Documente Academic
Documente Profesional
Documente Cultură
Segments
Seg's usage
Elements in a S
Submitter Name
PER
R S R R
1000B RECEIVER NAME NM1 Receiver Name R R R R R R Detail, Billing/Pay-to Provider Hierarchical Level 2000A BILLING/PAY-TO PROVIDER HL HL Billing Provider Hierarchical Level R R R R PRV Billing Provider Speciality Information S R R R CUR Foreign Currency Information S R R 2010AA BILLING PROVIDER NAME NM1 Billing Provider Name R R R R S S S S S N3 N4 Billing Provider Address Billing Provider City/State/ZipCode R R R S R S S S NM101 NM102 NM103 NM104 NM105 NM107 NM108 NM109 N301 N302 N401 N402 N403 N404 HL01 HL03 HL04 PVR01 PVR02 PVR03 CUR01 CUR02
REF PER
R R S R R S S S S
REF01 REF02 PER01 PER02 PER03 PER04 PER05 PER06 PER07 PER08 NM101 NM102 N301 N302 N401 N402 N403 N404 N407 NM101 NM102 NM103 NM108 NM109 N301 N302 N401 N402 N403 N404 N407 REF01 REF02 REF01 REF02
2010AB PAY-TO ADDRESS NAME NM1 Pay-to Address Name S R R N3 N4 Pay-to Address-ADDRESS Pay-To Address city,State,ZIP Code R R R S S S S 2010AC PAY-TO PLAN NAME NM1 Pay-to Plan Name S R R R R R N3 Pay-to Provider Address R R S N4 Pay-to Provider City/State/ZipCode R R S S S S REF Pay-to Provider Secondary Identification S R R REF Pay-To Plan Tax Idetification Number R R R Detail, Subscriber Hierarchical Level 2000B SUBSCRIBER HL R S
HL
R R R R
SBR
Subscriber Information
R S S S S S
PAT
Patiet Information
S S S S S
PAT05 PAT06 PAT07 PAT08 PAT09 NM01 NM02 NM03 NM04 NM05 NM07 NM08 NM09
N3
Subscriber Address
R S
N301 N302 N401 N402 N403 N404 N407 DMG01 DMG02 DMG03 REF01 REF02 REF01 REF02 PER01 PER02
N4
Subscriber City/State/Zipcode
R R R S S
DMG
R R R
REF
R R
REF PER
R R R S
NM109
N3
Payer Address
R S
N301 N302 N401 N402 N403 N407 REF01 REF02 REF01 REF02
N4
Payer City/State/Zipcode
R S S S
REF
R R
REF
R R
Detail, Patient Hierarchical Level 2000C PATIENT HL HL Patient Hierarchical Level S R R R R PAT Patient Information R R S S S S S 2010CA PATIENT NAME NM1 Patient Name R R R R R S S N3 Patient Address R R S NM101 NM102 NM103 NM104 NM105 NM107 N301 N302 HL01 HL02 HL03 HL04 PAT01 PAT05 PAT06 PAT07 PAT08 PAT09
N4
Patient City/State/ZipCode
R S S S S
N401 N402 N403 N404 N407 DMG01 DMG02 DMG03 REF01 REF02 REF01 REF02 PER01 PER02 PER03 PER04 PER05 PER06
DMG
R R R
Property and Casualty Calim Number Property and Casualty Patient Identifier
S S
R R R R R S R R S S
2300 CLAIM INFORMATION CLM Claim Information R R R R R R R R CLM01 CLM02 CLM05 CLM05-1 CLM05-2 CLM05-3 CLM06 CLM07
R R
CLM08 CLM09
S S R
S S S S
R DTP Date-Initial Treatment Date S R R R DTP DATE-Last Seen Date S R R R DTP Date - Acute Manifestation R R R DTP Date - Accident S R R R DTP Date - Last Menstrual Period S R R R DTP Date - Last X-ray S R R R DTP Date - Hearing and Vision Prescription Date S S S DTP Date - Disability Dates S R R R R R R DTP Date - Last Worked S R R R DTP Date - Authorized Return to Work S R R R DTP Date - Admission S R R R DTP Date - Discharge S R R R DTP Date - Assumed and Relinquished Care Dates S R R R
DPT03 DPT01 DPT02 DTP03 DPT01 DPT02 DTP03 DTP01 DTP02 DTP03 DTP01 DTP02 DTP03 DTP01 DTP02 DTP03 DTP01 DTP02 DTP03 DTP01 DTP02 DTP03 DTP01 DTP02 DTP03 DTP01 DTP02 DTP03 DTP01 DTP02 DTP03 DTP01 DTP02 DTP03 DTP01 DTP02 DTP03 DTP01 DTP02 DTP03
DTP
R R R
DTP01 DTP02 DTP03 DTP01 DTP02 DTP03 PWK01 PWK02 PWK05 PWK06 CN101 CN102 CN103 CN104 CN105 CN106 AMT01 AMT02 REF01 REF02
DTP
R R R
PWK
R R S S
CN1
Contract Information
R S S S S S
AMT
R R
REF
R R
REF
R R
REF01 REF02 REF01 REF02 REF01 REF02 REF01 REF02 REF01 REF02 REF01 REF02 REF01 REF02 REF01 REF02
REF
R R
REF
Referral Number
R R
REF
Prior Authorization
R R
REF
R R
REF
(CLIA) Number
R R
REF
R R
REF
R R
REF
REF01 REF02
REF
REF01 REF02
REF
