Right
12-22
Zeroes
11
PWK06
PWK06
Claim Adjustment
Reason Code (1)
Right
23-25
Spaces
Value code indicating

why services were
ineligible
PWK06
Claim Adjustment
Reason Code (2)
Right
26-28
Spaces
Value code indicating

why services were
ineligible
PWK06
Provider Type
Field Position
29-30
PWK06
Provider Specialty
Field Position
31-33
PWK06
DME Price
Field Position
34-44
11
Field indicating the

category of a provider
A code which further
describes the provider
type
DME Price
PWK06
Actual Ambulance
Mileage
Field Position
45-50
297
This field will contains

Actual Ambulance Miles
with an implied decimal.
Example
56.7 miles will be
supplied as 000567.
105 miles will be
supplied as 001050
April 2014
005010X223A2 837
C. Local ANSI Adjustment Reason Codes

Credit
Adjustment
Reason
Code
ANSI
Code
A07
22
Payment adjusted because this care may be covered by another payer per coordination of
benefits. This change to be effective 4/1/2008: This care may be covered by another payer
per coordination of benefits.
Start: 08/01/2008
A08
11
Late Credits Start: 08/01/2008
A09
13
Overbilling Start: 08/01/2008
A10
96
Non-covered charge(s).
Start: 08/01/2008
A11
89
Membership Change (100% of money returned)
A12
129
Payment denied - Prior processing information appears incorrect. This change to be effective
4/1/2008: Prior processing information appears incorrect.
Start: 08/01/2008
A13
15
Medicare Start: 08/01/2008
A14
17
Payment adjusted because requested information was not provided or was

insufficient/incomplete.
Start: 08/01/2008
298
ANSI Value Description
Payment adjusted because procedure/service was partially or fully furnished by another

provider. This change to be effective 4/1/2008: Procedure/service was partially or fully
furnished by another provider.
Start: 08/01/2008
A15
B20
A16
54
Different provider address (100% of money is returned)
A17
18
Duplicate claim/service.
Start: 08/01/2008
A18
131
Claim specific negotiated discount.

Start: 08/01/2008
A19
52
Damage Check (100% of money is returned) Start: 08/01/2008
A20
201
Workers Compensation case settled. Start: 08/01/2008
A21
112
Payment adjusted as not furnished directly to the patient and/or not documented. This change
to be effective 4/1/2008: Service not furnished directly to the patient and/or not documented.
Start: 08/01/2008
A22
125
Payment adjusted due to a submission/billing error(s).

Start 08/01/2008
A23
209
Incorrect Date of Service Start: 08/01/2008
A24
20
Claim denied because this injury/illness is covered by the liability carrier.

Start: 08/01/2008
A25
21
Claim denied because this injury/illness is the liability of the no-fault carrier.
Start: 08/01/2008
A26
38
Blue on Blue Start: 08/01/2008
A27
119
Benefit maximum for this time period or occurrence has been reached.
Start: 08/01/2008
A28
69
Fund Request refund Start: 08/01/2008
A29
95
Benefits adjusted. Plan procedures not followed. This change to be effective 4/1/2008: Plan
procedures not followed.
Start: 08/01/2008
Start: 08/01/2008
April 2014
005010X223A2 837
A30
181
Payment adjusted because this procedure code was invalid on the date of service.
Start: 08/01/2008
R05
90
Refund requests for $500.00 or less
R07
109
Claim not covered by this payer/contractor. You must send the claim to the correct
payer/contractor.
Start: 08/01/2008
Non-Credit
Adjustment
Reason
Code
ANSI
Code
R01
169
Payment adjusted because an alternate benefit has been provided. This change to be
effective 4/1/2008: Alternate benefit has been provided.
Start: 08/01/2008
R02
29
Charges are being reconsidered, per the Funds request (Discount applied to original claim)
Start: 08/01/2008
R03
23
Payment adjusted due to the impact of prior payer(s) adjudication including payments and/or
adjustments. This change to be effective 4/1/2008: The impact of prior payer(s) adjudication
including payments and/or adjustments.
Start: 08/01/2008
R06
91
Additional payment request (initiated by Fund)
Special
Claim
ANSI
Situation
Code
Adjustments
R04
299
193
Start: 08/01/2008
Start: 08/01/2008

Original payment decision is being maintained. This claim was processed properly the first
time.
Start: 08/01/2008
April 2014
005010X223A2 837
D. BlueCard ANSI Adjustment Reason Codes

Void Adjustment
Reason Code
Void Reissue
Adjustment
Reason Code
ANSI Code
201
254
B20
Payment adjusted because procedure/service was partially or fully

furnished by another provider.
Start: 08/01/2008
202
253
129
Payment denied - Prior processing information appears incorrect.

