Com1SoftwareInc.

X12 Parser

Model : C1D0N252
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Table of Contents

Section 1. - Overview X12 Parser
Section 2. - Features and Specifications
Section 3. - Parser Options
Section 4. - Using ODBC with the Parser
Section 5. - Customizing the X12 parser through the C1.INI
Section 6. - User Defined Fields
Section 7. - 837 Field Descriptions
Section 8. - 837 Field Descriptions
Section 9. - 835 Field Descriptions
Section 10. - 277 Field Descriptions

Updated:07/31/17



Section 1

Overview X12 Parser

[Table of Contents]

X12 Parser
Model C1D0U252 64bit
Model C1D0N252 32bit
Standard License

Copyright (c)1992-2014 Com1 Software Development
Com1 Software, Inc.
P.O. Box 482
Hudson, Ohio 44236
(330) 653-3771

Website: http://com1software.com
Support: http://com1software.net
Email: information@com1software.com



IMPORTANT NOTICE
    This computer program is protected by copyright law and
    international treaties. Any unauthorized reproduction or
    distribution of this program or any portion of it may result
    in severe civil or criminal penalties, and will be prosecuted
    under the maximum extent possible under the law.

    This program and all support programs and documents are
    provided "AS IS" without warranty of any kind, either
    expressed or implied, including and not limited to the
    implied warranties of merchantability and fitness for a
    particular purpose.

    In no event shall Com1 Software, Inc. or Com1 Software
    Development be liable for any damages arising out of the
    use or inability to use this program, support programs or
    documentation. All prices and other information is subject
    to change without notice.

    This program and support documents are for trial and
    demonstration purposes. Any other use is strictly prohibited.






Section 2

Features and Specifications

[Table of Contents]

BASIC CONCEPT


The X12 Parser allows a user to convert
X12 837 and 835 files into CSV or XML files.

The X12 Parser can be run from a command prompt
using parameters to specify format,input file,
output file, and options. 

The X12 Parser can parse all the x12 files in a
specified folder with a single execution.


The view function allows you to display and print
the contents of standard ANSI X12 837,277,276,835,864,
and 997 files in a user friendly format.

837 Health Care Claims
276 Claim Status Inquiry
277 Claim Status
835 Remittance Advice
997 Functional Acknowledgement
864 Informational Report

Data is displayed in context sensitive screens relative
to their transaction set.

Data can be exported to a file using a CSV or XML formats.

837 Health Care Claims can be printed on
CMS-1500 Forms.

837 Health Care Claims can be converted into 276 Claims
Status Inquries for submission.

Formats data as a HTML and loads the page
to your default browser.



FEATURES
- Ability to call and run the Parser from another
  application without user intervention.
- Create XML,CSV,DBF files.
- Create SQL Tables via ODBC.**
- View or Print Listings of Claims
- View or Print Data Sheet of Individual Claims
- View or Print Listings of Remittance
- View or Print Data Sheet of Remittance
- View or Print Functional Acknowledgements
- View or Print X12 Data in segmented lines
- Configurable print and listing fields
- Creates 276 Claim Status Inquiry from an 837 file.




SYSTEM SPECIFICATIONS

Requires a Microsoft Windows Operating System.

** 32 bit version only



Section 3

Parser Options

[Table of Contents]

The C1D0F252 X12 Parser can be run in either a user interface
mode, where a user is able to select files and options using
a windows dialog box, or by running the program in a command
line mode where parameters are passed to the program telling
it what to do. By Using the C1D0f252 in the command line mode
you will be able to run the X12 Parser from another application
or script file, and generate files without user intervention.



C1D0F252.EXE parm1 parm2 parm3 parm4

 parm1=Parse Output Type

 parm2=Source File or Directory

 parm3=Destination File or Directory

 parm4=Options



Parse Output Types options:

   CSV - Comma Separated Value
         837 or 835 source files Only

   XML - Extensible Markup Language 
         837 or 835 source files Only

   ODBC - Open Database Connectivity 
          837 or 835 source files Only

   TXT - ASCII Text
         All x12 source file types

   RTF - Rich Text Format
         All x12 source file types

   PDF - Portable Document Format
         All x12 source file types

   HTM - Hypertext Markup Language
         All input types


   EOB - Explanation of Benefits
         835 source files Only

   CMS1500 - CMS-1500 Form
         837p source files Only

   837 - X12 837 Claim File
         837 source files Only

   276 - X12 276 Claim Status Inquiry
         837 source files Only
   
   
   ISA - Create seperate X12 files from a 
          multi-ISA X12 file.




Source File or Directory:

  The progarm will process this parameter
  as a directory unless a file with an extension
  is specified.


Destination File or Directory

   If nothing is specified in this parameter
   the file being parsed will be written as the 
   name of the input file with an extension that is 
   based on which Parse Output Type Option was specified.
   
   Note: ODBC uses this syntax in the destination parameter:

                     dsn:table

         dsn= data source name
       table= name of the table to be used within the data set.
             
   

Options:
   

Options:
   
    IC - Individual Claim
         Generates a single output file for each claim in
         the file that is being parsed.

    OW - Overwrite any existing files.

    HO - Add a discriptive field header to each column in 
         the file.

    ST - The ST option will process multiple set transactions
         as a single set.


    SL - The SL option will process a record for each service
         line. (835 only)

    MO - Shuts the progress meters off.


    MF - Merge Files into single output.


    MAP= - User specified mapping fie.


    ML - Allows for multiple pares logs by assigning
         a date time stamp to the log.
    
   
    Multiple options may be used separated by commas.
    Option availability is dependent on output type.




Example:

cd\c1d0f252

C1D0F252.EXE CSV \source \output OW,HC




To create a custom map for the fields you would like to
export, load the x12 file that you will be mapping to into
the viewing portion of the parser. Once the data has been
displayed there will be an EXPORT button available on the 
screen. Select the EXPORT, and then select export type.

The export screen will be displayed with a basic list of
available fields for export. When you hit the SAVE button 
a mapping configuration file is created. The type of X12
file you are working with will determine the name of the
configuration file.

     C1837I.XML Institutional 837
     C1837P.XML Professional 837
     C1837D.XML Dental 837
     C1835.XML  Remittance 835

These configuration files can be modified using notepad.

If you require more then the 10 service lines defined in
the default mapping, you can add up to 99 additional 
service line fields using a text editor like notepad.









Section 4

Using ODBC with the Parser

[Table of Contents]

The X12 Parser can be configured and used to create and 
populate a table within an SQL database using ODBC, 
Open Database Connectivity for 837 or 835 source files.

   -------

Setting up a DSN

In windows XP and Windows 7
 Start, Control Panel, Administrative Tools, Data Sources(ODBC)

For testing we used MS EXpress SQL 2012.

After the MS Express 2012 has been installed on our computer we
run the ODBC Data Source Administarator. Select the User DSN Tab,
and click the Add button. 

In the Create New Data Source Selection screen, select the 
SQL Server Native Client 11.0. and click Finish.

In the Create a New Data Source to SQL Server screen, enter the 
Name, description, and Server, then click Finish.

Click the Test Data Source button to see if the ODBC has been 
configured correctly.

     -------

Once a ODBC DSN or User Data Source has been created using 
the ODBC Data Source Administrator the parser can then be used 
to create and then populate a table within that ODBC data set.

The X12 Parser can be run in the user interface mode, where
the user FIRST selects OUTPUT TYPE as ODBC and then sets the DSN and
Table using the DESTINATION FILE button. 

 

It is important to note that the table and its field names 
need to be created within the ODBC DSN by the Parser so that all fields
match want the Parser expects to write to. using the Output Type set to ODBC
then using the Destination File button you can set the Table name to create
in the select DSN screen. Click continue. The Destination should look something 
like:
DSNA:TABLE1

Where DSNA is the ODBC data set name
and TABLE1 is the name of the table to be created within the data set.

Each record within the table will have a unique record ID created by 
the parser. If you are using your own map, duplicate fields are not allowed.

The ODBC tables have a 255 field limit.


If a table has been properly created within the ODBC DSN using 
the Parser, then any addition running of the parser against that 
table and ODBC DSN will append the current runs records to the 
existing table.


Mapping for the table is controlled by the following files.

     C1837I.XML Institutional 837
     C1837P.XML Professional 837
     C1837D.XML Dental 837
     C1835.XML  Remittance 835



   
ODBC uses this syntax in the destination parameter:

             dsn:table

             dsn= data source name
           table= name of the table to be used within the data set.


Here is an examples of how to run the Parser in a command line prompt.

c:\c1d0f252\c1d0f252.exe ODBC,sourcefile.837,sqltestdsn:mytable
             


C1D0F252.EXE parm1 parm2 parm3

parm1=ODBC

parm2=Source File or Directory

parm3=DSN:TABLE




   



Section 5

Customizing the X12 parser through the C1.INI

[Table of Contents]

With the C1.INI Editor you can customize the product to better 
fit your needs.


The C1.INI file is a standard text sequential file and is
located in the product base and data subdirectory. It is loaded 
from the data subdirectory upon start up of the program.

Sections and respective commands are set in this file as needed.
  - - - - - - - - - - - - - - - - - - - - - - - - - - - -

[PARSER]

  XMLENCODING=value
   Default value : ISO-8859-1
   Can be use to set the type of XML encoding generated by the
   parser.
    Example : XMLENCODING=UTF-8
   


  MERGEST=option
   Option:ON (default)
          OFF
    Can be used with XML and CSV to generate seperate files for
    each ST batch within a file.


  MAXFIELDCOUNT=n
    This allows you to set the maximum number of fields
    in your export. 255 is the set default.


  SERVICELINECOUNT=n
     This allows you to set the number of service lines.


  OTHERDIGNOSISCOUNT=n
     This allows you to set the number of Diagnosis.


  OTHERPROCEDURECOUNT=n
     This allows you to set the number of Procedures .


  OCCURANCESPANCOUNT=n
     This allows you to set the number Occurance Spans.


  OCCURANCECODECOUNT=n
     This allows you to set the number Occurance Codes.


  VALUECODECOUNT=n
     This allows you to set the number Value Codes.


  CONDITIONCODECOUNT=n
     This allows you to set the number condition Codes.


  TREATMENTCODECOUNT=n
     This allows you to set the number Treatment Codes.


  DBFFIELDCOUNT=n
     This allows you to set the maximum number of
     DBF fields allowed.



  LOOP1000A=option
   Option:ON (default)
          OFF
      
  LOOP1000B=option
   Option:ON (default)
          OFF


  LOOP2010AABATCH=option
   Option:ON (default)
          OFF


  LOOP2010ABBATCH=option
   Option:ON (default)
          OFF
 

  LOOP2010AACLAIM=option
   Option:ON (default)
          OFF


  LOOP2010ABCLAIM=option
   Option:ON (default)
          OFF


  LOOP2000=option
   Option:ON (default)
          OFF


  LOOP2300=option
   Option:ON (default)
          OFF


  LOOP2400=option
   Option:ON (default)
          OFF


  NAMEMERGE=option
   Option:ON (default)
          OFF


      - - - - - - - - - - - - - - - - - - - - - - - - - - - -

 


[X12VIEWER]

  - For configuration of general use functions.

  SETEXTENSION=scope
     This allows you to filter the selection files based on
     file extention or on other supported wild card parameters.
     Example:
       setextension=*.tcf,*.837,*,835



  TEXTFORMCONTROL=option
     This allows you to set the CMS-1500/UB Formating

      TEXTFORMCONTROL=option
   Option:FLAT (default)
          FORMFEED


         - - - - - - - - - - - - - - - - - - - - - 



[X12837TO276]


  ISA06=value
     Allows you to set the value of ISA06, the Interchange Sender ID.

  ISA08=value
     Allows you to set the value of ISA08, the Interchange Receiver ID.

  ISA13=value
     Allows you to set the value of ISA13, the Interchange Control Number.
     Also sets IEA02 as well

  ISA15=value
     Allows you to set the value of ISA15, the Usage Indicator.


  GS02=value
     Allows you to set the value of GS02, the Application Sender Code.

  GS03=value
     Allows you to set the value of GS03, the Application Receiver Code.

  GS06=value
     Allows you to set the value of GS06, the Group Control Number.
     Also sets GE02 as well.


  ST02=value
     Allows you to set the value of ST02, the Group Control Number.
     Also sets SE02 as well.


         - - - - - - - - - - - - - - - - - - - - - 



[X12837TO837]

  CONVERSIONTYPE=option
   Options: 1 Allows you to set values through the C1.INI
            2 (default)
  
 Example:
    CONVERSIONTYPE=1
  


  ISA06=value
     Allows you to set the value of ISA06, the Interchange Sender ID.
       Note: Conversion Type must be set to 1


  ISA08=value
     Allows you to set the value of ISA08, the Interchange Receiver ID.
       Note: Conversion Type must be set to 1

  ISA13=value
     Allows you to set the value of ISA13, the Interchange Control Number.
     Also sets IEA02 as well
       Note: Conversion Type must be set to 1

  ISA15=value
     Allows you to set the value of ISA15, the Usage Indicator.
       Note: Conversion Type must be set to 1


  GS02=value
     Allows you to set the value of GS02, the Application Sender Code.
       Note: Conversion Type must be set to 1

  GS03=value
     Allows you to set the value of GS03, the Application Receiver Code.
       Note: Conversion Type must be set to 1

  GS06=value
     Allows you to set the value of GS06, the Group Control Number.
     Also sets GE02 as well.
       Note: Conversion Type must be set to 1


  ST02=value
     Allows you to set the value of ST02, the Group Control Number.
     Also sets SE02 as well.
       Note: Conversion Type must be set to 1



      - - - - - - - - - - - - - - - - - - - - - - - - - - - -

 


[X12UDF]

  - For configuration of user defined fields.

    

   UDF=udftest1
    segment=ref
    qualifier=ay
    return=3


  UDF=udftest2
   segment=nm1
   loop=2010bb
   return=3



      - - - - - - - - - - - - - - - - - - - - - - - - - - - -



  [CMS1500] 



  BOX4=OFF
     Suppresses boxs 4 and 7.
   BOX4=YESALWAYS
      Overides use of SAME when the Patient is the same as 
      the Guarantor for boxs 4 and 7.
  BOX6=OFF
     Suppresses box 6.

  BOX8=OFF
     Suppresses box 8.

   BOX9=OFF
      Suppresses box 9 and its associated Other Insurance
      Fields 9a through 9d.

   BOX9=YESALWAYS
      Overides medicare print supression of box 9 and its 
      associated Other Insurance Fields 9a through 9d.
  BOX10=OFF
     Suppresses box 10.

  BOX11=OFF
     Suppresses box 11.

   BOX12=ONFILE     **
      Will cause the Patient or Authorized Signature to display
      SIGNATURE ON FILE in the box for all claims.

   BOX12=DATEOFF     **
       Will leave the date field in box 12 off.

   BOX12=TODAY     **
      Will place the system date in the date field of box 12 for
      patient signature on file.

   BOX13=ONFILE     **
      The Insured's Authorized Signature will display SIGNATURE
      ON FILE in the box for all claims.

   BOX14=OFF
      Supresses the printing of information in box 14.

   BOX21=OFF
      Suppresses the printing of box 21.

   BOX21=DECIMALON
      Leaves the decimal point in the diagnoses codes displayed
      in Box 21.

   BOX24B=1992
      Standard two character Place of Service.(default)

   BOX24B=1984
      Previously used one character Place of Service.

   BOX24B=OFF
      Supresses the printing of box 24b, the Place of Service.
  
   SETPOS=x
       Sets the Place of Service to whatever characters are in position x.

   BOX24C=OFF
      Supresses the printing of box 24c, the Type of Service.

 
   SETTOS=x
      Sets the Type of Service to the characters are in x.
       Example: SETTOS=12

   SETTOSUDFn=x
     This function allows you to create up to 5 user defined types of service
     where n represents the user defined funtion 1 through 5 and will set the 
     type of service to the characters set in x. The user defined type of service
     is also set in the User Defaults and where the Type of Service is set at the 
     claim level.
       Example: SETTOSUDF1=18
 

    BOX24D=DESCRIPTION
      Uses procedure code discription instead of the procedure code.
 
   BOX24E=DX
      Uses the DX code instead of related item number.,
      i.e. 1,2,3,4

    BOX24E=OFF
      Supresses the printing of box 24e diagnosis code link.
    

   BOX24G=NORMAL
      Standard central right justified printing of units
      on form. Prints the right two characters in field.
      Maximum value to display is 99.
      Default setting.

   BOX24G=MAX
      Standard right justified printing of units on form.
      Prints full three chracter width in field. Maximum value
      to display is 999.

   BOX24G=TWOPOS
      Units are zero filled and displayed in a right justified
      two position format.

   BOX24G=THREEPOS
      Units are zero filled and displayed in a right justified
      three position format.

   BOX24K=PROVINSID
      Solo Version-will display the Provider Insurance ID#
      based on data entered in the Provider Insurance Contract
      Table.

      Institution Version-will display the Provider Insurance
      ID# based on data entered in the Provider Insurance ID
      Editor.

   BOX24K=REFSINSID
      Will display the Referring Source Insurance ID# based on
      data entered in the Referring Source Insurance ID Data
      Screen.

   BOX24K=INSTINSID
      Will display the Institution Insurance ID# based on
      data entered in the Institution Insurance Contract Table.

   BOX25=OFF
      Suppresses federal tax ID or social security number and
      the checking of the associated box.


    BOX25EIN=your id
      This will force the population of box25 of the
      CMS1500 with your id as an EIN.
      


    BOX25SSN=your id
      This will force the population of box25 of the
      CMS1500 with your id as an SSN.



   BOX26=ALTID
      Uses the patient Alternate ID instead of the system
      generated ID#.

   BOX26=SSN
      Use the patient Social Security Number instead of the
      system generated ID#.