REF01 REF02
REF
REF01 REF02
REF
REF01 REF02
K3 NTE
S S
R R
K301 NTE01
NTE02 CR101 CR102 CR104 CR105 CR106 CR109 CR110 CR208 CR211
CRC
Ambulance Certification
R R R S S S S
CRC01 CRC02 CRC03 CRC04 CRC05 CRC06 CRC07 CRC01 CRC02 CRC03
CRC
R R S
S S S S CRC Homebound Indicator S R R R CRC EPSDT Referral S R R R S S HI Health Care Diagnosis Code R R S S S S
CRC04 CRC05 CRC04 CRC05 CRC01 CRC02 CRC03 CRC01 CRC02 CRC03 CRC04 CRC05 HI01 HI02 HI03 HI04 HI05
HI06
HI07
S S S S S
HI
R S
HI01 HI02
HI
Condition Information
HI01
S S S S S S S S S S S
HI02 HI03 HI04 HI05 HI06 HI07 HI08 HI09 HI10 HI11 HI12
HCP
R R S S S S S S
HCP14
HCP15
2310A REFERRING PROVIDER NAME NM1 Referring Provider Name S R R R S NM101 NM102 NM103 NM104
2310B RENDERING PROVIDER NAME NM1 Rendering Provider Name S R R R S S S S S PRV Rendering Provider Specialty Information S R R R REF Rendering Provider Secondary Identification R R 2310C SERVICE FACILITY LOCATION NM1 Service Facility Location Name S R R R S S N3 N4 Service Facility Location Address Service Facility Location City/State/ZIP R R R S R S S S S REF Service Facility Location Secondary Identification S R NM101 NM102 NM103 NM108 NM109 N301 N302 N401 N402 N403 N404 N407 REF01 REF02 PER Service Facility Contact Information S R S R R S PER01 PER02 PER03 PER04 PER05 NM101 NM102 NM103 NM104 NM105 NM107 NM108 NM109 PRV01 PRV02 PRV03 REF01 REF02
S 2310D SUPERVISING PROVIDER NAME NM1 Supervising Provider Name S R R R S S S S R REF Supervising Provider Secondary Identification S R R 2310E AMBULANCE PICK-UP LOCATION NM1 N3 N4 Ambulance Pick-Up Location Ambulance Pick-Up Location Address S R R R S Ambulance Pick-Up Location City,State,ZIP R Code R S S S 2310F AMBULANCE DROP-OFF LOCATION NM1 Ambulance Drop-off Location S R R R N3 Ambulance Drop-off Location Address R R S N4 Ambulance Drop-off Location City,State ZIP R Code R S S S S 2320 OTHER SUBSCRIBER INFORMATION SBR Other Subscriber Information S R R S S S
PER06
NM01 NM02 NM03 NM04 NM05 NM07 NM08 NM09 REF01 REF02
NM101 NM102 NM103 N301 N302 N401 N402 N403 N404 N407
SBR09
CAS
CAS01
CAS02 CAS03 CAS04 CAS05 CAS06 CAS07 CAS08 CAS09 CAS10 CAS11 CAS12 CAS13 CAS14 CAS15 CAS16 CAS17 CAS18 CAS19 AMT01 AMT02
AMT
R R
AMT01 AMT02 AMT01 AMT02 OI03 OI04 OI06 MOA01 MOA02 MOA03 MOA04 MOA05 MOA06 MOA07 MOA08 MOA09
AMT
R R
OI
R S R
MOA
S S S S S S S S S
2330A OTHER SUBSCRIBER NAME NM1 Other Subscriber Name R R R R S S S R R NM101 NM102 NM103 NM104 NM105 NM107 NM108 NM109
N3 N4
S S
R S R S S S S
R R
REF01 REF02 NM101 NM102 NM103 NM108 NM109 N301 N302 N401 N402 N403 N404 N407 DTP01 DTP02 DTP03 REF01 REF02 REF01 REF02
R R R R R
N3
R S
N4
R S S S S
DTP
R R R
REF
R R
REF
Other Payer Referral Number Other Payer Claim Adjustment Indicator Other Payer Claim Control Number
S S S
R R R R R
2330C OTHER PAYER REFERRING PROVIDER NM1 Other Payer Referring Provider S R R REF Other Payer Referring Provider IdentificationR R R 2330D OTHER PAYER RENDERING PROVIDER NM101 Nm102 REF01 REF02
NM1
R R
REF
R R
2330E OTHER PAYER SERVICE FACILITY LOCATION NM1 Other Payer Service Facility Location S R R REF Other Payer Service Facility Location Identification R R R 2330F OTHER PAYER SUPERVISING PROVIDER NM1 Other Payer Supervising Provider S R R REF Other Payer Supervising Provider Identification R R R 2330G OTHER PAYER BILLING PROVIDER NM1 REF Other Payer Billing Provider Other Payer Billing Provider Secondary Identification S R R NM101 NM102 REF01 REF02 2400 SERVICE LINE LX SV1 Service Line Professional Service R R R LX01 SV101 NM101 NM102 REF01 REF02 NM01 NM02 REF01 REF02
R R R S R