Start:08/01/2008
203
251
B22
Wrong Payee
B23
Retroactive Cancellation
204
205
247
206
300
Start: 08/01/2008
Start: 08/01/2008
95
Benefits adjusted. Plan procedures not followed.

Start: 08/01/2008
18
Duplicate claim/service.
Start: 08/01/2008
207
252
52
Lost or Damage Check
208
272
189
HVA Incorrect Reject Start: 08/01/2008
Start: 08/01/2008
209
273
169
Payment adjusted because an alternate benefit has been

provided.
Start: 08/01/2008
210
260
201
Workers Compensation case settled.

Start: 08/01/2008
211
261
15
Medicare Start: 08/01/2008
212
262
20
Claim denied because this injury/illness is covered by the liability

carrier.
Start: 08/01/2008
213
263
22
Payment adjusted because this care may be covered by another

payer per coordination of benefits. This change to be effective
4/1/2008: This care may be covered by another payer per
coordination of benefits.
Start: 08/01/2008
214
245
140
Patient/Insured health identification number and name do not

match.
Start: 08/01/2008
215
250
112
Payment adjusted as not furnished directly to the patient and/or

not documented.
Start: 08/01/2008
216
240
D20
Incorrect Reject.
217
268
24
Payment for charges adjusted. Charges are covered under a

capitation agreement/managed care plan.
Start: 08/01/2008
218
265
74
Incorrect Provider / PCP Data Start: 08/01/2008
219
269
192
One Time Exception Start: 08/01/2008
220
274
D19
HVA Pricing Changed Start: 08/01/2008
221
258
172
Payment is adjusted when performed/billed by a provider of this

specialty.
Start: 08/01/2008
222
275
A1
HVA Medicare Start: 08/01/2008
223
270
193
Other HVA Home Start: 08/01/2008
224
271
194
Other HVA Host Start: 08/01/2008
226
280
178
Home / Control one time Exception Start: 08/01/2008
Start: 08/01/2008
April 2014
005010X223A2 837
227
281
154
No Fault
228
282
A5
Medicare Claim Audit
229
283
A6
Awaiting Primary Paid Start: 08/01/2008
230
284
A7
Medicare paid primary in error
231
285
D21
Provider Appeal Start: 08/01/2008
232
286
155
Host/Par One Time Exception
287
125
Payment adjusted due to a submission/billing error(s).

Start 08/01/2008
241
B8
Incorrect Deductible
242
B9
Incorrect Coinsurance
243
B10
Incorrect Sanction
244
B11
Incorrect Group Number
246
B13
Incorrect Address
248
186
Payment adjusted since the level of care changed.

Start: 08/01/2008
249
56
Resubmitted Billing
Start: 08/01/2008
255
58
Late Charges Start: 08/01/2008
256
10
Wrong Subscriber Information Start: 08/01/2008
257
135
Claim denied. Interim bills cannot be processed.

Start: 08/01/2008
264
70
Statistical Start: 08/01/2008
266
75
Incorrect Managed Care Information Start: 08/01/2008
267
76
Incorrect Financial Reimbursement to Provider Start: 08/01/2008
277
204
Additional PSA Payment Start: 08/01/2008
278
279
205
206
Incorrect PSA Payment Start: 08/01/2008

Incorrect PSA Fund Start: 08/01/2008
234
288
B19
Member Appeal Start: 04/01/2010
235
289
D9
Rejected as Duplicate in error
236
290
44
Payment made due to Prompt Pay
237
291
B6
238
292
B7
End to End Measurements: Valid Adjustment for Default Claim

Start: 10.1.2010
excluded from End to End Measurements: Valid adjustment for
Default Claim Start: 10.1.2010
293
101
233
301
Start:
08/01/2008
Start: 08/01/2008
Start: 08/01/2008
Start: 08/01/2008
Start: 08/01/2008
Start: 08/01/2008
Start: 08/01/2008
Start: 08/01/2008
Start: 08/01/2008
Start: 10.1.2010
Start: 10.1.2010
Predetermination : anticipated payment upon

completion of services or claim adjudication
April 2014
005010X223A2 837
E. Attachment Indicator (PWK01) Conversion