  BOX27=OFF
      Turns off Accept Assignment Box 27.

   BOX27=YESALWAYS
      Set accept assignment to say yes on all claims.

   BOX29=OFF
      Suppresses Amount Paid box.

   BOX30=OFF
      Suppresses Balance Due box.

   BOX30=BOX28     **
      Balance Due Box is equal to Box 28 the Total Charges


   BOX31=OFF
      Turns of all Data in box.

   BOX31=DATEONLY
      Print system Date

   BOX32=ONALWAYS
      Alternate Facility will display on all claims.

   BOX33=OFF
      Suppresses printing of name, address, pin# and group#.

   DATECTL=MMDDYY
      Will cause 6-digit dates in field items 12,14,15,16,18,
      24a,and 31 on the form.

   DATECTL=MMDDCCYY
      Will cause 8-digit dates in field items 12,14,15,16,18,
      24a,and 31 on the form.

      NOTE for DATECTL:
           All dates of birth field items 3, 9b, and 11a are
           set to 8-digit dates.


   FORM=PREPRINTEDNOCHOICE
      Use HCFA pre-printed forms only, it doesn't offer the
      user the Options choice.

   FORM=PREPRINTED
      Use pre-printed forms as the default in the Options.

   FORM=ARTWORK
      Generate an artwork form with your color printer.

   FORM=UPPERELITE
      Will cause all data printed on form to appear in
      10 character per inch upper case letters.

   FORMREVISION=0805     **
      Will use the 0805 CMS-1500 Form

   FORMREVISION=1290     **
      Will use the 1290 CMS-1500 Form

   TEXTFORMCONTROL=FLAT     **
      For ASCII text file creation of CMS-1500 data.
      Set for 80 characters wide with 72 lines.
     

   TEXTFORMCONTROL=FORMFEED    **
      For ASCII text file creation of CMS-1500 data.
      Set for 80 characters wide with 65 lines followed
      with a form feed.
      

   PROCLINE=DESC10
      Used to display the first ten characters of a procedure
      description starting in 24d, to the right of the procedure
      code using Modifier field.

   PROCLINE=DESC16
      Used to display the first sixteen characters of a procedure
      description starting in 24h through 24k.

   TOP=OFF
      Will control carrier address and ID's top of the HCFA form.
       Default is on with internal system ID dislayed. Options are:
                       OFF
                         - Address is not printed
                       SYSTEMIDON
                         - Address with internal system ID
                       SUBMITTERIDON
                         - Address with EMC Submitter ID
                       INSURANCEIDON
                         - Address with Insurance/UPIN ID
                       IDOFF
                         - Address with out ID

   TOPOFFSET=n
        Allows for the left to right placement of the carriers name,
        address,and ID information on the top of the form. Options
        for N are: 0,5,10,15,20,25,30,35,40,45,50,55,60. Offset
        increments are equal to one half inch increments. 0 represents
        that the original system position is being used. The default
        position of the carrier name is at 33. Offsets other than 0
        are based on position from the left edge of the form. To move 
        the name to the right use 35 or greater.



   FONT=ARIAL8
      Will set the size and font used to print the insurance
      form. Options are:
                        ARIAL8
                        COURRIERNEW8
                        TIMESNEWROMAN8
                        SANSERIEF8
                        ARIAL10
                        COURRIERNEW10
                        TIMESNEWROMAN10
                        SANSERIEF10
                        ARIAL12
                        COURRIERNEW12
                        TIMESNEWROMAN12
                        SANSERIEF12



EXAMPLE
In this example, the following text is entered into the
C1.INI editor and saved.  This will allow the default of the form
to have Signatures on File with today's date using full eight
digit dates:

[CMS1500]
 BOX12=ONFILE
 BOX12=TODAY
 BOX13=ONFILE
 DATECTL=MMDDCCYY



Note:
 ** Indicates availability in X12 to CMS-1500 Conversions




----------------------------------------------------------------------



Section 6

User Defined Fields

[Table of Contents]

User Defined Fields can be created to make a custom mapped 837 field.


In the mapping file define your unique field name that 
does not duplicate an existing mapped field in the parser.


Example of Mapping Files for:
       C1837P.XML
       C1837I.XML
       C1837D.XML




UDFTESTST
UDFTESTVER
UDFTESTSUBMITTER
UDFTESTRECEIVER
UDFTESTK3






In the C1.INI you will need to define the characteristics of
your UDF.


Section:
[x12udf]



User Defined Field Name
   UDF=udfname

  Example:
     udf=udftestsubmitter



Segment
   SEGMENT=segmentname

  Example:
     segment=NM1



Second Element Qualifier in the Segment
   QUALIFIER=value

   Example 
      qualifier=41
   

Loop
   LOOP=value

  Example:
     loop=2300



Element Value to return
   RETURN=element

   Example:
      return=4






Example of the c1.INI:

[x12udf]

   udf=udftestst
   segment=ST
   qualifier=837
   return=3

   udf=udftestver
   segment=REF
   qualifier=87
   return=3

   udf=udftestsubmitter
   segment=NM1
   qualifier=41
   return=4

   udf=udftestreceiver
   segment=NM1
   qualifier=40
   return=4


   udf=udftestk3
   segment=K3
   loop=2300
   return=2





Section 7

837 Field Descriptions

[Table of Contents]

  This is a list of the fields supported for mapping and are
stored in an XML file called:

C1837I.XML for Institutional

C1837P.XML for Professional 

C1837D.XML for Dental

Field names are placed inside the field tags of the xml.

Example :

CLAIMID
CLAIMAMTDDDDDD_CC
CLAIMAMT


- - - - - - - - - - - - - - - - - -





CLAIMID
      Claim ID
        Location :  CLM Segment, Element 1


CLAIMAMTDDDDDD_CC
      Claim Amount
        Location :  CLM Segment, Element 2


CLAIMAMT
      Claim Amount
        Location :  CLM Segment, Element 2


CLEARINGIDNUMBER
      Clearing Service ID
        Location :  REF Segment, Element 2
                    Qualifier D9


MULTICLAIMTOTAL
      Multi Claim Total Amount
        Location :  CLM Segment, Element 2



ICNDCN
      Internal Document Number Document Control Number
        Location :  REF Segment, Element 3
                    Qualifier F8


TAXONOMYCODE
      Taxonomy Code 
        Location :  PRV Segment, Element 4
                    Qualifier PE


EMPLOYERIDNUM
      Employer Identification Number      
        Location :  REF Segment, Element 3
                    Qualifier EI



PRIORAUTHORIZATIONNUMBER
      Prior Authorization Number
        Location :  REF Segment, Element 3
                    Qualifier G1


ORDERDATE
      Order Date
        Location :  DTP Segment, Element 3
                    Qualifier 938


INITIALTREATMENTDATE
      Initial Treatment Date
        Location :  DTP Segment, Element 3
                    Qualifier 454

REFERRALDATE
      Referral Date
        Location :  DTP Segment, Element 3
                    Qualifier 330

DATELASTSEEN
      Date last Seen
        Location :  DTP Segment, Element 3
                    Qualifier 304

ONSETOFILLNESDATE
      Onset of Current Symptoms or Illness Date
        Location :  DTP Segment, Element 3
                    Qualifier 431

ACUTEMANIFESTATIONDATE
      Acute Manifestation of a Chronic Condition Date
        Location :  DTP Segment, Element 3
                    Qualifier 453

SIMILARILLNESSONSETDATE
      Onset of Similar Symptoms or Illness Date
        Location :  DTP Segment, Element 3
                    Qualifier 438

ACCIDENTDATE
      Accident Date
        Location :  DTP Segment, Element 3
                    Qualifier 439

LMPDATE
      Last Menstrual Period Date
        Location :  DTP Segment, Element 3
                    Qualifier 484

LASTXRAYDATE
      Last X-Ray Date
        Location :  DTP Segment, Element 3
                    Qualifier 455

ESTIMATEDDATEOFBIRTH
      Estimated Date of Birth
        Location :  DTP Segment, Element 3
                    Qualifier ABC

HEARINGVISIONPRESCRIPTIONDATE
      Hearing and Vision Prescription Date
        Location :  DTP Segment, Element 3
                    Qualifier 471

DISABILITYBEGINDATE
      Disability Begin Date
        Location :  DTP Segment, Element 3
                    Qualifier 360

DISABILITYENDDATE
      Disability End Date
        Location :  DTP Segment, Element 3
                    Qualifier 361

DATELASTWORKED
       Date Last Worked
        Location :  DTP Segment, Element 3
                    Qualifier 297

RETURNTOWORKDATE
      Return to Work Date
        Location :  DTP Segment, Element 3
                    Qualifier 296

ASSUMEDCAREDATE
      Assumed Care Start Date
        Location :  DTP Segment, Element 3
                    Qualifier 090



RELINQUISHEDCAREDATE
      Relinquished Care End Date
        Location :  DTP Segment, Element 3
                    Qualifier 091







PROVSIGNATUREONFILE
      Provider Signature
        Location :  CLM Segment, Element 6


PROVACCEPTASSIGNMENTCODE
      Provider Assignment 
        Location :  CLM Segment, Element 7



BENEFITINDICATOR
      Benefit Indicator
        Location :  CLM Segment, Element 8



RELEASEOFINFORMATION
      Release of Information
        Location :  CLM Segment, Element 9



RELATEDCAUSECODE
      Related Cause
        Location :  CLM Segment, Element 11



RELATEDCAUSE
      Related Cause
        Location :  CLM Segment, Element 11


DISCHARGEHOUR
      Discharge Hour
        Location :  DTP Segment, Element 3
                    Qualifier 069


DISCHARGEDATE
      Discharge Date
        Location :  CR6 Segment, Element 5



STATEMENTDATE
      Statement Date
        Location :  DTP Segment, Element 3
                    Qualifier 434

ADMISSIONDATETIME
      Addmission Date Time
        Location :  DTP Segment, Element 3
                    Qualifier 435



ADMISSIONTYPECODE
      Addmission Type Code
        Location :  CL1 Segment, Element 1
                    Qualifier 435



ADMISSIONTYPE
      Addmission Type
        Location :  CL1 Segment, Element 1
                    Qualifier 435



ADMISSIONSOURCECODE
      Addmission Source Code
        Location :  CL1 Segment, Element 2



ADMISSIONSOURCE
      Addmission Source
        Location :  CL1 Segment, Element 2



PATIENTSTATUSCODE
      Patient Status Code
        Location :  CL1 Segment, Element 3



PATIENTSTATUS
      Patient Status
        Location :  CL1 Segment, Element 3


MEDICALRECORDNUMBER
      Medical Record Number
        Location :  REF Segment, Element 2
                    Qualifier EA


PATIENTAMOUNTPAID
      Patient Amount Paid
        Location :  AMT Segment, Element 2
                    Qualifier F5

TOTALPURCHASEDSERVICEAMOUNT
      Total Purchased Service Amount
        Location :  AMT Segment, Element 2
                    Qualifier NE



PAYERPRIORPAY
      Payer Prior Pay
        Location :  AMT Segment, Element 2
                    Qualifier C4


CLAIMNOTEADD
      Claim Note Additional Information
        Location :  NTE Segment, Element 2
                    Qualifier ADD


CLAIMNOTECER
      Claim Note Certification Narrative
        Location :  NTE Segment, Element 2
                    Qualifier CER


CLAIMNOTEDCP
      Claim Note Goals /Discharge Plan 
        Location :  NTE Segment, Element 2
                    Qualifier DCP


CLAIMNOTEDGN
      Claim Note Diagnosis Description
        Location :  NTE Segment, Element 2
                    Qualifier DGN


CLAIMNOTEPMT
      Claim Note Payment 
        Location :  NTE Segment, Element 2
                    Qualifier PMT


CLAIMNOTETPO
      Claim Note Third party Org 
        Location :  NTE Segment, Element 2
                    Qualifier TPO


OISUBORDER
      Other Insurance Subscriber Order
        Location :  NM1 Segment, Element 1
                  


OISUBID
      Other Insurance Subscriber ID
        Location :  NM1 Segment, Element 9
                    Qualifier IL



OISUBLNAME
      Other Insurance Subscriber Last Name
        Location :  NM1 Segment, Element 3
                    Qualifier IL



OISUBFNAME
      Other Insurance Subscriber First Name
        Location :  NM1 Segment, Element 4
                    Qualifier IL



OISUBMI
      Other Insurance Subscriber Middle Initial
        Location :  NM1 Segment, Element 5
                    Qualifier IL

OIPAYERADDR1
      Other Insurance Subscriber Address 1
        Location :  N3 Segment, Element 1

OIPAYERADDR2
      Other Insurance Subscriber Address 2
        Location :  N3 Segment, Element 2

OIPAYERCITY
      Other Insurance Subscriber City
        Location :  N4 Segment, Element 1

OIPAYERSTATE
      Other Insurance Subscriber State
        Location :  N4 Segment, Element 2

OIPAYERZIP
      Other Insurance Subscriber Zip Code
        Location :  N4 Segment, Element 3

OIPAYERID
      Other Insurance Payer ID
        Location :  NM1 Segment, Element 9
                    Qualifier PR

OIPAYERNAME
      Other Insurance Payer Name
        Location :  NM1 Segment, Element 3
                    Qualifier PR

SEGMENTNOTE
      Segment Note
        Location :  DMG Segment, Element 3


POSDESC
      Place of Service Description
        Location :  CLM Segment, Element 6


FACILITYCODEVALUE
      Facility Code Value
        Location :  CLM Segment, Element 6


FREQUENCYTYPECODE
      Frequency Type Code 
        Location :  CLM Segment, Element 6

POSCODE
      Place of Service Description
        Location :  CLM Segment, Element 6

K3DATA
      K3 Data
        Location :  K3 Segment, Element 1

NDCCODE
      National Drug Code
        Location :  LIN Segment, Element 3
                    Qualifier N4

NDCUNITPRICE
      NDC Drug Unit Price
        Location :  CTP Segment, Element 3

NDCUNITS
      NDC Units
        Location :  CTP Segment, Element 4

TYPEOFBILL
      Type of Bill
        Location :  CLM Segment, Element 6


FREQUENCYCODE
      Frequency Type Code 
        Location :  CLM Segment, Element 6

PRINCIPALDX
      Principle Diagnosis
        Location :  HI Segment, Element 1
                    Qualifier BK

ADMITDX
      Admitting Diagnosis
        Location :  HI Segment, Element 2
                    Qualifier BJ

ECODE
      Vital Statistics E-Code
        Location :  HI Segment, Element 3
                    Qualifier BN


DRG
      DRG
        Location :  HI Segment, Element 1
                    Qualifier DR

OTHERDX01 thru OTHERDX12
      Other Diagnosis 1 thru 12
        Location :  HI Segment, Element 1
                    Qualifier BF


OTHERDXA01 thru OTHERDXY12
      Other Diagnosis 1 thru 12
        Multi Segment
        Location :  HI Segment, Element 1
                    Qualifier BF



PRINCIPLEPROCDATE
      Principle Procedure Date
        Location :  HI Segment, Element 1
                    Qualifier BP,BR


PRINCIPLEPROC
      Principle Procedure Date
        Location :  HI Segment, Element 1
                    Qualifier BP,BR


OTHERPROC01 thru OTHERPROC12
      Other Procedures 1 thru 12
        Location :  HI Segment, Element 1
                    Qualifier BO,BQ

OTHERPROCA01 thru OTHERPROCY12
      Other Procedures 1 thru 12
      Multi Segment
        Location :  HI Segment, Element 1
                    Qualifier BO,BQ



OCCURRENCESPAN01 thru OCCURRENCESPAN12
      Occurance Span 1 thru 12
        Location :  HI Segment, Element 1
                    Qualifier BI

OCCURRENCESPANA01 thru OCCURRENCESPANY12
      Occurance Span 1 thru 12
      Multi Segment
        Location :  HI Segment, Element 1
                    Qualifier BI



OCCURRENCECODE01 thru OCCURRENCECODE12
      Occurance Code 1 thru 12
        Location :  HI Segment, Element 1
                    Qualifier BH

OCCURRENCECODEA01 thru OCCURRENCECODEY12
      Occurance Code 1 thru 12
      Multi Segment
        Location :  HI Segment, Element 1
                    Qualifier BH


OCCURRENCEDATE01 thru OCCURRENCEDATE12
      Occurance Date 1 thru 12
        Location :  HI Segment, Element 1
                    Qualifier BH

OCCURRENCEDATEA01 thru OCCURRENCEDATEY12
      Occurance Date 1 thru 12
      Multi Segment
        Location :  HI Segment, Element 1
                    Qualifier BH



VALUECODE01 thru VALUECODE12
      Value Codes 1 thru 12
        Location :  HI Segment, Element 1
                    Qualifier BE


VALUECODEA01 thru VALUECODEY12
      Value Codes 1 thru 12
      Multi Segment
        Location :  HI Segment, Element 1
                    Qualifier BE


VALUEAMOUNT01 thru VALUEAMOUNT12
      Value Amounts 1 thru 12
        Location :  HI Segment, Element 1
                    Qualifier BE

VALUEAMOUNTA01 thru VALUEAMOUNTY12
      Value Amounts 1 thru 12
       Multi Segment
        Location :  HI Segment, Element 1
                    Qualifier BE


VALUEQTY01 thru VALUEQTY12
      Value Quantity 1 thru 12
        Location :  HI Segment, Element 1
                    Qualifier BE


VALUEQTYA01 thru VALUEQTYY12
      Value Quantity 1 thru 12
      Multi segment
        Location :  HI Segment, Element 1
                    Qualifier BE


CONDITIONCODE01 thru CONDITIONCODE12
      Condition Codes 1 thru 12
        Location :  HI Segment, Element 1
                    Qualifier BG


CONDITIONCODEA01 thru CONDITIONCODEY12
      Condition Codes 1 thru 12
      Multi Segment
        Location :  HI Segment, Element 1
                    Qualifier BG