R R R PWK Line Supplemental Information S R R S S PWK CR1 Durable Medicl Equipment Certificate of Medical Necessity Indicator S Ambulance Transport Information S R R S S R R R S S CR3 Durable Medical Equipment Certification S R R R CRC Ambulance Certification S R R R S S S S CRC Hospice Employee Indicator S R R R CRC Condition Indicator/Durable Medical Equipment S R R R S DTP Date - Service Date R R R R DTP Date-Prescription Date S R R R DTP Date - Certification Revision/ Recertification S Date R R R DTP Date - Begin Therapy Date S R R R DTP Date - Last Certification Date S R R R DTP Date - Last Seen Date S R R R DTP Date - Test Date S R
SV504 SV505 SV506 PWK01 PWK02 PWK05 PWK06 PWK01 PWK02 CR101 CR102 CR104 CR105 CR106 CR109 CR110 CR301 CR302 CR303 CRC01 CRC02 CRC03 CRC04 CRC05 CRC06 CRC07 CRC01 CRC02 CRC03 CRC01 CRC02 CRC03 CRC04 DTP01 DTP02 DTP03 DTP01 DTP02 DTP03 DTP01 DTP02 DTP03 DTP01 DTP02 DTP03 DTP01 DTP02 DTP03 DTP01 DTP02 DTP03 DTP01
R R DTP Date - Shipped Date S R R R DTP Date - Last X-ray Date S R R R DTP Date - Initial Treatment Date S R R R QTY QTY MEA Ambulance Patient Count Obstetric Anesthesia Additional Units Test Result S S S R R R R R R R CN1 Contract Information S R
DTP02 DTP03 DTP01 DTP02 DTP03 DTP01 DTP02 DTP03 DTP01 DTP02 DTP03 QTY01 QTY02 QTY01 QTY02 MEA01 MEA02 MEA03 CN101
S S S S S REF REF REF Repriced Line Item Reference Number S R R Adjusted Repriced Line Item Reference Number S Prior Authorization S R R R R S R R REF REF REF REF REF REF Line Item Control Number Mammography Certification Number S S R R R R Clinical Laboratory Improvement Amendment S (CLIA) Identification Referring Clinical Laboratory Improvement Amendment S (CLIA) facility identification Immunization Batch Number Referral Number S S R R R R R R R R
CN102 CN103 CN104 CN105 CN106 REF01 REF02 REF01 REF02 REF01 REF02 REF04 REF04-1 REF04-2 REF01 REF02 REF01 REF02 REF01 REF02 REF01 REF02 REF01 REF02 REF01 REF02
S R R AMT AMT K3 NTE Sales Tax Amount Postage Claimed Amount File Information Line Note S S S S R R R R R R
R NTE PS1 HCP Third Party Organization Note Purchased Service Information Line Pricing/Repricing Information S S S R R R R R R S S S S S S S S S S S S
NTE02 NTEO1 NTEO2 PS101 PS102 HCP01 HCP02 HCP03 HCP04 HCP05 HCP06 HCP07 HCP09 HCP10 HCP11 HCP12 HCP13 HCP14 HCP15
2410 DRUG IDENTIFICATION LIN CPT Drug Identification Drug Quantity S R R R R R R LIN02 LIN03 CPT04 CPT05 CPT05-1
REF
R R
R R S S S S S
PRV
R R R
REF
R R S
2420B PURCHASED SERVICE PROVIDER NAME NM1 Purchased Service Provider Name S R R S S REF Purchased Service Provider Secondary Identification S R R R 2420C SERVICE FACILITY LOCATION NM1 Service Facility Location S R R R S S N3 Service Facility Location Address R R S N4 Service Facility Location City/State/ZIP R R S S S S REF Service Facility Location Secondary Identification R R R S NM01 NM02 NM03 NM108 NM109 N301 N302 N401 N402 N403 N404 N407 REF01 REF02 REF04 NM101 NM102 NM108 NM109 REF01 REF02 REF04
2420D SUPERVISING PROVIDER NAME NM1 Supervising Provider Name S R R NM01 NM02
R S S S S S
REF
R R S
2420E ORDERING PROVIDER NAME NM1 Ordering Provider Name S R R R S S S S S N3 Ordering Provider Address S R S N4 Ordering Provider City/State/ZIP Code S R S S S S REF Ordering Provider Secondary Identification S R R S R R PER Ordering Provider Contact Information S R S R R S S S S 2420F REFERRING PROVIDER NAME NM1 Referring Provider Name S R R R S S S S S NM101 NM102 NM103 NM104 NM105 NM107 NM108 NM109 NM101 NM102 NM103 NM104 NM105 NM107 NM108 NM109 N301 N302 N401 N402 N403 N404 N407 REF01 REF02 REF04 REF04-1 REF04-2 PER01 PER02 PER03 PER04 PER05 PER06 PER07 PER08
REF
R R S R R
REF01 REF02 REF04 REF04-1 REF04-2 NM101 NM102 N301 N302 N401 N402 N403 N404 N407 NM101 NM102 NM103 N301 N302 N401 N402 N403 N404 N407