Bluechip Value
Bluechip/Description
837
Value
837/Description
Not Applicable
Explanation of Medicare Benefits

attached/Medicare Voucher/Medigap
EOMB
EB
Explanation of Benefits (Coordination of

Benefits or Medicare Secondary Payor)
Physician Certification
CT
Certification
Additional Surgical Opinion

Program(ASOP)medical approval
B3
Physician Order
Transmittal form attached
OZ
EOMB attached/Physician certification
EB

No physician certification
CT
Certification
Mandatory Outpatient Surgery

Program(MOPS) inpatient certification
CT
Certification
Physician certification and MOPS

inpatient certification
CT
Certification
Hospice re-certified
NN
Nursing Notes
Hospice not re-certified
NN
Nursing Notes
Operative Report/Medical records

attached
OB
Operative Note
Other Carrier Information(OIC) attached
EB

Other correspondence attached
OZ
EOMB attached/Operative
Report/medical records attached
EB

EOMB attached/OIC attached
EB

EOMB attached/other correspondence

attached
EB

EOMB attached/physician
certification/Operative Report/medical
records attached
EB

certification/other correspondence
attached
EB

certification/other correspondence
attached
EB

Inter-Plan Teleprocessing System (ITS)

attachment
OZ
Do Not Execute the Logic
302
April 2014
005010X223A2 837
F. Blue Distinction Identifiers

Labor BlueCard Institutional Only
Blue Distinction Service
1018 Bariatric Surgery
1019 Cardiac Care
1020 Complex and Rare Cancers
1030 Spine Surgery
1032 Knee and Hip Replacement
1037 Transplant Alternate Models
BD services but its not a BD Provider
BD Provider but no BD services
BD Indicator Value
BAR
CCC
CRP
SSP
RHK
TAM
NBP
NBS
Institutional Only
Blue Distinction Service
Bariatric Surgery
Cardiac Care
Bone Tumor Cancer
Pancreatic Cancer
Soft Tissue Sarcomas Cancer
Esophageal Cancer
Acute Leukemia Cancer
Head and Neck Cancer
Bladder Cancer
Gastric Cancer
Liver Cancer
Thyroid Cancer
Ocular Melanoma Cancer
Brain Tumor Cancer
Rectal Cancer
Spine Surgery
Knee and Hip Replacement
Alternate Bone Marrow
Alternate Heart Transplant
Alternate Lung Transplant
Alternate Combination of Heart and Lung Transplant
Alternate Liver Transplant
Alternate Pancreas Transplant
Kidney in Conjunction with SPK Transplant
Bone Marrow Transplant
Heart Transplant
Lung Transplant
Heart and Lung Transplant
Liver Transplant
303
BD Indicator Value
BAR
CCC
CBN
CPN
CST
CES
CAL
CHN
CBL
CGA
CLV
CTH
COC
CBR
CRC
SSP
RHK
ABM
AHT
ALG
AHL
ALV
TPA
AKD
TBS
THT
TLG
THL
TLV
April 2014
005010X223A2 837
Pancreas and SPK Transplant

Default value when services are not considered
BD services but its not a BD Provider
BD Provider but no BD services
BDP - Bariatric Surgic Center
BDP - Cancer Care - Acute Leukemia (1)
BDP - Cancer Care - Bladder Cancer
BDP - Cancer Care - Bone Cancer
BDP - Cancer Care - Brain Tumors
BDP - Cardiac Care Center
BDP - Cancer Care - Esophageal Cancer
BDP - Cancer Care - Gastric Cancer
BDP - Cancer Care - Head and Neck Cancer
BDP - Cancer Care - Liver Cancer
BDP - Cancer Care - Ocular Melanoma Cancer
BDP - Cancer Care - Pancreatic Cancer
BDP - Cancer Care - Rectal Cancer
BDP - Cancer Care - Soft Tissue Sarcoma
BDP - Cancer Care - Thyroid Cancer
BDP - Knee and Hip Replacement
BDP- Surgery - Spine
304
TPK
XXXXX
NBP
NBS
BDBSC
BDCAL
BDCBL
BDCBO
BDCBT
BDCCC
BDCEC
BDCGC
BDCHH
BDCLC
BDCOM
BDCPC
BDCRC
BDCST
BDCTC
BDKHR
BDSUS
April 2014
005010X223A2 837
G. 837I Relaxed HIPAA Edits