CONDITIONDATE01 thru CONDITIONDATE12
      Condition Dates 1 thru 12
        Location :  HI Segment, Element 1
                    Qualifier BG

CONDITIONDATEA01 thru CONDITIONDATEY12
      Condition Dates 1 thru 12
      Multi Segment
        Location :  HI Segment, Element 1
                    Qualifier BG


TREATMENTCODE01 thru TREATMENTCODE12
      Treatment  Codes 1 thru 12
        Location :  HI Segment, Element 1
                    Qualifier TC

TREATMENTCODEA01 thru TREATMENTCODEY12
      Treatment  Codes 1 thru 12
      Multi Segment
        Location :  HI Segment, Element 1
                    Qualifier TC



SUBCLMTYPECODE
      Subscriber Claim Type
        Location :  SBR Segment, Element 9


SUBCLMTYPE
      Subscriber Claim Type
        Location :  SBR Segment, Element 9


SUBID
      Subscriber ID
        Location :  NM1 Segment, Element 9
                    Qualifier IL


SUBLNAME
      Subscriber Last Name
        Location :  NM1 Segment, Element 3
                    Qualifier IL


SUBFNAME
      Subscriber First Name
        Location :  NM1 Segment, Element 4
                    Qualifier IL


SUBMI
      Subscriber Middle Initial
        Location :  NM1 Segment, Element 5
                    Qualifier IL



SUBADDR1
      Subscriber Address 1
        Location :  N3 Segment, Element 1



SUBADDR2
      Subscriber Address 2
        Location :  N3 Segment, Element 2


SUBCITY
      Subscriber City
        Location :  N4 Segment, Element 1


SUBST
      Subscriber State
        Location :  N4 Segment, Element 2


SUBZIP
      Subscriber Zip 
        Location :  N4 Segment, Element 3


SUBDOB
      Subscriber Date of Birth
        Location :  DMG Segment, Element 2



SUBNAMEPREFIX
      Subscriber Prefix
        Location :  NM1 Segment, Element 6
                    Qualifier IL


SUBNAMESUFIX
      Subscriber Suffix
        Location :  NM1 Segment, Element 6
                    Qualifier IL


SUBMSTATUS
      Subscriber Prefix
        Location :  DMG Segment, Element 4



SUBORDER
      Subscriber Coverage Order
        Location :  SBR Segment, Element 1


SUBREL
      Subscriber Relationship to Patient
        Location :  SBR Segment, Element 2



SUBGROUPNAME
      Subscriber Group Name
        Location :  SBR Segment, Element 3



SUBSEX
      Subscriber Gender
        Location :  DMG Segment, Element 3





PROPERYCASUALTYCLAIMNUMBER
 Added Property Casuality Claim Number 
        Location :  REF Segment, Element 2
                    Qualifier Y4





PAYERID
      Payer ID
        Location :  NM1 Segment, Element 9
                    Qualifier PR

PAYERNAME
      Payer Name
        Location :  NM1 Segment, Element 3
                    Qualifier PR

PAYERADDR1
      Payer Address Line 1
        Location :  N3 Segment, Element 1


PAYERADDR2
      Payer Address Line 2
        Location :  N3 Segment, Element 2


PAYERCITY
      Payer City
        Location :  N4 Segment, Element 1

PAYERSTATE
      Payer State
        Location :  N4 Segment, Element 2

PAYERZIP
      Payer Zip Code
        Location :  N4 Segment, Element 3





PATLNAME
      Patient Last Name
        Location :  NM1 Segment, Element 3
                    Qualifier QC


PATFNAME
      Patient First Name
        Location :  NM1 Segment, Element 4
                    Qualifier QC


PATMI
      Patient Middle Initial
        Location :  NM1 Segment, Element 5
                    Qualifier QC


PATADDR1
      Patient Address 1
        Location :  N3 Segment, Element 1
          



PATADDR2
      Patient Address 2
        Location :  N3 Segment, Element 2
          

PATCITY
      Patient City
        Location :  N4 Segment, Element 1
          


PATST
      Patient State
        Location :  N4 Segment, Element 2

PATZIP
      Patient Zip
        Location :  N4 Segment, Element 3


PATDOB
      Patient Date of Birth
        Location :  DMG Segment, Element 2

PATSEX
      Patient Gender
        Location :  DMG Segment, Element 3



PATREL
      Patient Relationship to Subscriber
        Location :  PAT Segment, Element 2


PATSIGNATURESOURCE
      Patient Signature Source
        Location :  CLM Segment, Element 10



REFLNAME
      Referring Provider Last Name
        Location :  NM1 Segment, Element 3
                    Qualifier DN

REFFNAME
      Referring Provider First Name
        Location :  NM1 Segment, Element 4
                    Qualifier DN

REFID
      Referring Provider ID
        Location :  NM1 Segment, Element 9
                    Qualifier DN

REFIDTYPE
      Referring Provider ID Type
        Location :  NM1 Segment, Element 8
                    Qualifier DN


REFSECONDARYID
      Referring Provider Secondary ID
        Location :  REF Segment, Element 3

REFSECONDARYIDCODE
      Referring Provider Secondary ID Code
        Location :  REF Segment, Element 2



ATTENDLNAME
      Attending Provider Last Name
        Location :  NM1 Segment, Element 3
                    Qualifier 71


ATTENDFNAME
      Attending Provider First Name
        Location :  NM1 Segment, Element 4
                    Qualifier 71


ATTENDID
      Attending Provider ID
        Location :  NM1 Segment, Element 9
                    Qualifier 71

ATTENDSECONDARYID
      Attending Provider Secondary ID
        Location :  REF Segment, Element 2

ATTENDSECONDARYIDCODE
      Attending Provider Secondary ID Code
        Location :  REF Segment, Element 1


OPERATELNAME
      Operating Provider Last Name
        Location :  NM1 Segment, Element 3
                    Qualifier 72


OPERATEFNAME
      Operating Provider First Name
        Location :  NM1 Segment, Element 4
                    Qualifier 72


OPERATEID
      Operating Provider Last Name
        Location :  NM1 Segment, Element 3
                    Qualifier 72

OPERATESECONDARYID
      Operating Provider Secondary ID
        Location :  REF Segment, Element 2

OPERATESECONDARYIDCODE
      Operating Provider Secondary ID Code
        Location :  REF Segment, Element 1


RENLNAME
      Rendering Provider Last Name
        Location :  NM1 Segment, Element 3
                    Qualifier 82


RENFNAME
      Rendering Provider First Name
        Location :  NM1 Segment, Element 4
                    Qualifier 82

RENIDTYPECODE
      Rendering Provider ID Type Code
        Location :  NM1 Segment, Element 8
                    Qualifier 82

RENIDTYPE
      Rendering Provider ID Type
        Location :  NM1 Segment, Element 8
                    Qualifier 82


RENID
      Rendering Provider ID
        Location :  NM1 Segment, Element 9
                    Qualifier 82



FACILITYNAME
      Facility Name
        Location :  NM1 Segment, Element 3
                    Qualifier FA


FACILITYADDR1
      Facility Address Line 1
        Location :  N3 Segment, Element 1


FACILITYADDR2
      Facility Address Line 2
        Location :  N3 Segment, Element 2

FACILITYCITY
      Facility City
        Location :  N4 Segment, Element 1


FACILITYST
      Facility State
        Location :  N4 Segment, Element 2

FACILITYZIP
      Facility Zip Code
        Location :  N4 Segment, Element 3


FACILITYIDTYPE
      Facility ID Type
        Location :  NM1 Segment, Element 8
                    Qualifier FA


FACILITYIDCODE
      Facility ID Code
        Location :  NM1 Segment, Element 8
                    Qualifier FA


FACILITYID
      Facility ID
        Location :  NM1 Segment, Element 9
                    Qualifier FA


FACILITYSECONDARYIDTYPE
      Facility Secondary ID Type
        Location :  REF Segment, Element 1


FACILITYSECONDARYIDCODE
      Facility Secondary ID CODE
        Location :  REF Segment, Element 1


FACILITYSECONDARYID
      Facility Secondary ID Type
        Location :  REF Segment, Element 2


SERVICELOCATIONNAME
      Service Location Name
        Location :  NM1 Segment, Element 3
                    Qualifier 77


SERVICELOCATIONADDR1
      Service Localtion Address Line 1
        Location :  N3 Segment, Element 1


SERVICELOCATIONADDR2
      Service Localtion Address Line 2
        Location :  N3 Segment, Element 2


SERVICELOCATIONCITY
      Service Localtion City
        Location :  N4 Segment, Element 1


SERVICELOCATIONST
      Service Localtion State
        Location :  N4 Segment, Element 2


SERVICELOCATIONZIP
      Service Localtion Zip Code
        Location :  N4 Segment, Element 4


SERVICELOCATIONID
      Service Location Name
        Location :  NM1 Segment, Element 9
                    Qualifier 77


ILABNAME
      Independent LAB Name
        Location :  NM1 Segment, Element 3
                    Qualifier LI

ILABADDR1
     Independent LAB Address Line 1
        Location :  N3 Segment, Element 1


ILABADDR2
     Independent LAB Address Line 2
        Location :  N3 Segment, Element 2


ILABCITY
     Independent LAB City
        Location :  N4 Segment, Element 1


ILABST
     Independent LAB State
        Location :  N4 Segment, Element 2

ILABZIP
     Independent LAB Zip Code
        Location :  N4 Segment, Element 3


ILABID
      Independent LAB Name
        Location :  NM1 Segment, Element 9
                    Qualifier LI

TLABNAME
      Testing LAB Name
        Location :  NM1 Segment, Element 3
                    Qualifier TL


TLABADDR1
     Testing LAB Address Line 1
        Location :  N3 Segment, Element 1

TLABADDR2
     Testing LAB Address Line 2
        Location :  N3 Segment, Element 2


TLABCITY
     Testing LAB City
        Location :  N4 Segment, Element 1

TLABST
     Testing LAB State
        Location :  N4 Segment, Element 2


TLABZIP
     Testing LAB Zip Code
        Location :  N4 Segment, Element 3


TLABID
      Independent LAB Name
        Location :  NM1 Segment, Element 9
                    Qualifier TL


DX1_XX
     Diagnosis Code 1
        Location :  HI Segment, Element 1
         Sub Element 1
DX2_XX
     Diagnosis Code 2
        Location :  HI Segment, Element 1
         Sub Element 2

DX3_XX
     Diagnosis Code 3
        Location :  HI Segment, Element 1
         Sub Element 3

DX4_XX
     Diagnosis Code 4
        Location :  HI Segment, Element 1
         Sub Element 4

DX5_XX
     Diagnosis Code 5
        Location :  HI Segment, Element 1
         Sub Element 5



DX1
     Diagnosis Code 1
        Location :  HI Segment, Element 1
         Sub Element 1

DX2
     Diagnosis Code 2
        Location :  HI Segment, Element 1
         Sub Element 2

DX3
     Diagnosis Code 3
        Location :  HI Segment, Element 1
         Sub Element 3

DX4
     Diagnosis Code 4
        Location :  HI Segment, Element 1
         Sub Element 4

DX5
     Diagnosis Code 5
        Location :  HI Segment, Element 1
         Sub Element 5




MEDICALRECORDNUMBER
      Medical Record Number
        Location :  REF Segment, Element 2
                    Qualifier EA

CLAIMBILLINGPROVIDERNAME
     Claim Billing Provider Name
        Location :  NM1 Segment, Element 3
                    Qualifier 85


CLAIMBILLINGPROVIDERADDR1
     Claim Billing Provider Address 1
        Location :  N3 Segment, Element 1



CLAIMBILLINGPROVIDERADDR2
     Claim Billing Provider Address 2
        Location :  N3 Segment, Element 2


CLAIMBILLINGPROVIDERCITY
     Claim Billing Provider City
        Location :  N4 Segment, Element 1



CLAIMBILLINGPROVIDERST
     Claim Billing Provider State
        Location :  N4 Segment, Element 2


CLAIMBILLINGPROVIDERZIP
     Claim Billing Provider Zip Code
        Location :  N4 Segment, Element 3



CLAIMBILLINGPROVIDERIDTYPE
     Claim Billing Provider ID Type
        Location :  NM1 Segment, Element 8
                    Qualifier 85


CLAIMBILLINGPROVIDERIDCODE
     Claim Billing Provider ID Code
        Location :  NM1 Segment, Element 8
                    Qualifier 85


CLAIMBILLINGPROVIDERID
     Claim Billing Provider ID 
        Location :  NM1 Segment, Element 9
                    Qualifier 85


CLAIMBILLINGPROVIDERSECONDARYIDTYPE
     Claim Billing Provider Secondary ID Type
        Location :  REF Segment, Element 1



CLAIMBILLINGPROVIDERSECONDARYIDCODE
     Claim Billing Provider Secondary ID Code
        Location :  REF Segment, Element 1


CLAIMBILLINGPROVIDERSECONDARYID
     Claim Billing Provider Secondary ID 
        Location :  REF Segment, Element 2




CLAIMPAYTOPROVIDERNAME
     Claim Pay to  Provider Name
        Location :  NM1 Segment, Element 3
                    Qualifier 87


CLAIMPAYTOPROVIDERADDR1
     Claim Pay to  Provider Address 1
        Location :  N3 Segment, Element 1


CLAIMPAYTOPROVIDERADDR2
     Claim Pay to  Provider Address 2
        Location :  N3 Segment, Element 2


CLAIMPAYTOPROVIDERCITY
     Claim Pay to  Provider City
        Location :  N4 Segment, Element 1


CLAIMPAYTOPROVIDERST
     Claim Pay to  Provider State
        Location :  N4 Segment, Element 2



CLAIMPAYTOPROVIDERZIP
     Claim Pay to  Provider Zip Code
        Location :  N4 Segment, Element 3



CLAIMPAYTOPROVIDERIDTYPE
     Claim Pay to  Provider ID Type
        Location :  NM1 Segment, Element 8
                    Qualifier 87


CLAIMPAYTOPROVIDERIDCODE
     Claim Pay to  Provider ID Code
        Location :  NM1 Segment, Element 8
                    Qualifier 87


CLAIMPAYTOPROVIDERID
     Claim Pay to  Provider ID 
        Location :  NM1 Segment, Element 9
                    Qualifier 87





ADJUDDATE
    Claim Ajudication Date
        Location :  DTP Segment, Element 3
                    Qualifier 573




IADJUDIDn
    Line Claim Ajudication ID
        Location :  SVD Segment, Element 1
                    Qualifier 573
                    n=1 to 999


IADJUDAMTn
    Line Claim Ajudication Amount
        Location :  SVD Segment, Element 2
                    n=1 to 999




IADJUDDATEn
    Line Claim Ajudication Date
        Location :  DTP Segment, Element 3
                    Qualifier 573
                    n=1 to 999





PRIMARYGROUPID
      Primary Subscriber Group ID
        Location :  SBR Segment, Element 2
                    Qualifier P


PRIMARYGROUPNAME
      Primary Subscriber Group Name
        Location :  SBR Segment, Element 3
                    Qualifier P



PRIMARYSUBID
      Primary Subscriber ID
        Location :  NM1 Segment, Element 9
                    Qualifier IL



PRIMARYSUBLNAME
      Primary Subscriber Last Name
        Location :  NM1 Segment, Element 3
                    Qualifier IL


PRIMARYSUBFNAME
      Primary Subscriber First Name
        Location :  NM1 Segment, Element 4
                    Qualifier IL




PRIMARYSUBMI
      Primary Subscriber Middle Initial
        Location :  NM1 Segment, Element 5
                    Qualifier IL



PRIMARYSUBADDR1
      Primary Subscriber Address Line 1
        Location :  N3 Segment, Element 1



PRIMARYSUBADDR2
      Primary Subscriber Address Line 2
        Location :  N3 Segment, Element 2


PRIMARYSUBCITY
      Primary Subscriber City
        Location :  N4 Segment, Element 1


PRIMARYSUBSTATE
      Primary Subscriber State
        Location :  N4 Segment, Element 2


PRIMARYSUBZIP
      Primary Subscriber Zip Code
        Location :  N4 Segment, Element 3


PRIMARYSUBDOB
      Primary Subscriber Date of Birth
        Location :  DMG Segment, Element 2



PRIMARYSUBSEX
      Primary Subscriber Gender
        Location :  DMG Segment, Element 3


PRIMARYPAYERNAME
      Primary Payer Name
        Location :  NM1 Segment, Element 3
                    Qualifier PR



PRIMARYPAYERADDR1
      Primary Payer Address Line 1
        Location :  N3 Segment, Element 1


PRIMARYPAYERADDR2
      Primary Payer Address Line 2
        Location :  N3 Segment, Element 2



PRIMARYPAYERCITY
      Primary Payer City
        Location :  N4 Segment, Element 1



PRIMARYPAYERSTATE
      Primary Payer State
        Location :  N4 Segment, Element 2



PRIMARYPAYERZIP
      Primary Payer Zip Code
        Location :  N4 Segment, Element 3



PRIMARYPAYERID
      Primary Payer ID
        Location :  NM1 Segment, Element 9
                    Qualifier PR







SECONDARYGROUPID
      Secondary Subscriber Group ID
        Location :  SBR Segment, Element 2
                    Qualifier S


SECONDARYGROUPNAME
      Secondary Subscriber Group Name
        Location :  SBR Segment, Element 3
                    Qualifier S



SECONDARYSUBID
      Secondary Subscriber ID
        Location :  NM1 Segment, Element 9
                    Qualifier IL



SECONDARYSUBLNAME
      Secondary Subscriber Last Name
        Location :  NM1 Segment, Element 3
                    Qualifier IL


SECONDARYSUBFNAME
      Secondary Subscriber First Name
        Location :  NM1 Segment, Element 4
                    Qualifier IL