2420G AMBULANCE PICK-UP LOCATION NM1 N3 N4 Ambulance Pick-Up Location Ambulance Pick-Up Location Address S R R R S Ambulance Pick-up Location City,State,ZIP R Code R S S S S 2420H AMBULANCE DROP-OFF LOCATION NM1 Ambulance Drop-off Location S R S N3 N4 Ambulance Drop-off Location Address R R S Ambulance Drop-off Location City,State,ZIPR Code R S S S S 2430 LINE ADJUDICATION INFORMATION SVD Line Adjudication Information S R R R SVD01 SVD02 SVD03
R R S S S S S S S S S S S S S S S S
CAS02 CAS03 CAS04 CAS05 CAS06 CAS07 CAS08 CAS09 CAS10 CAS11 CAS12 CAS13 CAS14 CAS15 CAS16 CAS17 CAS18 CAS19
DTP
R R R
AMT
R R
2440 FORM IDENTIFICATION CODE LQ Form Identification Code S R R FRM Supporting Documentation R R S S S S LQ01 LQ02 FRM01 FRM02 FRM03 FRM04 FRM05
SE
R R
SE01 SE02
Elements in a Segment
Disucssion
Task
Entity Identifier Code Entity Type Qualifier Name Last or Organization Name NameFirst Identification Code Qualifier Identification Code
ID-
Contact Function Code Name(Submitter Contact Name) Communication Number Qualifier Communication Number Entity Identifier Code Entity Type Qualifier Name Last or Organization Name Identification Code Qualifier Identification Code
Hierarchical ID Number Hierarchical Level Code Hierarchical Child Code Provider Code Reference Identification Qualifier Reference Identification Entity Identifier Code Currency Code
Entity Identifier Code Entity Type Qualifier Name Last or Organization Name Name First Name Middle Name Suffix Identification Code Qualifier Identification Code Address Information Address Information City Name State or Province Code Postal Code Country Code
Country Subdivision Code Reference Identification Qualifier Reference Identification Reference Identification Qualifier Reference Identification Reference Identification Qualifier Reference Identification Contact Function Code Name Communication Number Qualifier Communication Number Communication Number Qualifier Communication Number Communication Number Qualifier Communication Number Entity Identifier Entity Type Quailifierr Addres Information Addres Information City Name State or Province Code Postal Code Country Code Country Subdivision Code Entity Identifier Code EntityType Qualifier Name Last Or Organization Name Identification Code Qualifier Identification Code Addres Information Addres Information City Name State or Province Code Postal Code Country Code Country Subdivision Code Reference Identification Qualifier Reference Identification Reference Identification Qualifier Reference Identification
Hierarchical ID Number Hierarchical Parent ID Number Hierarchical Level Code Hierarchical Child Code
Payer Responsibility Seq No: Code Individual Relationship Code Reference Identification Name Insurance Type Code Identification Code
Date Time Period Format Qualifier Date Time Period Unit or Dasis for Measurement Code Weight Yes/No Condition or Response Code Entity Identifier Code Entity Type Qualifier Name Last or Organization Name Name First Name Middle Name Suffix Identification Code Qualifier Identification Code
Address Information Address Information City Name State or Province Code Postal Code Country Code Country Subdivisiion Code Date Time Period Format Qualifier Date Time Period Gender Code Reference Identification Qualifier Reference Identification Reference Identification Qualifier Reference Identification Contact Function Code Name
Communication Number Qualifier Communication Number Communication Number Qualifier Communication Number Entity Identifier Code Entity Type Qualifier Name Last or Organization Name Identification Code Qualifier
Identification Code
Address Information Address Information City Name State or Province Code Postal Code Cuntry Subdivision Code Reference Identification Qualifier Reference Identification Reference Identification Qualifier Reference Identification