Error ID
Transacti
on
837I
Segment/Element
HCSC description of error message
0x39392E2
Snip Type
Level
4-Situational
CL102-Admission
Source Code
Element CL102 is missing. It is required for

all outpatient claims. Segment CL1 is
defined in the guideline at position 1400.
0x39392BD
4-Situational
837I
CL102-Admission
Source Code
Element CL102 is missing. It is required for

all inpatient claims. Segment CL1 is defined
in the guideline at position 1400
0x3938b80
4-Situational
837I
HI*BJ- HI (Admitting
Diagnosis)
Segment HI (Admitting Diagnosis) is used. It

should not be used when claim does not
involve inpatient admission. Segment HI is
0x3938bdd
4-Situational
837I
HI*BG-HI (Patient's
Reason For Visit)
Segment HI (Patient's Reason For Visit) is

missing. It is required when claim involves
outpatient visits. Patient Reason For Visit is
required on outpatient visits.
0x3939422
4-Situational
837I &
837P
DTP - Admission date
Value of element DTP02 (Admission

Date/Hour) is incorrect. Expected value is
'DT' on inpatient claims except for 21x.
Admission Date/Hour is invalid.
0x3939310
4-Situational
837I &
837P
PER02-Submitter EDI
Contact Name
Element PER02 is used. It should not be

used when name is the same as in segment
NM1, loop 1000A. Same value of Name
should not be sent.
0x9210016
1-EDI
Syntax
837I
3rd K3 instance-BDIS
Indicator
The Element K301 does not include any

significant data characters. Segment K3 is
0x393930D
2-HIPAA
Syntax
837I &
837P
Element PWK05 is used. It should not be

used when PWK02 is not one of 'BM', 'EL',
'EM', 'FX', 'FT'.
0x81002C
1-EDI
Syntax
837I &
837P
PWK05-Claim
Supplemental
Information ID
Qualifier
K301-File Information
0x3939436
2-HIPAA
Syntax
837I &
837P
K301-File Information
Value of element K301 is incorrect. It does

not follow any allowed usage patterns for K3
segments. Not allowed usage of File
Information.
0x3938EDC
3-Balancing
Error
837I &
837P
AMT*D*02~
Coordination of
Benefits (COB) Payer
Paid Amount
COB claim balancing is failed for payer with

ID '11111' (NM109 in loop 2330B): total
charge amount (CLM02) '11374.58' does not
equal sum of paid amount (AMT02 in loop
2320) and all adjustment amounts (CAS in
2320 and 2430) '11250.50'.
0x3938EDD
3-Balancing
Error
837I &
837P
SVD02-Line
Adjudication
Information
COB service line balancing is failed : charge

amount (SV203) '2640.00' does not equal
sum of paid amount (SVD02) and all line
adjustment amounts (CAS) '2574.78'.
305
Element K301 (Fixed Format Information)

has a data type of 'Alphanumeric' (AN).
Trailing spaces are not allowed. Segment K3
is defined in the guideline at position
April 2014
005010X223A2 837
0x3939487
2-HIPAA
Syntax
837I &
837P
N301-Billing Provider
Address Information
Value of element N301 is incorrect.

Expected value should not be a 'PO BOX' or
'P.O. BOX'. Segment N3 is defined in the
guideline at position 0250
0x3939607
4-Situational
837I &
837P
HI02-02-Diagnosis
Code Pointers
0x3938B7F
4-Situational
837I &
837P
DTP-Admission
Date/Hour
Value of sub-element HI02-02 cannot be

verified because there were no pointers to
this code. Health Care Diagnosis Code value
could not be verified because of missing
pointers
Segment DTP (Admission Date/Hour) is
used. It should not be used when claim is
not inpatient. Admission Date/Hour should
not be used on non-inpatient claims.
0x3938B7F
4-Situational
837I &
837P
HI-Other Procedure
Information
Segment HI (Other Procedure Information) is

used. It should not be used when claim is
not inpatient. Other Procedure Information
should not be used on non-inpatient claims
0x3938B7F
4-Situational
837I &
837P
HI-Principal
Procedure Information
0x3938B21
4-Situational
837I
DTP-Discharge Hour
Segment HI (Principal Procedure