SECONDARYSUBMI
      Secondary Subscriber Middle Initial
        Location :  NM1 Segment, Element 5
                    Qualifier IL



SECONDARYSUBADDR1
      Secondary Subscriber Address Line 1
        Location :  N3 Segment, Element 1



SECONDARYSUBADDR2
      Secondary Subscriber Address Line 2
        Location :  N3 Segment, Element 2


SECONDARYSUBCITY
      Secondary Subscriber City
        Location :  N4 Segment, Element 1


SECONDARYSUBSTATE
      Secondary Subscriber State
        Location :  N4 Segment, Element 2


SECONDARYSUBZIP
      Secondary Subscriber Zip Code
        Location :  N4 Segment, Element 3


SECONDARYSUBDOB
      Secondary Subscriber Date of Birth
        Location :  DMG Segment, Element 2



SECONDARYSUBSEX
      Secondary Subscriber Gender
        Location :  DMG Segment, Element 3


SECONDARYPAYERNAME
      Secondary Payer Name
        Location :  NM1 Segment, Element 3
                    Qualifier PR



SECONDARYPAYERADDR1
      Secondary Payer Address Line 1
        Location :  N3 Segment, Element 1


SECONDARYPAYERADDR2
      Secondary Payer Address Line 2
        Location :  N3 Segment, Element 2



SECONDARYPAYERCITY
      Secondary Payer City
        Location :  N4 Segment, Element 1



SECONDARYPAYERSTATE
      Secondary Payer State
        Location :  N4 Segment, Element 2



SECONDARYPAYERZIP
      Secondary Payer Zip Code
        Location :  N4 Segment, Element 3



SECONDARYPAYERID
      Secondary Payer ID
        Location :  NM1 Segment, Element 9
                    Qualifier PR







TERTIARYGROUPID
      Tertiary Subscriber Group ID
        Location :  SBR Segment, Element 2
                    Qualifier T


TERTIARYGROUPNAME
      Tertiary Subscriber Group Name
        Location :  SBR Segment, Element 3
                    Qualifier T



TERTIARYSUBID
      Tertiary Subscriber ID
        Location :  NM1 Segment, Element 9
                    Qualifier IL



TERTIARYSUBLNAME
      Tertiary Subscriber Last Name
        Location :  NM1 Segment, Element 3
                    Qualifier IL


TERTIARYSUBFNAME
      Tertiary Subscriber First Name
        Location :  NM1 Segment, Element 4
                    Qualifier IL




TERTIARYSUBMI
      Tertiary Subscriber Middle Initial
        Location :  NM1 Segment, Element 5
                    Qualifier IL



TERTIARYSUBADDR1
      Tertiary Subscriber Address Line 1
        Location :  N3 Segment, Element 1



TERTIARYSUBADDR2
      Tertiary Subscriber Address Line 2
        Location :  N3 Segment, Element 2


TERTIARYSUBCITY
      Tertiary Subscriber City
        Location :  N4 Segment, Element 1


TERTIARYSUBSTATE
      Tertiary Subscriber State
        Location :  N4 Segment, Element 2


TERTIARYSUBZIP
      Tertiary Subscriber Zip Code
        Location :  N4 Segment, Element 3


TERTIARYSUBDOB
      Tertiary Subscriber Date of Birth
        Location :  DMG Segment, Element 2



TERTIARYSUBSEX
      Tertiary Subscriber Gender
        Location :  DMG Segment, Element 3


TERTIARYPAYERNAME
      Tertiary Payer Name
        Location :  NM1 Segment, Element 3
                    Qualifier PR



TERTIARYPAYERADDR1
      Tertiary Payer Address Line 1
        Location :  N3 Segment, Element 1


TERTIARYPAYERADDR2
      Tertiary Payer Address Line 2
        Location :  N3 Segment, Element 2



TERTIARYPAYERCITY
      Tertiary Payer City
        Location :  N4 Segment, Element 1



TERTIARYPAYERSTATE
      Tertiary Payer State
        Location :  N4 Segment, Element 2



TERTIARYPAYERZIP
      Tertiary Payer Zip Code
        Location :  N4 Segment, Element 3



TERTIARYPAYERID
      Tertiary Payer ID
        Location :  NM1 Segment, Element 9
                    Qualifier PR















HIERARCHIALCLAIMBILLINGPROVIDERNAME
    Hierarchial Claim Billing Provider Name
        Location :  NM1 Segment, Element 3
                    Qualifier 85

HIERARCHIALCLAIMBILLINGPROVIDERADDR1
    Hierarchial Claim Billing Provider Address Line 1
        Location :  N3 Segment, Element 1


HIERARCHIALCLAIMBILLINGPROVIDERADDR2
    Hierarchial Claim Billing Provider Address Line 2
        Location :  N3 Segment, Element 2

HIERARCHIALCLAIMBILLINGPROVIDERCITY
    Hierarchial Claim Billing Provider City
        Location :  N4 Segment, Element 1


HIERARCHIALCLAIMBILLINGPROVIDERST
    Hierarchial Claim Billing Provider State
        Location :  N4 Segment, Element 2



HIERARCHIALCLAIMBILLINGPROVIDERZIP
    Hierarchial Claim Billing Provider Zip Code
        Location :  N4 Segment, Element 3



HIERARCHIALCLAIMBILLINGPROVIDERIDTYPE
    Hierarchial Claim Billing Provider ID Type
        Location :  NM1 Segment, Element 8
                    Qualifier 85


HIERARCHIALCLAIMBILLINGPROVIDERIDCODE
    Hierarchial Claim Billing Provider ID Code
        Location :  NM1 Segment, Element 8


HIERARCHIALCLAIMBILLINGPROVIDERID
    Hierarchial Claim Billing Provider ID 
        Location :  NM1 Segment, Element 9


HIERARCHIALCLAIMPAYTOPROVIDERNAME
    Hierarchial Claim Pay to Provider Provider Name
        Location :  NM1 Segment, Element 3
                    Qualifier 87



HIERARCHIALCLAIMPAYTOPROVIDERADDR1
    Hierarchial Claim Pay to Provider Provider Address Line 1
        Location :  N3 Segment, Element 1


HIERARCHIALCLAIMPAYTOPROVIDERADDR2
    Hierarchial Claim Pay to Provider Provider Address Line 2
        Location :  N3 Segment, Element 2



HIERARCHIALCLAIMPAYTOPROVIDERCITY
    Hierarchial Claim Pay to Provider Provider City
        Location :  N4 Segment, Element 1



HIERARCHIALCLAIMPAYTOPROVIDERST
    Hierarchial Claim Pay to Provider Provider State
        Location :  N4 Segment, Element 2



HIERARCHIALCLAIMPAYTOPROVIDERZIP
    Hierarchial Claim Pay to Provider Provider Zip Code
        Location :  N4 Segment, Element 3



HIERARCHIALCLAIMPAYTOPROVIDERIDTYPE
    Hierarchial Claim Pay to Provider Provider ID Type
        Location :  NM1 Segment, Element 8
                    Qualifier 87



HIERARCHIALCLAIMPAYTOPROVIDERIDCODE
    Hierarchial Claim Pay to Provider Provider ID Code
        Location :  NM1 Segment, Element 8
                    Qualifier 87


HIERARCHIALCLAIMPAYTOPROVIDERID
    Hierarchial Claim Pay to Provider Provider ID 
        Location :  NM1 Segment, Element 9
                    Qualifier 87



TSCONTROLNUMBER
   Batch Conrol Number 
        Location :  ST Segment, Element 2


BHTREFID
   BHT Segment Reference Identification
        Location :  BHT Segment, Element 4


SUBMITTERNAME
   Submitter Name
        Location :  NM1 Segment, Element 3
                    Qualifier 41



SUBMITTERADDR1
    Submitter Address Line 1
        Location :  N3 Segment, Element 1


SUBMITTERADDR2
    Submitter Address Line 2
        Location :  N3 Segment, Element 2



SUBMITTERCITY
    Submitter City
        Location :  N4 Segment, Element 1


SUBMITTERST
    Submitter State
        Location :  N4 Segment, Element 2



SUBMITTERZIP
    Submitter Zip Code
        Location :  N4 Segment, Element 3



SUBMITTERCONTACT
    Submitter Contact
        Location :  PER Segment, Element 2


SUBMITTERID
   Submitter ID
        Location :  NM1 Segment, Element 9
                    Qualifier 41



SUBMITTERCONTACT
   Submitter ID
        Location :  PER Segment, Element 3


SUBMITTERCOMMQUALA
   Submitter ID
        Location :  PER Segment, Element 4


SUBMITTERCOMMNUMBERA
   Submitter ID
        Location :  PER Segment, Element 5


SUBMITTERCOMMQUALB
   Submitter ID
        Location :  PER Segment, Element 6


SUBMITTERCOMMNUMBERB
   Submitter ID
        Location :  PER Segment, Element 7

SUBMITTERCOMMQUALC
   Submitter ID
        Location :  PER Segment, Element 8


SUBMITTERCOMMNUMBERC
   Submitter ID
        Location :  PER Segment, Element 9


         


RECEIVERID
   Receiver
        Location :  NM1 Segment, Element 9
                    Qualifier 41


RECEIVERNAME
   Receiver Name
        Location :  NM1 Segment, Element 3
                    Qualifier 40


RECEIVERADDITIONALNAME
   Receiver Additional Name
        Location :  N2 Segment, Element 1


RECEIVERADDR1
   Receiver Address Line 1
        Location :  N3 Segment, Element 1



RECEIVERADDR2
   Receiver Address Line 2
        Location :  N3 Segment, Element 2


RECEIVERCITY
   Receiver Address City
        Location :  N4 Segment, Element 1

RECEIVERST
   Receiver Address State
        Location :  N4 Segment, Element 2


RECEIVERZIP
   Receiver Address Zip Code
        Location :  N4 Segment, Element 3



BILLINGPROVIDERNAME
     Billing Provider Name
        Location :  NM1 Segment, Element 3
                    Qualifier 85


BILLINGPROVIDERADDR1
    Billing Provider Address Line 1
        Location :  N3 Segment, Element 1


BILLINGPROVIDERADDR2
    Billing Provider Address Line 2
        Location :  N3 Segment, Element 2


BILLINGPROVIDERCITY
    Billing Provider City
        Location :  N4 Segment, Element 1


BILLINGPROVIDERST
    Billing Provider State
        Location :  N4 Segment, Element 2



BILLINGPROVIDERZIP
    Billing Provider Zip Code
        Location :  N4 Segment, Element 3


BILLINGPROVIDERIDTYPE
     Billing Provider ID Type
        Location :  NM1 Segment, Element 8
                    Qualifier 85


BILLINGPROVIDERIDCODE
     Billing Provider ID Code
        Location :  NM1 Segment, Element 8
                    Qualifier 85


BILLINGPROVIDERID
     Billing Provider ID 
        Location :  NM1 Segment, Element 9
                    Qualifier 85



BILLINGPROVIDERCONTACT
   BILLINGPROVIDER ID
        Location :  PER Segment, Element 3


BILLINGPROVIDERCOMMQUALA
   BILLINGPROVIDER ID
        Location :  PER Segment, Element 4


BILLINGPROVIDERCOMMNUMBERA
   BILLINGPROVIDER ID
        Location :  PER Segment, Element 5


BILLINGPROVIDERCOMMQUALB
   BILLINGPROVIDER ID
        Location :  PER Segment, Element 6


BILLINGPROVIDERCOMMNUMBERB
   BILLINGPROVIDER ID
        Location :  PER Segment, Element 7

BILLINGPROVIDERCOMMQUALC
   BILLINGPROVIDER ID
        Location :  PER Segment, Element 8


BILLINGPROVIDERCOMMNUMBERC
   BILLINGPROVIDER ID
        Location :  PER Segment, Element 9


         





PAYTOPROVIDERNAME
     Pay to Provider Name
        Location :  NM1 Segment, Element 3
                    Qualifier 87



PAYTOPROVIDERADDR1
    Pay to Provider Address Line 1
        Location :  N3 Segment, Element 1



PAYTOPROVIDERADDR2
    Pay to Provider Address Line 2
        Location :  N3 Segment, Element 2


PAYTOPROVIDERCITY
    Pay to Provider City
        Location :  N4 Segment, Element 1


PAYTOPROVIDERST
    Pay to Provider State
        Location :  N4 Segment, Element 2



PAYTOPROVIDERZIP
    Pay to Provider Zip Code
        Location :  N4 Segment, Element 3



PAYTOPROVIDERIDTYPE
     Pay to Provider ID Type
        Location :  NM1 Segment, Element 8
                    Qualifier 87




PAYTOPROVIDERIDCODE
     Pay to Provider ID Code
        Location :  NM1 Segment, Element 8
                    Qualifier 87



PAYTOPROVIDERID
     Pay to Provider ID 
        Location :  NM1 Segment, Element 9
                    Qualifier 87




PRIMARYINSURANCETYPECODE
Primary Insurance Type Code
Location : SBR Segment, Element 5
Qualifier P

SECONDARYINSURANCETYPECODE
Secondary Insurance Type Code
Location : SBR Segment, Element 5
Qualifier S

TERTIARYINSURANCETYPECODE
Tertiary Insurance Type Code
Location : SBR Segment, Element 5
Qualifier T



COBPAYERPAIDAMT
Coordination of Benefits Payer Paid Amount
Location : AMT Segment, Element 2
Qualifier D

COBAPPROVEDAMT
Coordination of Benefits Payer Approved Amount
Location : AMT Segment, Element 2
Qualifier AAE


COBPAYERALLOWEDAMT
Coordination of Benefits Payer Allowed  Amount
Location : AMT Segment, Element 2
Qualifier B6


COBPATRESPONSE
Coordination of Benefits Patient Responsibility
Location : AMT Segment, Element 2
Qualifier F2


COBCOVEREDAMT
Coordination of Benefits Covered Amount
Location : AMT Segment, Element 2
Qualifier AU

COBDISCOUNTAMT
Coordination of Benefits Discount Amount
Location : AMT Segment, Element 2
Qualifier D8

COBPERDAYLIMIT
Coordination of Benefits Per Day Limit
Location : AMT Segment, Element 2
Qualifier DY

COBPATPAIDAMT
Coordination of Benefits Patient Amount Paid
Location : AMT Segment, Element 2
Qualifier F5

COBTAX
Coordination of Benefits Tax
Location : AMT Segment, Element 2
Qualifier T

COBCLMTOTTAX
Coordination of Benefits Claim Total Tax
Location : AMT Segment, Element 2
Qualifier T2


OIPAYERMEMNUM
Other Insurance Payer Member Number
Location : REF Segment, Element 2
Qualifier 1W

OIPAYERCLINUM
Other Insurance Payer Client Number
Location : REF Segment, Element 2
Qualifier 23


OIPAYERPOLNUM
Other Insurance Payer Policy Number
Location : REF Segment, Element 2
Qualifier IG


OIPAYERSSN
Other Insurance Payer Social Security Number
Location : REF Segment, Element 2
Qualifier SY


- - - - - - - - - - - - - -

Institutional Service Line Level Fields
01 to 999
- - - - - - - - - - - - - -


ILINE01

IPROCTYPE01

IPROC01

IMODA01

IMODB01

IMODC01

IMODD01

IAMT01

IUNITSTYPE01

IUNITSQTY01

IUNITSRATE01

IUNITS01

IDOS01

NDCCODE01

NDCUNITPRICE01

NDCUNITS01

IADJUDDATE01

IADJUDID01

IADJUDAMT01



- - - - - - - - - - - - - -

Professional Service Line Level Fields
01 to 99
- - - - - - - - - - - - - -


PPROC01

MODA01

MODB01

MODC01

MODD01

DOS01

MM_DD_YY_DOSF01

MM_DD_YY_DOST01

AMT01

DDDDDD_CC01

POSLINECODE01

UNITS01

DXLINK01

SUPDXLINKA01

SUPDXLINKB01

SUPDXLINKC01

SUPDXLINKD01


- - - - - - - - - - - - - -

Dental Service Line Level Fields
01 to 99
- - - - - - - - - - - - - -

DPROC01

DMODA01

DMODB01

DMODC01

DMODD01

DAMT01

TOOTHSURFACE

TOOTH01

- - - - - - - - - - - - - -

General Service Line Level Fields

- - - - - - - - - - - - - -

LINEITEMCONTROLNUMBER01



Section 8

837 Field Descriptions

[Table of Contents]

This is a list of the fields supported for mapping and are
stored in an XML file called:

C1837I.XML for Institutional

C1837P.XML for Professional 

C1837D.XML for Dental

Field names are placed inside the field tags of the xml.