Hierarchical ID Number Hierarchical Parent ID Number Hierarchical Level Code Hierarchical Child Code Individual Relationship Code Date Time Period Format Qualifier Date Time Period Unit or Basis for Measurement Code Weight Yes/No Condition or Response Code Entity Identifier Code Entity Type Qualifier Name Last or Organization Name Name First Name Middle Name Suffix Address Information Address Information
City Name State or Province Code Postal Code Cuntry Code Country Subdivision Code Date Time Period Format Qualifier Date Time Period Gender Code Reference Identification Qualifier Reference Identifiction Reference Identification Qualifier Reference Identifiction Contact Function Code Name Communication Number Qualifier Communication Number Communication Number Qualifier Communication Number
Claim Submitters Identifier Monetary Amount HEALTH CARE SERVICE LOCATION INFORMATION Facility code value Facility code Qualifier Claim frequency Type Code Yes/No Condition or Response Code Provider Accept Assignment Code
Related-Causes Code Satae or Province Code Country Code Special Program Code
Delay Reason Code Date/Time Qualifier Date Time Period Format Qualifier
DATE TIME PERIOD Date/Time Qualifier Date Time Period Format Qualifier Date Time Period Date/Time Qualifier Date Time Period Format Qualifier Date Time Period Date/Time Qualifier Date Time Period Format Qualifier Date Time Period Date/Time Qualifier Date Time Period Format Qualifier Date Time Period Date/Time Qualifier Date Time Period Format Qualifier Date Time Period Date/Time Qualifier Date Time Period Format Qualifier Date Time Period Date/Time Qualifier Date Time Period Format Qualifier Date Time Period Date/Time Qualifier Date Time Period Format Qualifier Date Time Period Date/Time Qualifier Date Time Period Format Qualifier Date Time Period Date/Time Qualifier Date Time Period Format Qualifier Date Time Period Date/Time Qualifier Date Time Period Format Qualifier Date Time Period Date/Time Qualifier Date Time Period Format Qualifier Date Time Period Date/Time Qualifier Date Time Period Format Qualifier Date Time Period
Date/Time Qualifier Date Time Period Format Qualifier Date Time Period Date/Time Qualifier Date Time Period Format Qualifier Date Time Period Reort Type Code Report Transmission Code Identification Code Qualifier Identification Code Contract Type Code Monetary Amount Percent Decimal Format Reference Identification Terms Discount Percent Verson Identifier Amount Qualifier Code Monetary Amount Reference Identification Qualifier Reference Identification
Reference Identification Qualifier Reference Identification Reference Identification Qualifier Reference Identification Reference Identification Qualifier Reference Identification Reference Identification Qualifier Reference Identification Reference Identification Qualifier Reference Identification Reference Identification Qualifier Reference Identification Reference Identification Qualifier Reference Identification Reference Identification Qualifier Reference Identification
Reference Identification Qualifier Reference Identification Reference Identification Qualifier Reference Identification Reference Identification Qualifier Reference Identification Reference Identification Qualifier Reference Identification Reference Identification Qualifier Reference Identification Fixed Format Information Note Reference Code
Claim Note Text Unit or Basis for Measurement Code Weight Ambulance Transport Reason Code Unit or Basis for Measurement Code Quantity Description Description Nature of Condition Code Description