Information) is used. It should not be used
when claim is not inpatient. Principal
Procedure Information should not be used
on non-inpatient claims
Segment DTP (Discharge Hour) is missing.
It is required on all final inpatient claims.
0x39395ec
2-HIPAA
Syntax
837I &
837P
HI01- Diagnosis
Codes (Primary &
Secondary)
Value of sub-element HI01-02 has been

already used. Diagnosis Codes (primary and
secondary) are expected to be unique within
claim.
0x810050
1-EDI
Syntax
837I
SV202-02 Procedure Code
Sub-Element SV202-02 (Product/Service ID)

is missing. This Sub-Element's standard
option is 'Mandatory'. Segment
0x3938c58
4-Situational
837I &
837P
2310B- Rendering
Provider Name
0x39393d2
2-HIPAA
Syntax
2-HIPAA
Syntax
837I &
837P
837I &
837P
N403-Zipcode
Loop 2310B (Rendering Provider Name) is

missing. It is expected to be used when loop
2420A is used with the same value in every
loop 2400
Value of element N403 is incorrect. It should
be formatted as 5 or 9 digits for US zip code
Value of element N403 is incorrect. Last four
digits should not be '0000' or '9999' for US
zip code
0x3938bef
4-Situational
837I &
837P
AMT- Remaining
Patient Liability
Segment AMT (Remaining Patient Liability)

is missing. It is required when Other Payer
has adjudicated the claim and provided
claim level information only.
0x3939600
2-HIPAA
Syntax
837I
HI- E-code
Value of sub-element HI01-02 is incorrect.

E-code cannot be used as
Primary/Admitting/'Reason for Visit'
Diagnosis code.
0x3939656
4-Situational
837I
HI- Occurrence and

Occurrence Span
Codes
0x3938c89
4-Situational
837I &
837P
NM1*82 - 2420A
Rendering Provider
Name

already used. Occurrence and Occurrence
Span Codes are expected to be unique
within a claim
Loop 2420A (Rendering Provider Name) is
used. It should not be used when loop
2310B is used with the same information
0x3938af6
4-Situational
837I &
837P
HI - Admitting
Diagnosis
0x3939447
306
N403-Zipcode
Segment HI (Admitting Diagnosis) is

missing. It is required on all inpatient
admission claims
April 2014
005010X223A2 837
0x3939652
4-Situational
837I &
837P
HI01-02 Procedure
Code
Value in sub-element HI01-02 has been

already used. Procedure codes are expected
to be unique
0x3938bde
4-Situational
837I &
837P
HI - Patients reason
for visit
Segment HI (Patients reason for visit) is

used. It should not be used when claim does
not involve outpatient visits
0x393948c
4-Situational
SV103- Service Units
0x393946e
4-Situational
837I &
837P
837I &
837P
Value of element SV103 is incorrect.

Expected value is MJ for anesthesia claims
Value of element DTP03 (Service Date) is
incorrect. Expected value for date should be
within the Statement Dates range
0x39395EE
2-HIPAA
Syntax
837I
SV202-05 -Procedure
modifier codes
Value of sub-element SV202-05 has been

already used. Procedure modifier codes are
expected to be unique for every
product/service
0x39393b5
2-HIPAA
Syntax
2-HIPAA
Syntax
837I &
837P
837I
NM1*DK - Ordering
Provider Name
NM1*77 - Attending
Provider
NM1*DK - NPI is missing
0x3938C72
4-Situational
837I
NM1*82 - 2310D Rendering Provider

Name
0x3939388
4-Situational
837I
DTP03 (Adjudication
for Payment Date)
Value of element DTP03 (Adjudication for

Payment Date) is incorrect. Value of date or
start period is expected to be a date earlier
than the Transaction Creation Date.
0x3939383
4-Situational
837I &
837P
REF*D9 (Claim
Identifier For
Transmission
Intermediaries)
Value of element REF02 (Claim Identifier

For Transmission Intermediaries) is
incorrect. Expected value is up to 20
characters.
0x3939653
4-Situational
837I
Segment HI*BN
External cause of
Injury

already used. Value Codes are expected to
be unique within claim. Duplicate Value
Code in Value Information validation.
0x39393d0
4-Situational
837I &
837P
Other SBR
Information element
NM109 Loop 2320
0x3938BEA
4-Situational
837I &
837P
AMT Segment in
2320 Loop
0x3939418
4-Situational
837I &
837P
Referring Provider
Sec Information Loop
2420F
In 2320 Loop Value of element NM109