Example :

CLAIMID
CLAIMAMTDDDDDD_CC
CLAIMAMT


- - - - - - - - - - - - - - - - - -





CLAIMID
      Claim ID
        Location :  CLM Segment, Element 1


CLAIMAMTDDDDDD_CC
      Claim Amount
        Location :  CLM Segment, Element 2


CLAIMAMT
      Claim Amount
        Location :  CLM Segment, Element 2


CLEARINGIDNUMBER
      Clearing Service ID
        Location :  REF Segment, Element 2
                    Qualifier D9


MULTICLAIMTOTAL
      Multi Claim Total Amount
        Location :  CLM Segment, Element 2



ICNDCN
      Internal Document Number Document Control Number
        Location :  REF Segment, Element 3
                    Qualifier F8


TAXONOMYCODE
      Taxonomy Code 
        Location :  PRV Segment, Element 4
                    Qualifier PE


EMPLOYERIDNUM
      Employer Identification Number      
        Location :  REF Segment, Element 3
                    Qualifier EI



PRIORAUTHORIZATIONNUMBER
      Prior Authorization Number
        Location :  REF Segment, Element 3
                    Qualifier G1


ORDERDATE
      Order Date
        Location :  DTP Segment, Element 3
                    Qualifier 938


INITIALTREATMENTDATE
      Initial Treatment Date
        Location :  DTP Segment, Element 3
                    Qualifier 454

REFERRALDATE
      Referral Date
        Location :  DTP Segment, Element 3
                    Qualifier 330

DATELASTSEEN
      Date last Seen
        Location :  DTP Segment, Element 3
                    Qualifier 304

ONSETOFILLNESDATE
      Onset of Current Symptoms or Illness Date
        Location :  DTP Segment, Element 3
                    Qualifier 431

ACUTEMANIFESTATIONDATE
      Acute Manifestation of a Chronic Condition Date
        Location :  DTP Segment, Element 3
                    Qualifier 453

SIMILARILLNESSONSETDATE
      Onset of Similar Symptoms or Illness Date
        Location :  DTP Segment, Element 3
                    Qualifier 438

ACCIDENTDATE
      Accident Date
        Location :  DTP Segment, Element 3
                    Qualifier 439

LMPDATE
      Last Menstrual Period Date
        Location :  DTP Segment, Element 3
                    Qualifier 484

LASTXRAYDATE
      Last X-Ray Date
        Location :  DTP Segment, Element 3
                    Qualifier 455

ESTIMATEDDATEOFBIRTH
      Estimated Date of Birth
        Location :  DTP Segment, Element 3
                    Qualifier ABC

HEARINGVISIONPRESCRIPTIONDATE
      Hearing and Vision Prescription Date
        Location :  DTP Segment, Element 3
                    Qualifier 471

DISABILITYBEGINDATE
      Disability Begin Date
        Location :  DTP Segment, Element 3
                    Qualifier 360

DISABILITYENDDATE
      Disability End Date
        Location :  DTP Segment, Element 3
                    Qualifier 361

DATELASTWORKED
       Date Last Worked
        Location :  DTP Segment, Element 3
                    Qualifier 297

RETURNTOWORKDATE
      Return to Work Date
        Location :  DTP Segment, Element 3
                    Qualifier 296

ASSUMEDCAREDATE
      Assumed Care Start Date
        Location :  DTP Segment, Element 3
                    Qualifier 090



RELINQUISHEDCAREDATE
      Relinquished Care End Date
        Location :  DTP Segment, Element 3
                    Qualifier 091







PROVSIGNATUREONFILE
      Provider Signature
        Location :  CLM Segment, Element 6


PROVACCEPTASSIGNMENTCODE
      Provider Assignment 
        Location :  CLM Segment, Element 7



BENEFITINDICATOR
      Benefit Indicator
        Location :  CLM Segment, Element 8



RELEASEOFINFORMATION
      Release of Information
        Location :  CLM Segment, Element 9



RELATEDCAUSECODE
      Related Cause
        Location :  CLM Segment, Element 11



RELATEDCAUSE
      Related Cause
        Location :  CLM Segment, Element 11


DISCHARGEHOUR
      Discharge Hour
        Location :  DTP Segment, Element 3
                    Qualifier 069


DISCHARGEDATE
      Discharge Date
        Location :  CR6 Segment, Element 5



STATEMENTDATE
      Statement Date
        Location :  DTP Segment, Element 3
                    Qualifier 434

ADMISSIONDATETIME
      Addmission Date Time
        Location :  DTP Segment, Element 3
                    Qualifier 435



ADMISSIONTYPECODE
      Addmission Type Code
        Location :  CL1 Segment, Element 1
                    Qualifier 435



ADMISSIONTYPE
      Addmission Type
        Location :  CL1 Segment, Element 1
                    Qualifier 435



ADMISSIONSOURCECODE
      Addmission Source Code
        Location :  CL1 Segment, Element 2



ADMISSIONSOURCE
      Addmission Source
        Location :  CL1 Segment, Element 2



PATIENTSTATUSCODE
      Patient Status Code
        Location :  CL1 Segment, Element 3



PATIENTSTATUS
      Patient Status
        Location :  CL1 Segment, Element 3


MEDICALRECORDNUMBER
      Medical Record Number
        Location :  REF Segment, Element 2
                    Qualifier EA


PATIENTAMOUNTPAID
      Patient Amount Paid
        Location :  AMT Segment, Element 2
                    Qualifier F5

TOTALPURCHASEDSERVICEAMOUNT
      Total Purchased Service Amount
        Location :  AMT Segment, Element 2
                    Qualifier NE



PAYERPRIORPAY
      Payer Prior Pay
        Location :  AMT Segment, Element 2
                    Qualifier C4


CLAIMNOTEADD
      Claim Note Additional Information
        Location :  NTE Segment, Element 2
                    Qualifier ADD


CLAIMNOTECER
      Claim Note Certification Narrative
        Location :  NTE Segment, Element 2
                    Qualifier CER


CLAIMNOTEDCP
      Claim Note Goals /Discharge Plan 
        Location :  NTE Segment, Element 2
                    Qualifier DCP


CLAIMNOTEDGN
      Claim Note Diagnosis Description
        Location :  NTE Segment, Element 2
                    Qualifier DGN


CLAIMNOTEPMT
      Claim Note Payment 
        Location :  NTE Segment, Element 2
                    Qualifier PMT


CLAIMNOTETPO
      Claim Note Third party Org 
        Location :  NTE Segment, Element 2
                    Qualifier TPO


OISUBORDER
      Other Insurance Subscriber Order
        Location :  NM1 Segment, Element 1
                  


OISUBID
      Other Insurance Subscriber ID
        Location :  NM1 Segment, Element 9
                    Qualifier IL



OISUBLNAME
      Other Insurance Subscriber Last Name
        Location :  NM1 Segment, Element 3
                    Qualifier IL



OISUBFNAME
      Other Insurance Subscriber First Name
        Location :  NM1 Segment, Element 4
                    Qualifier IL



OISUBMI
      Other Insurance Subscriber Middle Initial
        Location :  NM1 Segment, Element 5
                    Qualifier IL

OIPAYERADDR1
      Other Insurance Subscriber Address 1
        Location :  N3 Segment, Element 1

OIPAYERADDR2
      Other Insurance Subscriber Address 2
        Location :  N3 Segment, Element 2

OIPAYERCITY
      Other Insurance Subscriber City
        Location :  N4 Segment, Element 1

OIPAYERSTATE
      Other Insurance Subscriber State
        Location :  N4 Segment, Element 2

OIPAYERZIP
      Other Insurance Subscriber Zip Code
        Location :  N4 Segment, Element 3

OIPAYERID
      Other Insurance Payer ID
        Location :  NM1 Segment, Element 9
                    Qualifier PR

OIPAYERNAME
      Other Insurance Payer Name
        Location :  NM1 Segment, Element 3
                    Qualifier PR

SEGMENTNOTE
      Segment Note
        Location :  DMG Segment, Element 3


POSDESC
      Place of Service Description
        Location :  CLM Segment, Element 6


FACILITYCODEVALUE
      Facility Code Value
        Location :  CLM Segment, Element 6


FREQUENCYTYPECODE
      Frequency Type Code 
        Location :  CLM Segment, Element 6

POSCODE
      Place of Service Description
        Location :  CLM Segment, Element 6

K3DATA
      K3 Data
        Location :  K3 Segment, Element 1

NDCCODE
      National Drug Code
        Location :  LIN Segment, Element 3
                    Qualifier N4

NDCUNITPRICE
      NDC Drug Unit Price
        Location :  CTP Segment, Element 3

NDCUNITS
      NDC Units
        Location :  CTP Segment, Element 4

TYPEOFBILL
      Type of Bill
        Location :  CLM Segment, Element 6


FREQUENCYCODE
      Frequency Type Code 
        Location :  CLM Segment, Element 6

PRINCIPALDX
      Principle Diagnosis
        Location :  HI Segment, Element 1
                    Qualifier BK

ADMITDX
      Admitting Diagnosis
        Location :  HI Segment, Element 2
                    Qualifier BJ

ECODE
      Vital Statistics E-Code
        Location :  HI Segment, Element 3
                    Qualifier BN


DRG
      DRG
        Location :  HI Segment, Element 1
                    Qualifier DR

OTHERDX01 thru OTHERDX12
      Other Diagnosis 1 thru 12
        Location :  HI Segment, Element 1
                    Qualifier BF


OTHERDXA01 thru OTHERDXY12
      Other Diagnosis 1 thru 12
        Multi Segment
        Location :  HI Segment, Element 1
                    Qualifier BF



PRINCIPLEPROCDATE
      Principle Procedure Date
        Location :  HI Segment, Element 1
                    Qualifier BP,BR


PRINCIPLEPROC
      Principle Procedure Date
        Location :  HI Segment, Element 1
                    Qualifier BP,BR


OTHERPROC01 thru OTHERPROC12
      Other Procedures 1 thru 12
        Location :  HI Segment, Element 1
                    Qualifier BO,BQ

OTHERPROCA01 thru OTHERPROCY12
      Other Procedures 1 thru 12
      Multi Segment
        Location :  HI Segment, Element 1
                    Qualifier BO,BQ



OCCURRENCESPAN01 thru OCCURRENCESPAN12
      Occurance Span 1 thru 12
        Location :  HI Segment, Element 1
                    Qualifier BI

OCCURRENCESPANA01 thru OCCURRENCESPANY12
      Occurance Span 1 thru 12
      Multi Segment
        Location :  HI Segment, Element 1
                    Qualifier BI



OCCURRENCECODE01 thru OCCURRENCECODE12
      Occurance Code 1 thru 12
        Location :  HI Segment, Element 1
                    Qualifier BH

OCCURRENCECODEA01 thru OCCURRENCECODEY12
      Occurance Code 1 thru 12
      Multi Segment
        Location :  HI Segment, Element 1
                    Qualifier BH


OCCURRENCEDATE01 thru OCCURRENCEDATE12
      Occurance Date 1 thru 12
        Location :  HI Segment, Element 1
                    Qualifier BH

OCCURRENCEDATEA01 thru OCCURRENCEDATEY12
      Occurance Date 1 thru 12
      Multi Segment
        Location :  HI Segment, Element 1
                    Qualifier BH



VALUECODE01 thru VALUECODE12
      Value Codes 1 thru 12
        Location :  HI Segment, Element 1
                    Qualifier BE


VALUECODEA01 thru VALUECODEY12
      Value Codes 1 thru 12
      Multi Segment
        Location :  HI Segment, Element 1
                    Qualifier BE


VALUEAMOUNT01 thru VALUEAMOUNT12
      Value Amounts 1 thru 12
        Location :  HI Segment, Element 1
                    Qualifier BE

VALUEAMOUNTA01 thru VALUEAMOUNTY12
      Value Amounts 1 thru 12
       Multi Segment
        Location :  HI Segment, Element 1
                    Qualifier BE


VALUEQTY01 thru VALUEQTY12
      Value Quantity 1 thru 12
        Location :  HI Segment, Element 1
                    Qualifier BE


VALUEQTYA01 thru VALUEQTYY12
      Value Quantity 1 thru 12
      Multi segment
        Location :  HI Segment, Element 1
                    Qualifier BE


CONDITIONCODE01 thru CONDITIONCODE12
      Condition Codes 1 thru 12
        Location :  HI Segment, Element 1
                    Qualifier BG


CONDITIONCODEA01 thru CONDITIONCODEY12
      Condition Codes 1 thru 12
      Multi Segment
        Location :  HI Segment, Element 1
                    Qualifier BG


CONDITIONDATE01 thru CONDITIONDATE12
      Condition Dates 1 thru 12
        Location :  HI Segment, Element 1
                    Qualifier BG

CONDITIONDATEA01 thru CONDITIONDATEY12
      Condition Dates 1 thru 12
      Multi Segment
        Location :  HI Segment, Element 1
                    Qualifier BG


TREATMENTCODE01 thru TREATMENTCODE12
      Treatment  Codes 1 thru 12
        Location :  HI Segment, Element 1
                    Qualifier TC

TREATMENTCODEA01 thru TREATMENTCODEY12
      Treatment  Codes 1 thru 12
      Multi Segment
        Location :  HI Segment, Element 1
                    Qualifier TC



SUBCLMTYPECODE
      Subscriber Claim Type
        Location :  SBR Segment, Element 9


SUBCLMTYPE
      Subscriber Claim Type
        Location :  SBR Segment, Element 9


SUBID
      Subscriber ID
        Location :  NM1 Segment, Element 9
                    Qualifier IL


SUBLNAME
      Subscriber Last Name
        Location :  NM1 Segment, Element 3
                    Qualifier IL


SUBFNAME
      Subscriber First Name
        Location :  NM1 Segment, Element 4
                    Qualifier IL


SUBMI
      Subscriber Middle Initial
        Location :  NM1 Segment, Element 5
                    Qualifier IL



SUBADDR1
      Subscriber Address 1
        Location :  N3 Segment, Element 1



SUBADDR2
      Subscriber Address 2
        Location :  N3 Segment, Element 2


SUBCITY
      Subscriber City
        Location :  N4 Segment, Element 1


SUBST
      Subscriber State
        Location :  N4 Segment, Element 2


SUBZIP
      Subscriber Zip 
        Location :  N4 Segment, Element 3


SUBDOB
      Subscriber Date of Birth
        Location :  DMG Segment, Element 2



SUBNAMEPREFIX
      Subscriber Prefix
        Location :  NM1 Segment, Element 6
                    Qualifier IL


SUBNAMESUFIX
      Subscriber Suffix
        Location :  NM1 Segment, Element 6
                    Qualifier IL


SUBMSTATUS
      Subscriber Prefix
        Location :  DMG Segment, Element 4



SUBORDER
      Subscriber Coverage Order
        Location :  SBR Segment, Element 1


SUBREL
      Subscriber Relationship to Patient
        Location :  SBR Segment, Element 2



SUBGROUPNAME
      Subscriber Group Name
        Location :  SBR Segment, Element 3



SUBSEX
      Subscriber Gender
        Location :  DMG Segment, Element 3





PROPERYCASUALTYCLAIMNUMBER
 Added Property Casuality Claim Number 
        Location :  REF Segment, Element 2
                    Qualifier Y4





PAYERID
      Payer ID
        Location :  NM1 Segment, Element 9
                    Qualifier PR

PAYERNAME
      Payer Name
        Location :  NM1 Segment, Element 3
                    Qualifier PR

PAYERADDR1
      Payer Address Line 1
        Location :  N3 Segment, Element 1


PAYERADDR2
      Payer Address Line 2
        Location :  N3 Segment, Element 2


PAYERCITY
      Payer City
        Location :  N4 Segment, Element 1

PAYERSTATE
      Payer State
        Location :  N4 Segment, Element 2

PAYERZIP
      Payer Zip Code
        Location :  N4 Segment, Element 3





PATLNAME
      Patient Last Name
        Location :  NM1 Segment, Element 3
                    Qualifier QC


PATFNAME
      Patient First Name
        Location :  NM1 Segment, Element 4
                    Qualifier QC


PATMI
      Patient Middle Initial
        Location :  NM1 Segment, Element 5
                    Qualifier QC


PATADDR1
      Patient Address 1
        Location :  N3 Segment, Element 1
          



PATADDR2
      Patient Address 2
        Location :  N3 Segment, Element 2
          

PATCITY
      Patient City
        Location :  N4 Segment, Element 1
          


PATST
      Patient State
        Location :  N4 Segment, Element 2

PATZIP
      Patient Zip
        Location :  N4 Segment, Element 3


PATDOB
      Patient Date of Birth
        Location :  DMG Segment, Element 2

PATSEX
      Patient Gender
        Location :  DMG Segment, Element 3



PATREL
      Patient Relationship to Subscriber
        Location :  PAT Segment, Element 2


PATSIGNATURESOURCE
      Patient Signature Source
        Location :  CLM Segment, Element 10



REFLNAME
      Referring Provider Last Name
        Location :  NM1 Segment, Element 3
                    Qualifier DN

REFFNAME
      Referring Provider First Name
        Location :  NM1 Segment, Element 4
                    Qualifier DN

REFID
      Referring Provider ID
        Location :  NM1 Segment, Element 9
                    Qualifier DN

REFIDTYPE
      Referring Provider ID Type
        Location :  NM1 Segment, Element 8
                    Qualifier DN


REFSECONDARYID
      Referring Provider Secondary ID
        Location :  REF Segment, Element 3

REFSECONDARYIDCODE
      Referring Provider Secondary ID Code
        Location :  REF Segment, Element 2



ATTENDLNAME
      Attending Provider Last Name
        Location :  NM1 Segment, Element 3
                    Qualifier 71


ATTENDFNAME
      Attending Provider First Name
        Location :  NM1 Segment, Element 4
                    Qualifier 71


ATTENDID
      Attending Provider ID
        Location :  NM1 Segment, Element 9
                    Qualifier 71

ATTENDSECONDARYID
      Attending Provider Secondary ID
        Location :  REF Segment, Element 2

ATTENDSECONDARYIDCODE
      Attending Provider Secondary ID Code
        Location :  REF Segment, Element 1


OPERATELNAME
      Operating Provider Last Name
        Location :  NM1 Segment, Element 3
                    Qualifier 72


OPERATEFNAME
      Operating Provider First Name
        Location :  NM1 Segment, Element 4
                    Qualifier 72


OPERATEID
      Operating Provider Last Name
        Location :  NM1 Segment, Element 3
                    Qualifier 72

OPERATESECONDARYID
      Operating Provider Secondary ID
        Location :  REF Segment, Element 2

OPERATESECONDARYIDCODE
      Operating Provider Secondary ID Code
        Location :  REF Segment, Element 1


RENLNAME
      Rendering Provider Last Name
        Location :  NM1 Segment, Element 3
                    Qualifier 82


RENFNAME
      Rendering Provider First Name
        Location :  NM1 Segment, Element 4
                    Qualifier 82

RENIDTYPECODE
      Rendering Provider ID Type Code
        Location :  NM1 Segment, Element 8
                    Qualifier 82