Code Category Yes/No Condition or Response Code Condition Indicator Condition Indicator Condition Indicator Condition Indicator Condition Indicator Code Category Yes/No Condition or Response Code Condition Indicator
Condition Indicator Condition Indicator Condition Indicator Condition Indicator Code Category Y/N Condition Or Response Code Condition Indicator Code Category Y/N Condition Or Response Code Condition Indicator Condition Indicator Condition Indicator HEALTH CARE CODE INFORMATION HEALTH CARE CODE INFORMATION Code List Qualifier Code Health Cate Code Information Health Care Code Information
Health Care Code Information Health Care Code Information Health Care Code Information Health Care Code Information Health Care Code Information
Health Care Code Information Health Care Code Information Health Care Code Information Health Care Code Information Health Care Code Information Health Care Code Information Health Care Code Information Health Care Code Information Health Care Code Information Health Care Code Information Health Care Code Information
Pricing Methodology Monetary Amount Monetary Amount Reference Identification Rate Reference Identification Monetary Amount Reject Reason Code
Exception Code
Entity Identifier Code Entity Type Qualifier Name Last or Organization Name Name First
Name Middle Name Suffix Identification Code Qualifier Identification Code Reference Identification Qualifier REference Identification
Entity Identifier Code Entity Type Qualifier Name Last or Organization Name Name First Name Middle Name Suffix Identification Code Qualifier Identification Code Provider Code Reference Identification Qualifier Reference Identification Reference Identification Qualifier Reference Identification
Entity Identifier Code Entity Type Qualifier Name Last or Organization Name Identification Code Qualifier Identification Code Address Information Address Information City Name State or Province Code Postal Code Cuntry Code Country Subdivision Code Reference Identification Qualifier Reference Identification Contact Function Code Name Communication Number Qualifier Communication Number Communication Number Qualifier
Communication Number
Entity Identifier Code Entity Type Qualifier Name Last or Organization Name Name First Name Middle Name Suffix Identification Code Qualifier Identification Code Reference Identification Qualifier Reference Identification
Entity Identifier Code Entity Type Qualifier Address Information Address Information City Name State or Province Code Cuntry Code Country Subdivision Code
Entity Identifier Code Entity Type Qualifier Name Last or Organization Name Address Information Address Information City Name State or Province Code Postal Code Cuntry Code Country Subdivision Code
Payer Responsibility Sequence Number Code Individual Relationship Code Reference Identification Name Insurance Type Code
Claim Adjustment Reason Code Monetary Amount Quantity Claim Adjustment Reason Code Monetary Amount Quantity Claim Adjustment Reason Code Monetary Amount Quantity Claim Adjustment Reason Code Monetary Amount Quantity Claim Adjustment Reason Code Monetary Amount Quantity Claim Adjustment Reason Code Monetary Amount Quantity Amount Qualifier Code Monetary Amount
Amount Qualifier Code 0 Amount Qualifier Code Monetary Amount Yes/No Condition or Response Code Patient Signature Source Code Release of Information Code Percentage as Decimal Monetary Amount Reference Identification Reference Identification Reference Identification Reference Identification Reference Identification Reference Identification Reference Identification
Entity Identifier Code Entity Type Qualifier Name Last or Organization Name Name First Name Middle Name Suffix Identification Code Qualifier Identification Code