(Other subcriber ID) is incorrect. It should be
different from value of element SBR03(Other
subcriber group number). Subscriber ID
should be different from Group/Policy
Number.
Segment AMT (Payer paid amount) is
missing-- Segment AMT (COB) Payer Paid
Amount is missing. It is required when payer
responsibility sequence 2320/SBR01 is
before responsibility sequence of destination
payer 2000B/SBR01.
Idenfication_Ref*1G
0x3938b60
4-Situational
837I &
837P
Segment PAT Loop

2000B
Subscriber Level_PAT Loop Should Not Be

Used When Subscriber & Patient are
different
0x9210016
1- EDI
Syntax
837I &
837P
K301
Allows spaces in K301

Subscriber/Dependent is the patient, both at
claim and line level.
0x39392E1
307
DTP03 - Service Date
Element NM104 is missing. It is

recommended to be used when Attending
Provider is a person (NM102='1').
Loop 2310D (NM1*82*1*) should not be
used when 2310A(NM1*71*1*) is used with
same information.
April 2014
005010X223A2 837
H. 5010 File Extension Naming Convention
I.
File
Regular
Regular
Claim
INST electronic
PROF electronic
Extension
LI
LP
DOL
INST electronic
DI
DOL
PROF electronic
DP
Regular
INST ITS/BlueCard
BI
Regular
PROF ITS/BlueCard
BP
DOL
INST ITS/BlueCard
CI
DOL
Regular
Regular
DOL
DOL
Reject Report
PROF ITS/BlueCard
INST paper
PROF paper
INST paper
PROF paper
Electronic
CP
PI
PP
EI
EP
RL
Reject Report
ITS / BlueCard
RB
Description
Institutional Claim File (HIPAA 837 Format)
Professional Claim File (HIPAA 837 Format)
Institutional DOL Informational File (HIPAA
837 Format)
Professional DOL Informational File (HIPAA
837 Format)
Bluecard Institutional Claim File (HIPAA 837
Format)
Bluecard Professional Claim File (HIPAA
837 Format)
Bluecard Institutional DOL Informational File
(HIPAA 837 Format)
Bluecard Institutional DOL Informational File
(HIPAA 837 Format)
Paper - Institutional Claim File
Paper Professional Claim File
Paper Institutional DOL Informational File
Paper Professional DOL Informational File
Reject Report (HIPAA 835 Format)
BlueCard Reject Report (HIPAA 835
Format)
Default Values
If the values are not present from original provider submitted 837, then the below Default
values will be used
Field Name
Other Subscriber Last Name
Other Subscriber First Name
Other Insurance Payer ID
NPI
Tax ID (REF*EI/TJ)
Provider Number - PFIN
Other Insurance Carrier Name
Patient Relationship code
If ETR3 value for Admit hour =
99
CLM01(Patient Control
Number)
Blue Distinct Indicator
CL101 (Admission Type Code)
CL102 (Admission Source
Code)
308
Default values
HCSC UNKNOWN
HCSC UNKNOWN
999999999
1234567893
999999999
999999999
HCSC UNKNOWN
21
1200
999999999
XXX
9
9
April 2014
005010X223A2 837
J.
Other Carrier Payment Information

(Note: All COB edits must be relaxed in order to accept Other Carrier Payment information. BCBSIL
system does not require or validate that the information submitted by the provider was accurate or
complete; therefore BCBSIL will forward all information that was submitted by the provider.
All items in red are changes effective April or July 2014. All Accounts must align their system
accordingly.
PAYER A
Bluechip Field
LABOR 837
FUND IMPACTED
Other Insured Last Name

(SF data element name)
Other Insured First Name
EXISTING
NO
EXISTING
NO
Patient Relationship to
Other Insured
Other Insured ID Number
EXISTING
NO
EXISTING
NO
Other Insured Payer

Name
EXISTING
NO
LABOR MAPPING/COMMENTS
837I:
837P:
837I:
837P:
837I:
837P:
837I:
837P:
837I:
837P:
Loop 2330A NM1 103

Loop 2330A NM1 103
Loop 2330A NM1 104
Loop 2330A NM1 104
Loop 2320 SBR 01
Loop 2320 SBR 01
Loop 2330A NM1 109
Loop 2330A NM1 109
Loop 2330B NM1 103
Loop 2330B NM1 103
*If not submitted to HCSC. SCP will

receive HCSC UNKNOWN
Claim Level (Other Carrier Payment info)