RENIDTYPE
      Rendering Provider ID Type
        Location :  NM1 Segment, Element 8
                    Qualifier 82


RENID
      Rendering Provider ID
        Location :  NM1 Segment, Element 9
                    Qualifier 82



FACILITYNAME
      Facility Name
        Location :  NM1 Segment, Element 3
                    Qualifier FA


FACILITYADDR1
      Facility Address Line 1
        Location :  N3 Segment, Element 1


FACILITYADDR2
      Facility Address Line 2
        Location :  N3 Segment, Element 2

FACILITYCITY
      Facility City
        Location :  N4 Segment, Element 1


FACILITYST
      Facility State
        Location :  N4 Segment, Element 2

FACILITYZIP
      Facility Zip Code
        Location :  N4 Segment, Element 3


FACILITYIDTYPE
      Facility ID Type
        Location :  NM1 Segment, Element 8
                    Qualifier FA


FACILITYIDCODE
      Facility ID Code
        Location :  NM1 Segment, Element 8
                    Qualifier FA


FACILITYID
      Facility ID
        Location :  NM1 Segment, Element 9
                    Qualifier FA


FACILITYSECONDARYIDTYPE
      Facility Secondary ID Type
        Location :  REF Segment, Element 1


FACILITYSECONDARYIDCODE
      Facility Secondary ID CODE
        Location :  REF Segment, Element 1


FACILITYSECONDARYID
      Facility Secondary ID Type
        Location :  REF Segment, Element 2


SERVICELOCATIONNAME
      Service Location Name
        Location :  NM1 Segment, Element 3
                    Qualifier 77


SERVICELOCATIONADDR1
      Service Localtion Address Line 1
        Location :  N3 Segment, Element 1


SERVICELOCATIONADDR2
      Service Localtion Address Line 2
        Location :  N3 Segment, Element 2


SERVICELOCATIONCITY
      Service Localtion City
        Location :  N4 Segment, Element 1


SERVICELOCATIONST
      Service Localtion State
        Location :  N4 Segment, Element 2


SERVICELOCATIONZIP
      Service Localtion Zip Code
        Location :  N4 Segment, Element 4


SERVICELOCATIONID
      Service Location Name
        Location :  NM1 Segment, Element 9
                    Qualifier 77


ILABNAME
      Independent LAB Name
        Location :  NM1 Segment, Element 3
                    Qualifier LI

ILABADDR1
     Independent LAB Address Line 1
        Location :  N3 Segment, Element 1


ILABADDR2
     Independent LAB Address Line 2
        Location :  N3 Segment, Element 2


ILABCITY
     Independent LAB City
        Location :  N4 Segment, Element 1


ILABST
     Independent LAB State
        Location :  N4 Segment, Element 2

ILABZIP
     Independent LAB Zip Code
        Location :  N4 Segment, Element 3


ILABID
      Independent LAB Name
        Location :  NM1 Segment, Element 9
                    Qualifier LI

TLABNAME
      Testing LAB Name
        Location :  NM1 Segment, Element 3
                    Qualifier TL


TLABADDR1
     Testing LAB Address Line 1
        Location :  N3 Segment, Element 1

TLABADDR2
     Testing LAB Address Line 2
        Location :  N3 Segment, Element 2


TLABCITY
     Testing LAB City
        Location :  N4 Segment, Element 1

TLABST
     Testing LAB State
        Location :  N4 Segment, Element 2


TLABZIP
     Testing LAB Zip Code
        Location :  N4 Segment, Element 3


TLABID
      Independent LAB Name
        Location :  NM1 Segment, Element 9
                    Qualifier TL


DX1_XX
     Diagnosis Code 1
        Location :  HI Segment, Element 1
         Sub Element 1
DX2_XX
     Diagnosis Code 2
        Location :  HI Segment, Element 1
         Sub Element 2

DX3_XX
     Diagnosis Code 3
        Location :  HI Segment, Element 1
         Sub Element 3

DX4_XX
     Diagnosis Code 4
        Location :  HI Segment, Element 1
         Sub Element 4

DX5_XX
     Diagnosis Code 5
        Location :  HI Segment, Element 1
         Sub Element 5



DX1
     Diagnosis Code 1
        Location :  HI Segment, Element 1
         Sub Element 1

DX2
     Diagnosis Code 2
        Location :  HI Segment, Element 1
         Sub Element 2

DX3
     Diagnosis Code 3
        Location :  HI Segment, Element 1
         Sub Element 3

DX4
     Diagnosis Code 4
        Location :  HI Segment, Element 1
         Sub Element 4

DX5
     Diagnosis Code 5
        Location :  HI Segment, Element 1
         Sub Element 5




MEDICALRECORDNUMBER
      Medical Record Number
        Location :  REF Segment, Element 2
                    Qualifier EA

CLAIMBILLINGPROVIDERNAME
     Claim Billing Provider Name
        Location :  NM1 Segment, Element 3
                    Qualifier 85


CLAIMBILLINGPROVIDERADDR1
     Claim Billing Provider Address 1
        Location :  N3 Segment, Element 1



CLAIMBILLINGPROVIDERADDR2
     Claim Billing Provider Address 2
        Location :  N3 Segment, Element 2


CLAIMBILLINGPROVIDERCITY
     Claim Billing Provider City
        Location :  N4 Segment, Element 1



CLAIMBILLINGPROVIDERST
     Claim Billing Provider State
        Location :  N4 Segment, Element 2


CLAIMBILLINGPROVIDERZIP
     Claim Billing Provider Zip Code
        Location :  N4 Segment, Element 3



CLAIMBILLINGPROVIDERIDTYPE
     Claim Billing Provider ID Type
        Location :  NM1 Segment, Element 8
                    Qualifier 85


CLAIMBILLINGPROVIDERIDCODE
     Claim Billing Provider ID Code
        Location :  NM1 Segment, Element 8
                    Qualifier 85


CLAIMBILLINGPROVIDERID
     Claim Billing Provider ID 
        Location :  NM1 Segment, Element 9
                    Qualifier 85


CLAIMBILLINGPROVIDERSECONDARYIDTYPE
     Claim Billing Provider Secondary ID Type
        Location :  REF Segment, Element 1



CLAIMBILLINGPROVIDERSECONDARYIDCODE
     Claim Billing Provider Secondary ID Code
        Location :  REF Segment, Element 1


CLAIMBILLINGPROVIDERSECONDARYID
     Claim Billing Provider Secondary ID 
        Location :  REF Segment, Element 2




CLAIMPAYTOPROVIDERNAME
     Claim Pay to  Provider Name
        Location :  NM1 Segment, Element 3
                    Qualifier 87


CLAIMPAYTOPROVIDERADDR1
     Claim Pay to  Provider Address 1
        Location :  N3 Segment, Element 1


CLAIMPAYTOPROVIDERADDR2
     Claim Pay to  Provider Address 2
        Location :  N3 Segment, Element 2


CLAIMPAYTOPROVIDERCITY
     Claim Pay to  Provider City
        Location :  N4 Segment, Element 1


CLAIMPAYTOPROVIDERST
     Claim Pay to  Provider State
        Location :  N4 Segment, Element 2



CLAIMPAYTOPROVIDERZIP
     Claim Pay to  Provider Zip Code
        Location :  N4 Segment, Element 3



CLAIMPAYTOPROVIDERIDTYPE
     Claim Pay to  Provider ID Type
        Location :  NM1 Segment, Element 8
                    Qualifier 87


CLAIMPAYTOPROVIDERIDCODE
     Claim Pay to  Provider ID Code
        Location :  NM1 Segment, Element 8
                    Qualifier 87


CLAIMPAYTOPROVIDERID
     Claim Pay to  Provider ID 
        Location :  NM1 Segment, Element 9
                    Qualifier 87





ADJUDDATE
    Claim Ajudication Date
        Location :  DTP Segment, Element 3
                    Qualifier 573




IADJUDIDn
    Line Claim Ajudication ID
        Location :  SVD Segment, Element 1
                    Qualifier 573
                    n=1 to 999


IADJUDAMTn
    Line Claim Ajudication Amount
        Location :  SVD Segment, Element 2
                    n=1 to 999




IADJUDDATEn
    Line Claim Ajudication Date
        Location :  DTP Segment, Element 3
                    Qualifier 573
                    n=1 to 999





PRIMARYGROUPID
      Primary Subscriber Group ID
        Location :  SBR Segment, Element 2
                    Qualifier P


PRIMARYGROUPNAME
      Primary Subscriber Group Name
        Location :  SBR Segment, Element 3
                    Qualifier P



PRIMARYSUBID
      Primary Subscriber ID
        Location :  NM1 Segment, Element 9
                    Qualifier IL



PRIMARYSUBLNAME
      Primary Subscriber Last Name
        Location :  NM1 Segment, Element 3
                    Qualifier IL


PRIMARYSUBFNAME
      Primary Subscriber First Name
        Location :  NM1 Segment, Element 4
                    Qualifier IL




PRIMARYSUBMI
      Primary Subscriber Middle Initial
        Location :  NM1 Segment, Element 5
                    Qualifier IL



PRIMARYSUBADDR1
      Primary Subscriber Address Line 1
        Location :  N3 Segment, Element 1



PRIMARYSUBADDR2
      Primary Subscriber Address Line 2
        Location :  N3 Segment, Element 2


PRIMARYSUBCITY
      Primary Subscriber City
        Location :  N4 Segment, Element 1


PRIMARYSUBSTATE
      Primary Subscriber State
        Location :  N4 Segment, Element 2


PRIMARYSUBZIP
      Primary Subscriber Zip Code
        Location :  N4 Segment, Element 3


PRIMARYSUBDOB
      Primary Subscriber Date of Birth
        Location :  DMG Segment, Element 2



PRIMARYSUBSEX
      Primary Subscriber Gender
        Location :  DMG Segment, Element 3


PRIMARYPAYERNAME
      Primary Payer Name
        Location :  NM1 Segment, Element 3
                    Qualifier PR



PRIMARYPAYERADDR1
      Primary Payer Address Line 1
        Location :  N3 Segment, Element 1


PRIMARYPAYERADDR2
      Primary Payer Address Line 2
        Location :  N3 Segment, Element 2



PRIMARYPAYERCITY
      Primary Payer City
        Location :  N4 Segment, Element 1



PRIMARYPAYERSTATE
      Primary Payer State
        Location :  N4 Segment, Element 2



PRIMARYPAYERZIP
      Primary Payer Zip Code
        Location :  N4 Segment, Element 3



PRIMARYPAYERID
      Primary Payer ID
        Location :  NM1 Segment, Element 9
                    Qualifier PR







SECONDARYGROUPID
      Secondary Subscriber Group ID
        Location :  SBR Segment, Element 2
                    Qualifier S


SECONDARYGROUPNAME
      Secondary Subscriber Group Name
        Location :  SBR Segment, Element 3
                    Qualifier S



SECONDARYSUBID
      Secondary Subscriber ID
        Location :  NM1 Segment, Element 9
                    Qualifier IL



SECONDARYSUBLNAME
      Secondary Subscriber Last Name
        Location :  NM1 Segment, Element 3
                    Qualifier IL


SECONDARYSUBFNAME
      Secondary Subscriber First Name
        Location :  NM1 Segment, Element 4
                    Qualifier IL




SECONDARYSUBMI
      Secondary Subscriber Middle Initial
        Location :  NM1 Segment, Element 5
                    Qualifier IL



SECONDARYSUBADDR1
      Secondary Subscriber Address Line 1
        Location :  N3 Segment, Element 1



SECONDARYSUBADDR2
      Secondary Subscriber Address Line 2
        Location :  N3 Segment, Element 2


SECONDARYSUBCITY
      Secondary Subscriber City
        Location :  N4 Segment, Element 1


SECONDARYSUBSTATE
      Secondary Subscriber State
        Location :  N4 Segment, Element 2


SECONDARYSUBZIP
      Secondary Subscriber Zip Code
        Location :  N4 Segment, Element 3


SECONDARYSUBDOB
      Secondary Subscriber Date of Birth
        Location :  DMG Segment, Element 2



SECONDARYSUBSEX
      Secondary Subscriber Gender
        Location :  DMG Segment, Element 3


SECONDARYPAYERNAME
      Secondary Payer Name
        Location :  NM1 Segment, Element 3
                    Qualifier PR



SECONDARYPAYERADDR1
      Secondary Payer Address Line 1
        Location :  N3 Segment, Element 1


SECONDARYPAYERADDR2
      Secondary Payer Address Line 2
        Location :  N3 Segment, Element 2



SECONDARYPAYERCITY
      Secondary Payer City
        Location :  N4 Segment, Element 1



SECONDARYPAYERSTATE
      Secondary Payer State
        Location :  N4 Segment, Element 2



SECONDARYPAYERZIP
      Secondary Payer Zip Code
        Location :  N4 Segment, Element 3



SECONDARYPAYERID
      Secondary Payer ID
        Location :  NM1 Segment, Element 9
                    Qualifier PR







TERTIARYGROUPID
      Tertiary Subscriber Group ID
        Location :  SBR Segment, Element 2
                    Qualifier T


TERTIARYGROUPNAME
      Tertiary Subscriber Group Name
        Location :  SBR Segment, Element 3
                    Qualifier T



TERTIARYSUBID
      Tertiary Subscriber ID
        Location :  NM1 Segment, Element 9
                    Qualifier IL



TERTIARYSUBLNAME
      Tertiary Subscriber Last Name
        Location :  NM1 Segment, Element 3
                    Qualifier IL


TERTIARYSUBFNAME
      Tertiary Subscriber First Name
        Location :  NM1 Segment, Element 4
                    Qualifier IL




TERTIARYSUBMI
      Tertiary Subscriber Middle Initial
        Location :  NM1 Segment, Element 5
                    Qualifier IL



TERTIARYSUBADDR1
      Tertiary Subscriber Address Line 1
        Location :  N3 Segment, Element 1



TERTIARYSUBADDR2
      Tertiary Subscriber Address Line 2
        Location :  N3 Segment, Element 2


TERTIARYSUBCITY
      Tertiary Subscriber City
        Location :  N4 Segment, Element 1


TERTIARYSUBSTATE
      Tertiary Subscriber State
        Location :  N4 Segment, Element 2


TERTIARYSUBZIP
      Tertiary Subscriber Zip Code
        Location :  N4 Segment, Element 3


TERTIARYSUBDOB
      Tertiary Subscriber Date of Birth
        Location :  DMG Segment, Element 2



TERTIARYSUBSEX
      Tertiary Subscriber Gender
        Location :  DMG Segment, Element 3


TERTIARYPAYERNAME
      Tertiary Payer Name
        Location :  NM1 Segment, Element 3
                    Qualifier PR



TERTIARYPAYERADDR1
      Tertiary Payer Address Line 1
        Location :  N3 Segment, Element 1


TERTIARYPAYERADDR2
      Tertiary Payer Address Line 2
        Location :  N3 Segment, Element 2



TERTIARYPAYERCITY
      Tertiary Payer City
        Location :  N4 Segment, Element 1



TERTIARYPAYERSTATE
      Tertiary Payer State
        Location :  N4 Segment, Element 2



TERTIARYPAYERZIP
      Tertiary Payer Zip Code
        Location :  N4 Segment, Element 3



TERTIARYPAYERID
      Tertiary Payer ID
        Location :  NM1 Segment, Element 9
                    Qualifier PR















HIERARCHIALCLAIMBILLINGPROVIDERNAME
    Hierarchial Claim Billing Provider Name
        Location :  NM1 Segment, Element 3
                    Qualifier 85

HIERARCHIALCLAIMBILLINGPROVIDERADDR1
    Hierarchial Claim Billing Provider Address Line 1
        Location :  N3 Segment, Element 1


HIERARCHIALCLAIMBILLINGPROVIDERADDR2
    Hierarchial Claim Billing Provider Address Line 2
        Location :  N3 Segment, Element 2

HIERARCHIALCLAIMBILLINGPROVIDERCITY
    Hierarchial Claim Billing Provider City
        Location :  N4 Segment, Element 1


HIERARCHIALCLAIMBILLINGPROVIDERST
    Hierarchial Claim Billing Provider State
        Location :  N4 Segment, Element 2



HIERARCHIALCLAIMBILLINGPROVIDERZIP
    Hierarchial Claim Billing Provider Zip Code
        Location :  N4 Segment, Element 3



HIERARCHIALCLAIMBILLINGPROVIDERIDTYPE
    Hierarchial Claim Billing Provider ID Type
        Location :  NM1 Segment, Element 8
                    Qualifier 85


HIERARCHIALCLAIMBILLINGPROVIDERIDCODE
    Hierarchial Claim Billing Provider ID Code
        Location :  NM1 Segment, Element 8


HIERARCHIALCLAIMBILLINGPROVIDERID
    Hierarchial Claim Billing Provider ID 
        Location :  NM1 Segment, Element 9


HIERARCHIALCLAIMPAYTOPROVIDERNAME
    Hierarchial Claim Pay to Provider Provider Name
        Location :  NM1 Segment, Element 3
                    Qualifier 87



HIERARCHIALCLAIMPAYTOPROVIDERADDR1
    Hierarchial Claim Pay to Provider Provider Address Line 1
        Location :  N3 Segment, Element 1


HIERARCHIALCLAIMPAYTOPROVIDERADDR2
    Hierarchial Claim Pay to Provider Provider Address Line 2
        Location :  N3 Segment, Element 2



HIERARCHIALCLAIMPAYTOPROVIDERCITY
    Hierarchial Claim Pay to Provider Provider City
        Location :  N4 Segment, Element 1



HIERARCHIALCLAIMPAYTOPROVIDERST
    Hierarchial Claim Pay to Provider Provider State
        Location :  N4 Segment, Element 2



HIERARCHIALCLAIMPAYTOPROVIDERZIP
    Hierarchial Claim Pay to Provider Provider Zip Code
        Location :  N4 Segment, Element 3