Address Information Address Information City Name State or Province Code Postal Code Cuntry Code Country Subdivision Code
Reference Identification Qualifier Reference Identification Entity Identifier Code Entity Type Qualifier Name Last or Organization Name Identification Code Qualifier Identification Code Address Information Address Information City Name State or Province Code Postal Code Cuntry Code Country Subdivision Code Date/Time Qualifier DateTime Period format Qualifier Date Time Period Reference Identification Qualifier Reference Identification Reference Identification Qualifier reference Identification Reference Identification Qualifier reference Identification Reference Identification Qualifier reference Identification Reference Identification Qualifier reference Identification Entity Identifier Code Entity Type Code Reference Identification Qualifier Reference Identification
Entity Identifier Code Entity type Qualifier Reference Identification Qualifier REference Identification
Entity Identifier Code Entity Type Qualifier Reference Identification Qualifier REference Identification
Entity Identifier Code EntityType Qualifier Reference Identification Qualifier REference Identification
Entity Identifier Code EntityType Qualifier Reference Identification Qualifier REference Identification
Monetary Amount Unit or Basis for Measurement Code Quantity Faculty Code Value COMPOSITE DIAGNOSIS CODE POINTER
Yes/No Condition or Response Code Yes/No Condition or Response Code Yes/No Condition or Response Code Copay Status Code COMPOSITE MEDICAL PROCEDURE IDENTIFIER Unit or Basis for Measurement Code Quantity
Monetary Amount Monetary Amount Frequency Code Report Type Code Report Transmission Code Identification Code Qualifier Identification Code Report Type Code Report Transmission Code Unit or Basis for Measurement Code Weight Ambulance Transport Reason Code Unit or Basis for Measurement Code Quantity Description Description Certification Type Code Unit or Basis for Measurement Code Quantity Code Category Yes/No Condition or Response Code Condition Indicator Condition Indicator Condition Indicator Condition Indicator Condition Indicator Code Category Yes/No Condition or Response Code Condition Indicator Code Category Yes/No Condition or Response Code Condition Indicator Condition Indicator Date/Time Qualifier Date Time Period Format Qualifier Date Time Period Date/Time Qualifier Date Time Period Format Qualifier Date Time Period Date/Time Qualifier Date Time Period Format Qualifier Date Time Period Date/Time Qualifier Date Time Period Format Qualifier Date Time Period Date/Time Qualifier Date Time Period Format Qualifier Date Time Period Date/Time Qualifier Date Time Period Format Qualifier Date Time Period Date/Time Qualifier
Date Time Period Format Qualifier Date Time Period Date/Time Qualifier Date Time Period Format Qualifier Date Time Period Date/Time Qualifier Date Time Period Format Qualifier Date Time Period Date/Time Qualifier Date Time Period Format Qualifier Date Time Period Quantity Qualifier Quantity Quantity Qualifier Quantity Measurement Reference ID Code Measurement Qualifier Measurement Values Contract Type Code
Monetary Amount Percent,Decimal Format Reference Identification Terms Discount Percent Version Identifier Reference Identification Qualifier Reference Identification Reference Identification Qualifier Reference Identification Reference Identification Qualifier Reference Identification Reference Identifier Reference Identification Qualifier Reference Identification Reference Identification Qualifier Reference Identification Reference Identification Qualifier Reference Identification Reference Identification Qualifier Reference Identification Reference Identification Qualifier Reference Identification Reference Identification Qualifier Reference Identification Reference Identification Qualifier Reference Identification