Bluechip Field
PERSONAL SAVING AMT
LABOR 837
FUND IMPACTED
NEW: Field will not be

passed in production until
July 14, 2014
YES
Loop 2320 (CAS): PR*187

Consumer Spending Account payments
(includes but is not limited to Flexible
Spending Account, Health Savings
Account, Health Reimbursement
Account, etc
Available for fund testing in

March 2014
DEDUCTIBLE AMT
EXISTING
NO
Loop 2320 (CAS): PR*1
COINSURANCE AMT
EXISTING
NO
OI PAID AMT
EXISTING
NO
Loop 2320 (AMT):D
ALLOW AMT
Field will no longer be passed
Allowed amount
was removed from
the 837 with 5010.
The value is now
calculated.
NON COVERED AMT
EXISTING
NO
Loop 2320 (CAS): OA*96
HELDHARMLESS AMT
EXISTING
NO
Loop 2320 (CAS): CO*45
SUBSCRIBER LIABILITY
AMT
WITHHOLD RISK
EXISTING
NO
Loop 2320 (AMT): EAF
EXISTING
Field will no longer

be passed
NO
LABOR 837
FUND IMPACTED
Informational: HCSC will

pass up to max. 6 CAS
segments. Reference HIPAA
guidelines for additional
details
YES
COPAY AMT
Bluechip Field
ADJ GRP
309
Loop 2320 (CAS)
April 2014
005010X223A2 837
ADJ RSN
ADJ AMT
Bluechip Field
PERSONAL SAVING AMT

YES
Loop 2320 (CAS)
details
YES
Loop 2320 (CAS)
details
Service Level (Other Carrier Payment info)
LABOR 837
FUND IMPACTED

July 14, 2014
YES
Loop 2430 (CAS): PR*187

Account, etc

March 2014
DEDUCTIBLE AMT
EXISTING
NO
COINSURANCE AMT
EXISTING
NO
OI PAID AMT
EXISTING
NO
837 I- Loop 2400 (PWK) pos. 1-11

837 P- Loop 2400 (PWK) pos. 1-11
Loop 2430 (SVD)
ALLOW AMT
Allowed amount
was removed from
the 837 with 5010.
The value is now
calculated.

July 14, 2014
YES
YES
YES
NON COVERED AMT

March 2014
HELDHARMLESS AMT

July 14, 2014
March 2014
AMT

July 14, 2014
March 2014
WITHHOLD RISK
COPAY AMT

EXISTING mapping in PWK

be passed
YES
NEW: CAS mapping

Available in production April
2014.
Bluechip Field
ADJ GRP
310

March 2014
LABOR 837
I Informational: HCSC will
details

837 P - Loop 2400 (PWK) pos. 12-22
837 I - Loop 2400 (PWK) pos. 12-22
Loop 2430 (CAS) PR*3
FUND IMPACTED
YES
Loop 2430 (CAS)
April 2014
005010X223A2 837
ADJ RSN
ADJ AMT

details
details
YES
Loop 2430 (CAS)
YES
Loop 2430 (CAS)
PAYER B
Bluechip Field
Other Insured Last Name
(SF data element name)
Other Insured First Name
Patient Relationship to
Other Insured
Other Insured ID Number
Other Insured Payer

Name
LABOR 837
FUND IMPACTED

July 14, 2014
YES
837I: Loop 2330A NM1 103

837P: Loop 2330A NM1 103

Mid-May 2014
July 14, 2014
YES
837I: Loop 2330A NM1 104

837P: Loop 2330A NM1 104

Mid-May 2014
July 14, 2014
YES
837I: Loop 2320 SBR 01

837P: Loop 2320 SBR 01

Mid-May 2014
July 14, 2014
YES
837I: Loop 2330A NM1 109

837P: Loop 2330A NM1 109

Mid-May 2014
July 14, 2014
YES
837I: Loop 2330B NM1 103

837P: Loop 2330B NM1 103
LABOR 837
FUND IMPACTED

July 14, 2014
YES
Loop 2320 (CAS): PR*187

Account, etc
YES
YES
YES
Loop 2320 (AMT):D
*If not submitted to HCSC. SCP will

receive HCSC UNKNOWN
Mid-May 2014
Claim Level (Other Carrier Payment info)
Bluechip Field
PERSONAL SAVING AMT