HIERARCHIALCLAIMPAYTOPROVIDERIDTYPE
    Hierarchial Claim Pay to Provider Provider ID Type
        Location :  NM1 Segment, Element 8
                    Qualifier 87



HIERARCHIALCLAIMPAYTOPROVIDERIDCODE
    Hierarchial Claim Pay to Provider Provider ID Code
        Location :  NM1 Segment, Element 8
                    Qualifier 87


HIERARCHIALCLAIMPAYTOPROVIDERID
    Hierarchial Claim Pay to Provider Provider ID 
        Location :  NM1 Segment, Element 9
                    Qualifier 87



TSCONTROLNUMBER
   Batch Conrol Number 
        Location :  ST Segment, Element 2


BHTREFID
   BHT Segment Reference Identification
        Location :  BHT Segment, Element 4


SUBMITTERNAME
   Submitter Name
        Location :  NM1 Segment, Element 3
                    Qualifier 41



SUBMITTERADDR1
    Submitter Address Line 1
        Location :  N3 Segment, Element 1


SUBMITTERADDR2
    Submitter Address Line 2
        Location :  N3 Segment, Element 2



SUBMITTERCITY
    Submitter City
        Location :  N4 Segment, Element 1


SUBMITTERST
    Submitter State
        Location :  N4 Segment, Element 2



SUBMITTERZIP
    Submitter Zip Code
        Location :  N4 Segment, Element 3



SUBMITTERCONTACT
    Submitter Contact
        Location :  PER Segment, Element 2


SUBMITTERID
   Submitter ID
        Location :  NM1 Segment, Element 9
                    Qualifier 41



SUBMITTERCOMMQUALA
   Submitter ID
        Location :  PER Segment, Element 3


SUBMITTERCOMMNUMBERA
   Submitter ID
        Location :  PER Segment, Element 4


SUBMITTERCOMMQUALB
   Submitter ID
        Location :  PER Segment, Element 5


SUBMITTERCOMMNUMBERB
   Submitter ID
        Location :  PER Segment, Element 6

SUBMITTERCOMMQUALC
   Submitter ID
        Location :  PER Segment, Element 7


SUBMITTERCOMMNUMBERC
   Submitter ID
        Location :  PER Segment, Element 8


         


RECEIVERID
   Receiver
        Location :  NM1 Segment, Element 9
                    Qualifier 41


RECEIVERNAME
   Receiver Name
        Location :  NM1 Segment, Element 3
                    Qualifier 40


RECEIVERADDITIONALNAME
   Receiver Additional Name
        Location :  N2 Segment, Element 1


RECEIVERADDR1
   Receiver Address Line 1
        Location :  N3 Segment, Element 1



RECEIVERADDR2
   Receiver Address Line 2
        Location :  N3 Segment, Element 2


RECEIVERCITY
   Receiver Address City
        Location :  N4 Segment, Element 1

RECEIVERST
   Receiver Address State
        Location :  N4 Segment, Element 2


RECEIVERZIP
   Receiver Address Zip Code
        Location :  N4 Segment, Element 3



BILLINGPROVIDERNAME
     Billing Provider Name
        Location :  NM1 Segment, Element 3
                    Qualifier 85


BILLINGPROVIDERADDR1
    Billing Provider Address Line 1
        Location :  N3 Segment, Element 1


BILLINGPROVIDERADDR2
    Billing Provider Address Line 2
        Location :  N3 Segment, Element 2


BILLINGPROVIDERCITY
    Billing Provider City
        Location :  N4 Segment, Element 1


BILLINGPROVIDERST
    Billing Provider State
        Location :  N4 Segment, Element 2



BILLINGPROVIDERZIP
    Billing Provider Zip Code
        Location :  N4 Segment, Element 3


BILLINGPROVIDERIDTYPE
     Billing Provider ID Type
        Location :  NM1 Segment, Element 8
                    Qualifier 85


BILLINGPROVIDERIDCODE
     Billing Provider ID Code
        Location :  NM1 Segment, Element 8
                    Qualifier 85


BILLINGPROVIDERID
     Billing Provider ID 
        Location :  NM1 Segment, Element 9
                    Qualifier 85



BILLINGPROVIDERCONTACT
   BILLINGPROVIDER ID
        Location :  PER Segment, Element 3


BILLINGPROVIDERCOMMQUALA
   BILLINGPROVIDER ID
        Location :  PER Segment, Element 4


BILLINGPROVIDERCOMMNUMBERA
   BILLINGPROVIDER ID
        Location :  PER Segment, Element 5


BILLINGPROVIDERCOMMQUALB
   BILLINGPROVIDER ID
        Location :  PER Segment, Element 6


BILLINGPROVIDERCOMMNUMBERB
   BILLINGPROVIDER ID
        Location :  PER Segment, Element 7

BILLINGPROVIDERCOMMQUALC
   BILLINGPROVIDER ID
        Location :  PER Segment, Element 8


BILLINGPROVIDERCOMMNUMBERC
   BILLINGPROVIDER ID
        Location :  PER Segment, Element 9


         





PAYTOPROVIDERNAME
     Pay to Provider Name
        Location :  NM1 Segment, Element 3
                    Qualifier 87



PAYTOPROVIDERADDR1
    Pay to Provider Address Line 1
        Location :  N3 Segment, Element 1



PAYTOPROVIDERADDR2
    Pay to Provider Address Line 2
        Location :  N3 Segment, Element 2


PAYTOPROVIDERCITY
    Pay to Provider City
        Location :  N4 Segment, Element 1


PAYTOPROVIDERST
    Pay to Provider State
        Location :  N4 Segment, Element 2



PAYTOPROVIDERZIP
    Pay to Provider Zip Code
        Location :  N4 Segment, Element 3



PAYTOPROVIDERIDTYPE
     Pay to Provider ID Type
        Location :  NM1 Segment, Element 8
                    Qualifier 87




PAYTOPROVIDERIDCODE
     Pay to Provider ID Code
        Location :  NM1 Segment, Element 8
                    Qualifier 87



PAYTOPROVIDERID
     Pay to Provider ID 
        Location :  NM1 Segment, Element 9
                    Qualifier 87




PRIMARYINSURANCETYPECODE
Primary Insurance Type Code
Location : SBR Segment, Element 5
Qualifier P

SECONDARYINSURANCETYPECODE
Secondary Insurance Type Code
Location : SBR Segment, Element 5
Qualifier S

TERTIARYINSURANCETYPECODE
Tertiary Insurance Type Code
Location : SBR Segment, Element 5
Qualifier T



COBPAYERPAIDAMT
Coordination of Benefits Payer Paid Amount
Location : AMT Segment, Element 2
Qualifier D

COBAPPROVEDAMT
Coordination of Benefits Payer Approved Amount
Location : AMT Segment, Element 2
Qualifier AAE


COBPAYERALLOWEDAMT
Coordination of Benefits Payer Allowed  Amount
Location : AMT Segment, Element 2
Qualifier B6


COBPATRESPONSE
Coordination of Benefits Patient Responsibility
Location : AMT Segment, Element 2
Qualifier F2


COBCOVEREDAMT
Coordination of Benefits Covered Amount
Location : AMT Segment, Element 2
Qualifier AU

COBDISCOUNTAMT
Coordination of Benefits Discount Amount
Location : AMT Segment, Element 2
Qualifier D8

COBPERDAYLIMIT
Coordination of Benefits Per Day Limit
Location : AMT Segment, Element 2
Qualifier DY

COBPATPAIDAMT
Coordination of Benefits Patient Amount Paid
Location : AMT Segment, Element 2
Qualifier F5

COBTAX
Coordination of Benefits Tax
Location : AMT Segment, Element 2
Qualifier T

COBCLMTOTTAX
Coordination of Benefits Claim Total Tax
Location : AMT Segment, Element 2
Qualifier T2


OIPAYERMEMNUM
Other Insurance Payer Member Number
Location : REF Segment, Element 2
Qualifier 1W

OIPAYERCLINUM
Other Insurance Payer Client Number
Location : REF Segment, Element 2
Qualifier 23


OIPAYERPOLNUM
Other Insurance Payer Policy Number
Location : REF Segment, Element 2
Qualifier IG


OIPAYERSSN
Other Insurance Payer Social Security Number
Location : REF Segment, Element 2
Qualifier SY


- - - - - - - - - - - - - -

Institutional Service Line Level Fields
01 to 999
- - - - - - - - - - - - - -


ILINE01

IPROCTYPE01

IPROC01

IMODA01

IMODB01

IMODC01

IMODD01

IAMT01

IUNITSTYPE01

IUNITSQTY01

IUNITSRATE01

IUNITS01

IDOS01

NDCCODE01

NDCUNITPRICE01

NDCUNITS01

IADJUDDATE01

IADJUDID01

IADJUDAMT01



- - - - - - - - - - - - - -

Professional Service Line Level Fields
01 to 99
- - - - - - - - - - - - - -


PPROC01

MODA01

MODB01

MODC01

MODD01

DOS01

MM_DD_YY_DOSF01

MM_DD_YY_DOST01

AMT01

DDDDDD_CC01

POSLINECODE01

UNITS01

DXLINK01

SUPDXLINKA01

SUPDXLINKB01

SUPDXLINKC01

SUPDXLINKD01


- - - - - - - - - - - - - -

Dental Service Line Level Fields
01 to 99
- - - - - - - - - - - - - -

DPROC01

DMODA01

DMODB01

DMODC01

DMODD01

DAMT01

TOOTHSURFACE

TOOTH01

- - - - - - - - - - - - - -

General Service Line Level Fields

- - - - - - - - - - - - - -

LINEITEMCONTROLNUMBER01




Section 9

835 Field Descriptions

[Table of Contents]

This is a list of the fields supported for mapping and are 
stored in an XML file called C1835.XML. Field names are placed
inside the field tags of the xml.

 Example :

         CLAIMPATCTL
         CLAIMSTATUSCODE
         CLAIMTOTALCHARGE
         CLAIMTOTALPAID


           - - - - - - - - - - - - - - - - - -


SETCONTROLNUMBER
     Transaction Set Control Number
        Location :  ST Segment, Element 2



CLAIMPATCTL
     Claim Patient Control Number
        Location :  CLP Segment, Element 1



CLAIMSTATUSCODE
     Claim Staus Code
        Location :  CLP Segment, Element 2


CLAIMSTATUSDESC
     Claim Status Description
        Location :  CLP Segment, Element 2


CLAIMTOTALCHARGE
     Claim Total Charge
        Location :  CLP Segment, Element 3


CLAIMTOTALPAID
     Claim Total Paid
        Location :  CLP Segment, Element 4


PATRESPONSIBLE
     Patient Responsibility
        Location :  CLP Segment, Element 5


FILIND
     Filing Indicator
        Location :  CLP Segment, Element 6


FILINDDESC
     Filing Indicator Description
        Location :  CLP Segment, Element 6

PAYERCLAIMCODE
  Payer Claim Code
        Location :  CLP Segment, Element 7


FACILITYTYPECODE
     Facility Type Code
        Location :  CLP Segment, Element 8


PAYERCLAIMCODE
     Payer Claim Code
        Location :  CLP Segment, Element 8


CLAIMFREQ
     Claim Frequency Code
        Location :  CLP Segment, Element 9


PATSTATCODE
     Patient Status Code
        Location : CLP Segment, Element 10


DRGCODE
     Diagnosis Related Group (DRG) Code
        Location : CLP Segment, Element 11


DRGQTY
     Diagnosis Related Group (DRG) Weight
        Location : CLP Segment, Element 12


DISCHGPCT
     Discharge Fraction
        Location : CLP Segment, Element 13


CLMADJGRPCODE
      Claim Adjustment Group Code
        Location :  CAS Segment, Element 1


CLMADJGRPDESC
      Claim Adjustment Group Code Description
        Location :  CAS Segment, Element 1


CLMADJCODE
        Location :  CAS Segment, Element 2
        Loop 2100        
 

CLMADJAMT
        Location :  CAS Segment, Element 3
        Loop 2100        



CLMADJQTY
        Location :  CAS Segment, Element 4
        Loop 2100        



CLMADJCODEn
      Claim Adjustment Code 1 thru 99
        n = 1 to 99
        Location :  CAS Segment, Element 2
        
 

CLMADJAMTn
      Claim Adjustment Amount 1 thru 99
        n = 1 to 99
        Location :  CAS Segment, Element 3


CLMADJQTYn
      Claim Adjustment Quantity 1 thru 99
      n = 1 to 99
      Location :  CAS Segment, Element 4




CLAIMDATEEXP
      Claim Expiration Date
        Location :  DTM Segment, Element 2
                    Element 1 Qualifier 036


CLAIMDATEREC
      Claim Date Received
        Location :  DTM Segment, Element 2
                    Element 1 Qualifier 050


CLAIMMSTATEMENTPERIODSTART
    Claim Statement Period Start
        Location :  DTM Segment, Element 2
                    Element 1 Qualifier 232


CLAIMMSTATEMENTPERIODEND
    Claim Statement Period End
        Location :  DTM Segment, Element 2
                    Element 1 Qualifier 233




TRANSHANDCODE
    Transaction Handling Code
        Location :  BPR Segment, Element 1




TRANSTOTALPAYAMT
    Total Actual Provider Payment Amount
        Location :  BPR Segment, Element 2



TRANSDC
    Transaction Type Credit/Debit 
        Location :  BPR Segment, Element 3




TRANSPAYMETHOD
    Transaction Payment Method
        Location :  BPR Segment, Element 4




TRANSDATE
    Transaction Date
        Location :  BPR Segment, Element 16



TRACEREFRENCEID
    Trace Reference Identification
        Location :  TRN Segment, Element 4


TRACEREFID
    Trace Reference Identification
        Location :  TRN Segment, Element 2


TRACEORGID
    Trace Originating Identifier
        Location :  TRN Segment, Element 4


XOVERCARRIER
    CROSSOVER CARRIER NAME
        Location :  NM1 Segment, Element 3
                    Element 1 Qualifier TT



PAYEEADID
    PAYEE ADDITIONAL IDENTIFICATION
        Location :  REF Segment, Element 2


RECEIVERID
    Receiver ID
        Location :  REF Segment, Element 2
                    Element 1 Qualifier EV


PRODDATE
    Production Date
        Location :  DTM Segment, Element 2
                    Element 1 Qualifier 405


PAYERNAME
    Payer Name
        Location :  N1 Segment, Element 2
                    Element 1 Qualifier PR


PAYERADDRESS1
    Payer Address 1
        Location :  N3 Segment, Element 1


PAYERADDRESS2
    Payer Address 2
        Location :  N3 Segment, Element 2


PAYERCITY
    Payer City
        Location :  N4 Segment, Element 1


PAYERSTATE
    Payer State
        Location :  N4 Segment, Element 2


PAYERZIPCODE
    Payer Zip Code
        Location :  N4 Segment, Element 3



PAYEEIDQUAL
    Payee ID Code Qualifier
        Location :  N1 Segment, Element 3
                    Element 1 Qualifier PE


PAYEEID
    Payee ID Code Qualifier
        Location :  N1 Segment, Element 4
                    Element 1 Qualifier PE


PAYEEADIDQUAL
    Payee ID Code Qualifier
        Location :  N1 Segment, Element 3
                    Element 1 Qualifier PE


PAYEEADID
    Payee Additional ID Code 
        Location :  REF Segment, Element 2


PAYEENAME
    Payee Name
        Location :  N1 Segment, Element 2


PAYEEADDRESS1
    Payee Address 1
        Location :  N3 Segment, Element 1

PAYEEADDRESS2
    Payee Address 2
        Location :  N3 Segment, Element 3

PAYEECITY
    Payee City
        Location :  N4 Segment, Element 1

PAYEESTATE
    Payee State
        Location :  N4 Segment, Element 2

PAYEEZIPCODE
    Payee Zip Code
        Location :  N4 Segment, Element 3

SERVICEPROVIDER
    Service Provider 
        Location :  NM1 Segment, Element 3
                    Element 1 Qualifier 82

SERVICEPROVIDERID
    Service Provider 
        Location :  NM1 Segment, Element 9
                    Element 1 Qualifier 82

SERVICEPROVIDERIDQUAL
    Service Provider 
        Location :  NM1 Segment, Element 3
                    Element 1 Qualifier 82




PRIMARYCLAIMPATCTL
     Claim Patient Control Number
        Location :  CLP Segment, Element 1



PRIMARYCLAIMSTATUSCODE
     Claim Staus Code
        Location :  CLP Segment, Element 2


PRIMARYCLAIMSTATUSDESC
     Claim Status Description
        Location :  CLP Segment, Element 2


PRIMARYCLAIMTOTALCHARGE
     Claim Total Charge
        Location :  CLP Segment, Element 3


PRIMARYCLAIMTOTALPAID
     Claim Total Paid
        Location :  CLP Segment, Element 4


PRIMARYPATRESPONSIBLE
     Patient Responsibility
        Location :  CLP Segment, Element 5


PRIMARYFILIND
     Filing Indicator
        Location :  CLP Segment, Element 6


PRIMARYFILINDDESC
     Filing Indicator Description
        Location :  CLP Segment, Element 6

PRIMARYPAYERCLAIMCODE
  Payer Claim Code
        Location :  CLP Segment, Element 7


PRIMARYFACILITYTYPECODE
     Facility Type Code
        Location :  CLP Segment, Element 8


PRIMARYPAYERCLAIMCODE
     Payer Claim Code
        Location :  CLP Segment, Element 8


PRIMARYCLAIMFREQ
     Claim Frequency Code
        Location :  CLP Segment, Element 9



PRIMARYPATSTATCODE
     Patient Status Code
        Location : CLP Segment, Element 10


PRIMARYDRGCODE
     Diagnosis Related Group (DRG) Code
        Location : CLP Segment, Element 11


PRIMARYDRGQTY
     Diagnosis Related Group (DRG) Weight
        Location : CLP Segment, Element 12