Reference Identifier Reference Identification Qualifier Reference Identification Amount Qualifier Code Monetory Amount Amount Qualifier Code Monetory Amount Fixed Format Information Note Reference Code
Description Note Reference Code Description Reference Identification Monetory Amount Pricing Methodology Monetory Amount Monetory Amount Reference Identification Rate Reference Identification Monetory Amount Product/Service ID Qualifier Product/Service ID Unit or Basis for Measurement Code Quantity Reject Reason Code Policy Compliance Code Exception Code
Product/Service ID Qualifier Product/Service ID Quantity Composite Unit of Measure Unit or Basis for Measurement Code
Entity Type Qualifier Name Last Or Organization Name Name First Name Middle Name Suffix Identification Code Qualifier Identification Code
Provider Code Reference Identification Qualifier Reference identification Reference Identification Qualifier Reference Identification Reference Identification
Entity Identifier Code Entity Type Qualifier Identification Code Qualifier Identification Code Reference Identification Qualifier Reference Identification Reference Identifier
Entity Identifier Code Entity Type Qualifier Namne Last or Organization Name Identification Code Qualifier Identification Code Address Information Address Information City Name State or Province Code Postal Code Cuntry Code Country Subdivision Code Reference Identification Qualifier Reference Identification Reference Idenftifier
Name Last Or Organization Name Name First Name Middle Name Suffix Identification Code Qualifier Identification Code
Entity Idetifier Code Entity Type Qualifier Name Last or OrganiZation Name Name First Name Middle Name Suffix Identification Code Qualifier Identification Code Address Information Address Information City Name State or Province Code Postal Code Country Code Country Subdivision Code Reference Identification Qualifier Reference identification Reference identifier Reference Identification Qualifier Reference identification Contact Function Code Name Communication Number Qualifier Communication Number Communication Number Qualifier Communication Number Communication Number Qualifier Communication Number Entity Idetifier Code Entity Type Qualifier Name Last or OrganiZation Name Name First Name Middle Name Suffix Identification Code Qualifier Identification Code
Reference Identification Qualifier Reference identification Reference identifier Reference Identification Qualifier Reference identification Entity identifier Code EntityType Qualifier Address Information Address Information City Name State or Province Code Postal Code Country Code Country Subdivision Code Entity identifier Code EntityType Qualifier Name Last or OrganiZation Name Address Information Address Information City Name State or Province Code Postal Code Country Code Country Subdivision Code
Claim Adjustment Reason Code Monetary Amount Quantity Claim Adjustment Reason Code Monetary Amount Quantity Claim Adjustment Reason Code Monetary Amount Quantity Claim Adjustment Reason Code Monetary Amount Quantity Claim Adjustment Reason Code Monetary Amount Quantity Claim Adjustment Reason Code Monetary Amount Quantity
Date/Time Qualifier Date Time Period Format Qualifier Date Time Period Amount Qualifier Code Monetary Amount
Code List Qualifier Code Industry Code Assigned Identification Yes/No Condition or Response Code Reference Identification Date Percent Decimal Format