Mid-May 2014
DEDUCTIBLE AMT
COINSURANCE AMT
OI PAID AMT
311

July 14, 2014
Mid-May 2014
July 14, 2014
Mid-May 2014
April 2014
005010X223A2 837
July 14, 2014
ALLOW AMT
NON COVERED AMT
HELDHARMLESS AMT
AMT
WITHHOLD RISK
COPAY AMT
Bluechip Field
ADJ GRP
ADJ RSN
ADJ AMT
Bluechip Field
PERSONAL SAVING AMT

Mid-May 2014

July 14, 2014
Allowed amount
was removed from
the 837 with 5010.
The value is now
calculated.
YES

Mid-May 2014
July 14, 2014
YES

Mid-May 2014
July 14, 2014
YES

Mid-May 2014
July 14, 2014
Mid-May 2014
LABOR 837

be passed
YES
FUND IMPACTED

YES
Loop 2320 (CAS)
details
YES
Loop 2320 (CAS)
segments Reference HIPAA
details
YES
Loop 2320 (CAS)
details
Service Level (Other Carrier Payment info)
LABOR 837
FUND IMPACTED

July 14, 2014
YES
Loop 2430 (CAS): PR*187

Account, etc
YES

Mid-May 2014
DEDUCTIBLE AMT

July 14, 2014

Mid-May 2014
312
April 2014
005010X223A2 837
COINSURANCE AMT
OI PAID AMT
ALLOW AMT
NON COVERED AMT
HELDHARMLESS AMT
AMT
WITHHOLD RISK
COPAY AMT
Bluechip Field
ADJ GRP
ADJ RSN
ADJ AMT
313

July 14, 2014
Mid-May 2014
July 14, 2014
Mid-May 2014

July 14, 2014
YES
YES
Loop 2430 (SVD)
Allowed amount
was removed from
the 837 with 5010.
The value is now
calculated.
YES

Mid-May 2014
July 14, 2014
YES

Mid-May 2014
July 14, 2014
YES

Mid-May 2014
July 14, 2014
Mid-May 2014
LABOR 837
details
details
details

be passed
YES
FUND IMPACTED
YES
Loop 2430 (CAS)
YES
Loop 2430 (CAS)
YES
Loop 2430 (CAS)
April 2014

Hipaa 837 Inst

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005010X223A2 837

HEALTH CARE CLAIM: INSTITUTIONAL

Health Care Claim

Health Care Service Corporation (HCSC) Shared Claims Processing

SCP Labor Team

SCP Labor Team

SCP Labor Team

SCP Labor Team

Updated CAS: Payer A and B (Other

SCP Labor Team

SCP Labor Team

837 Health Care Claim

Beginning of Hierarchical Transaction

Submitter EDI Contact Information

Billing Provider Hierarchical Level

Billing Provider Specialty Information

Foreign Currency Information

Billing Provider Name

Billing Provider Address

Billing Provider City/State/ZIP Code

Billing Provider Secondary Identification

Billing Provider Contact Information

Pay-To Address Name

Pay-To Address City/State/ZIP Code

Subscriber Hierarchical Level

Subscriber City/State/ZIP Code

Subscriber Demographic Information

Subscriber Secondary Identification

Property and Casualty Claim Number

Payer City/State/ZIP Code

Payer Secondary Identification

Billing Provider Secondary Identification

Patient Hierarchical Level

Patient City/State/ZIP Code

Patient Demographic Information

Property and Casualty Claim Number

Property and Casualty Patient Identifier

Date - Repricer Received Date

Institutional Claim Code

Claim Supplemental Information

Patient Estimated Amount Due

Service Authorization Exception Code

Payer Claim Control Number

Repriced Claim Number

Adjusted Repriced Claim Number

Investigational Device Exemption Number

Claim Identification For Transmission

Medical Record Number

Demonstration Project Identifier

Peer Review Organization (PRO) Approval

Patient Reason For Visit

External Cause of Injury

Diagnosis Related Group (DRG)

Principal Procedure Information

Other Procedure Information

Occurrence Span Information

Treatment Code Information

Claim Pricing/Repricing Information

Attending Provider Name

Attending Provider Secondary

Operating Physician Name

Operating Physician Secondary

Other Operating Physician Name

Other Operating Physician Secondary

TR3 Example: ST837987654*005010X223A2~