PRIMARYDISCHGPCT
     Discharge Fraction
        Location : CLP Segment, Element 13


SECONDARYCLAIMPATCTL
     Claim Patient Control Number
        Location :  CLP Segment, Element 1


SECONDARYCLAIMSTATUSCODE
     Claim Staus Code
        Location :  CLP Segment, Element 2


SECONDARYCLAIMSTATUSDESC
     Claim Status Description
        Location :  CLP Segment, Element 2


SECONDARYCLAIMTOTALCHARGE
     Claim Total Charge
        Location :  CLP Segment, Element 3


SECONDARYCLAIMTOTALPAID
     Claim Total Paid
        Location :  CLP Segment, Element 4


SECONDARYPATRESPONSIBLE
     Patient Responsibility
        Location :  CLP Segment, Element 5


SECONDARYFILIND
     Filing Indicator
        Location :  CLP Segment, Element 6


SECONDARYFILINDDESC
     Filing Indicator Description
        Location :  CLP Segment, Element 6

SECONDARYPAYERCLAIMCODE
  Payer Claim Code
        Location :  CLP Segment, Element 7


SECONDARYFACILITYTYPECODE
     Facility Type Code
        Location :  CLP Segment, Element 8


SECONDARYPAYERCLAIMCODE
     Payer Claim Code
        Location :  CLP Segment, Element 8


SECONDARYCLAIMFREQ
     Claim Frequency Code
        Location :  CLP Segment, Element 9


SECONDARYPATSTATCODE
     Patient Status Code
        Location : CLP Segment, Element 10


SECONDARYDRGCODE
     Diagnosis Related Group (DRG) Code
        Location : CLP Segment, Element 11


SECONDARYDRGQTY
     Diagnosis Related Group (DRG) Weight
        Location : CLP Segment, Element 12


SECONDARYDISCHGPCT
     Discharge Fraction
        Location : CLP Segment, Element 13


TERTIARYCLAIMPATCTL
     Claim Patient Control Number
        Location :  CLP Segment, Element 1



TERTIARYCLAIMSTATUSCODE
     Claim Staus Code
        Location :  CLP Segment, Element 2


TERTIARYCLAIMSTATUSDESC
     Claim Status Description
        Location :  CLP Segment, Element 2


TERTIARYCLAIMTOTALCHARGE
     Claim Total Charge
        Location :  CLP Segment, Element 3


TERTIARYCLAIMTOTALPAID
     Claim Total Paid
        Location :  CLP Segment, Element 4


TERTIARYPATRESPONSIBLE
     Patient Responsibility
        Location :  CLP Segment, Element 5


TERTIARYFILIND
     Filing Indicator
        Location :  CLP Segment, Element 6


TERTIARYFILINDDESC
     Filing Indicator Description
        Location :  CLP Segment, Element 6

TERTIARYPAYERCLAIMCODE
  Payer Claim Code
        Location :  CLP Segment, Element 7


TERTIARYFACILITYTYPECODE
     Facility Type Code
        Location :  CLP Segment, Element 8


TERTIARYPAYERCLAIMCODE
     Payer Claim Code
        Location :  CLP Segment, Element 8


TERTIARYCLAIMFREQ
     Claim Frequency Code
        Location :  CLP Segment, Element 9


TERTIARYPATSTATCODE
      Patient Status Code
        Location : CLP Segment, Element 10


TERTIARYDRGCODE
     Diagnosis Related Group (DRG) Code
         Location : CLP Segment, Element 11


TERTIARYDRGQTY
      Diagnosis Related Group (DRG) Weight
         Location : CLP Segment, Element 12


TERTIARYDISCHGPCT
      Discharge Fraction
         Location : CLP Segment, Element 13



SUBFNAME
    Subscribers First Name
        Location :  NM1 Segment, Element 4
                    Element 1 Qualifier IL

SUBLNAME
    Subscribers Last Name
        Location :  NM1 Segment, Element 3
                    Element 1 Qualifier IL

SUBMI
    Subscribers Middle Initial
        Location :  NM1 Segment, Element 5
                    Element 1 Qualifier IL

SUBID
    Subscribers ID
        Location :  NM1 Segment, Element 9
                    Element 1 Qualifier IL

SUBIDQUAL
    Subscribers ID Qualifier
        Location :  NM1 Segment, Element 8
                    Element 1 Qualifier IL





PATFNAME
    Patient First Name
        Location :  NM1 Segment, Element 4
                    Element 1 Qualifier QC

PATLNAME
    Patient Last Name
        Location :  NM1 Segment, Element 3
                    Element 1 Qualifier QC

PATMI
    Patient Middle Initial
        Location :  NM1 Segment, Element 5
                    Element 1 Qualifier QC

PATID
    Patient ID
        Location :  NM1 Segment, Element 9
                    Element 1 Qualifier QC

PATIDQUAL
    Patient ID Qualifier
        Location :  NM1 Segment, Element 8
                    Element 1 Qualifier QC



MEDICALRECORDIDNUMBER
    OTHER CLAIM RELATED IDENTIFICATION
    Medical Record Identification Number
        Location :  REF Segment, Element 2
                    Element 1 Qualifier EA


GROUPPOLICYNUMBER
    OTHER CLAIM RELATED IDENTIFICATION
    Group or Policy Number
        Location :  REF Segment, Element 2
                    Element 1 Qualifier 1L


MEMBERIDNUMBER
    OTHER CLAIM RELATED IDENTIFICATION
    Member Identification Number
        Location :  REF Segment, Element 2
                    Element 1 Qualifier 1W


REPRICECLAIMREFNUMBER
    OTHER CLAIM RELATED IDENTIFICATION
    Repriced Claim Reference Number
        Location :  REF Segment, Element 2
                    Element 1 Qualifier 9a


ADJREPRICECLAIMREFNUMBER
    OTHER CLAIM RELATED IDENTIFICATION
    Adjusted Repriced Claim Reference Number
        Location :  REF Segment, Element 2
                    Element 1 Qualifier 9c


EMPLOYEEIDNUMBER
    OTHER CLAIM RELATED IDENTIFICATION
    Employee Identification Number
        Location :  REF Segment, Element 2
                    Element 1 Qualifier A6


AUTHORIZATIONNUMBER
    OTHER CLAIM RELATED IDENTIFICATION
    Authorization Number
        Location :  REF Segment, Element 2
                    Element 1 Qualifier BB


CLASSCONTRACTCODE
    OTHER CLAIM RELATED IDENTIFICATION
    Class of Contract Code
        Location :  REF Segment, Element 2
                    Element 1 Qualifier CE


ORIGINALREFNUMBER
    OTHER CLAIM RELATED IDENTIFICATION
    Original Reference Number
        Location :  REF Segment, Element 2
                    Element 1 Qualifier FB


PRIORAUTHORIZATIONMUMBER
    OTHER CLAIM RELATED IDENTIFICATION
    Prior Authorization Number
        Location :  REF Segment, Element 2
                    Element 1 Qualifier G1


BENEFITIDNUMBER
    OTHER CLAIM RELATED IDENTIFICATION
    Predetermination of Benefits Identification Number
        Location :  REF Segment, Element 2
                    Element 1 Qualifier G3


INSURANCEPOLICYNUMBER
    OTHER CLAIM RELATED IDENTIFICATION
    Insurance Policy Number
        Location :  REF Segment, Element 2
                    Element 1 Qualifier IG

SSN
    OTHER CLAIM RELATED IDENTIFICATION
    Social Security Number
        Location :  REF Segment, Element 2
                    Element 1 Qualifier SY



RENPROVBLUECROSSID
    RENDERING PROVIDER INFORMATION
    Blue Cross Provider Number
        Location :  REF Segment, Element 2
                    Element 1 Qualifier 1A


RENPROVBLUESHIELDID
    RENDERING PROVIDER INFORMATION
    Blue Shield Provider Number
        Location :  REF Segment, Element 2
                    Element 1 Qualifier 1B

RENPROVMEDICAREID
    RENDERING PROVIDER INFORMATION
    Medicare Provider Number
        Location :  REF Segment, Element 2
                    Element 1 Qualifier 1C

RENPROVMEDICAIDID
    RENDERING PROVIDER INFORMATION
    Medicaid Provider Number
        Location :  REF Segment, Element 2
                    Element 1 Qualifier 1D

RENPROVUPINID
    RENDERING PROVIDER INFORMATION
    UPIN Provider Number
        Location :  REF Segment, Element 2
                    Element 1 Qualifier 1G

RENPROVCHAMUSID
    RENDERING PROVIDER INFORMATION
    Champus Provider Number
        Location :  REF Segment, Element 2
                    Element 1 Qualifier 1H

RENPROVFACILITYID
    RENDERING PROVIDER INFORMATION
    Facility Provider Number
        Location :  REF Segment, Element 2
                    Element 1 Qualifier 1J


RENPROVNPIID
    RENDERING PROVIDER INFORMATION
    Natioanl Provider ID Number
        Location :  REF Segment, Element 2
                    Element 1 Qualifier HPI

RENPROVTAXID
    RENDERING PROVIDER INFORMATION
    Federal Tax ID Number
        Location :  REF Segment, Element 2
                    Element 1 Qualifier TJ


CLAIMSUPPLEMENTALCA
    Claim Supplemental Quantity Information Covered - Actual
          Location :  REF Segment, Element 2
                      Element 1 Qualifier CA



CLAIMSUPPLEMENTALCD
    Claim Supplemental Quantity Information Co-insured - Actual
          Location :  REF Segment, Element 2
                      Element 1 Qualifier CD


CLAIMSUPPLEMENTALLA
    Claim Supplemental Quantity Information Life-time Reserve - Actual
          Location :  REF Segment, Element 2
                      Element 1 Qualifier LA



CLAIMSUPPLEMENTALLE
    Claim Supplemental Quantity Information Life-time Reserve - Estimated
          Location :  REF Segment, Element 2
                      Element 1 Qualifier LE



CLAIMSUPPLEMENTALNA
    Claim Supplemental Quantity Information Number of Non-covered Days
          Location :  REF Segment, Element 2
                      Element 1 Qualifier NA


CLAIMSUPPLEMENTALNE
    Claim Supplemental Quantity Information Non-Covered - Estimated
          Location :  REF Segment, Element 2
                      Element 1 Qualifier NE


CLAIMSUPPLEMENTALNR
    Claim Supplemental Quantity Information Not Replaced Blood Units
          Location :  REF Segment, Element 2
                      Element 1 Qualifier NR


CLAIMSUPPLEMENTALOU
    Claim Supplemental Quantity Information Outlier Days
          Location :  REF Segment, Element 2
                      Element 1 Qualifier OU


CLAIMSUPPLEMENTALPS
    Claim Supplemental Quantity Information Prescription
          Location :  REF Segment, Element 2
                      Element 1 Qualifier PS


CLAIMSUPPLEMENTALVS
    Claim Supplemental Quantity Information Visits
          Location :  REF Segment, Element 2
                      Element 1 Qualifier VS


CLAIMSUPPLEMENTALZK
    Claim Supplemental Quantity Information Federal
    Medicare or Medicaid Payment Mandate - Category 1
          Location :  REF Segment, Element 2
                      Element 1 Qualifier ZK


CLAIMSUPPLEMENTALZL
    Claim Supplemental Quantity Information Federal
    Medicare or Medicaid Payment Mandate - Category 2
          Location :  REF Segment, Element 2
                      Element 1 Qualifier ZL


CLAIMSUPPLEMENTALZM
    Claim Supplemental Quantity Information Federal
    Medicare or Medicaid Payment Mandate - Category 3
          Location :  REF Segment, Element 2
                      Element 1 Qualifier ZM

CLAIMSUPPLEMENTALZN
    Claim Supplemental Quantity Information Federal
    Medicare or Medicaid Payment Mandate - Category 4
          Location :  REF Segment, Element 2
                      Element 1 Qualifier ZN

CLAIMSUPPLEMENTALZO
    Claim Supplemental Quantity Information Federal
    Medicare or Medicaid Payment Mandate - Category 5
          Location :  REF Segment, Element 2
                      Element 1 Qualifier ZO



            - - - - - - - - - - - - - - 



                Service Line Level

                     01 to 99


            - - - - - - - - - - - - - - 


DATEOFSERVICE01
     Date of Service
        Location :  DTM Segment, Element 2
                    Element 1 Qualifier 472


PROCEDURE01
     Procedure
        Location :  SVC Segment, Element 1
                    Subvalue 2

PROCEDUREMODA01
     Procedure Modifier
        Location :  SVC Segment, Element 1
                    Subvalue 3


PROCEDUREMODB01
     Procedure Modifier
        Location :  SVC Segment, Element 1
                    Subvalue 4

PROCEDUREMODC01
     Procedure Modifier
        Location :  SVC Segment, Element 1
                    Subvalue 5

PROCEDUREMODD01
     Procedure Modifier
        Location :  SVC Segment, Element 1
                    Subvalue 6

PROCBILLEDAMT01
     Procedure Billed Amount
        Location :  SVC Segment, Element 2
                    

PROCPAYAMT01
     Procedure Paid Amount
        Location :  SVC Segment, Element 3
                    


PROCREVENUECODE01
     Procedure Revenue Code
        Location :  SVC Segment, Element 4
                    


PROCUNITSPAID01
     Procedure Units Paid
        Location :  SVC Segment, Element 5
                    


PROCUNITS01
     Procedure Original Units
        Location :  SVC Segment, Element 7
                    


PROCEDUREDESCRIPTION
     Procedure Code Description
        Location :  SVC Segment, Element 1
                    Subelement 7


PROCALLOWEDAMT01
     Procedure Allowed Amount
        Location :  AMT Segment, Element 2
                    Element 1 Qualifier B6


PROCPERDAYLIMITAMT01
     Procedure Per Day Limit
        Location :  AMT Segment, Element 2
                    Element 1 Qualifier DY


PROCDEDUCTIONAMT01
     Procedure Deduction Amount
        Location :  AMT Segment, Element 2
                    Element 1 Qualifier KH


PROCNETBILLEDAMT01
     Procedure Net Billed
        Location :  AMT Segment, Element 2
                    Element 1 Qualifier NE



PROCTAXAMT01
     Procedure Tax
        Location :  AMT Segment, Element 2
                    Element 1 Qualifier T


PROCTOTALBEFORETAXESAMT01
     Procedure Total Claim Before Taxes
        Location :  AMT Segment, Element 2
                    Element 1 Qualifier T2




PROCPAYAMT01
     Procedure Pay Amount
        Location :  CAS Segment, Element 3
                    Element 1 Qualifier PR


PROCDEDUCTAMT01
     Procedure Deductable Amount
        Location :  CAS Segment, Element 1
                    Element 1 Qualifier PR


PROCCOINSAMT01
     Procedure Coinsurance Amount Amount
        Location :  CAS Segment, Element 2
                    Element 1 Qualifier PR



PROCCOADJAMT01
        Location :  CAS Segment, Element 3
                    Element 1 Qualifier CO

PROCPROTHERAM01
        Location :  CAS Segment, Element 2,5
                    Element 1 Qualifier PR


PROCCOPAYAMT01
        Location :  CAS Segment, Element 3
                    Element 1 Qualifier PR




SERVICEDATEFROM01
      Service Date From
        Location :  DTM Segment, Element 2
                    Element 1 Qualifier 150


SERVICEDATETO01
      Service Date From
        Location :  DTM Segment, Element 2
                    Element 1 Qualifier 151


PROCPRIORAUTHNUMBER01
      Prior Auth
        Location :  REF Segment, Element 2
                    Element 1 Qualifier G1


PROCCTLNUMBER01
      Procedur Line Control Number
        Location :  REF Segment, Element 2
                    Element 1 Qualifier 6R



PROCREMARKCODE01
     Procedure Remark Code
        Location :  LQ Segment, Element 1


Note: 
     n = service line number
     s = segemet occurrence
     o = Occurrence of Field within a segement.

Example : PROCADJCODE1.1
          PROCADJCODE1.2

          PROCADJCODE1.1.1
          PROCADJCODE1.1.2
          PROCADJCODE1.1.3



PROCADJGRPCODEn
PROCADJGRPCODEn.s
     Procedure Adjustment Group Code
        Location :  CAS Segment, Element 2


PROCADJCODEn
PROCADJCODEn.s
PROCADJCODEn.s.o
     Procedure Adjustment Code
        Location :  CAS Segment, Element 3

PROCADJAMTn
PROCADJAMTn.s
PROCADJAMTn.s.o
     Procedure Adjustment Amount
        Location :  CAS Segment, Element 4


PROCADJQTYn
PROCADJQTYn.s
PROCADJQTYn.s.o
     Procedure Adjustment quantity
        Location :  CAS Segment, Element 5




            - - - - - - - - - - - - - - 



                Provider Adjustment



            - - - - - - - - - - - - - - 




PROVADJREFID
    Provider Adjustment Provider Reference ID
        Location :  PLB Segment, Element 1


PROVADJPERIOD
    Provider Adjustment Period
        Location :  PLB Segment, Element 2


PROVADJRESONCODE1
    Provider Adjustment Reason Code
        Location :  PLB Segment, Element 3 
                    SubValue 1                       
PROVADJREASONID1
    Provider Adjustment Reason ID
        Location :  PLB Segment, Element 3 
                    SubValue 2                    
PROVADJAMT1
    Provider Adjustment Amount
        Location :  PLB Segment, Element 4

PROVADJRESONCODE2
    Provider Adjustment Reason Code
        Location :  PLB Segment, Element 5
                    SubValue 1                       
PROVADJREASONID2
    Provider Adjustment Reason ID
        Location :  PLB Segment, Element 5
                    SubValue 2                    
PROVADJAMT2
    Provider Adjustment Amount
        Location :  PLB Segment, Element 6

PROVADJRESONCODE3
    Provider Adjustment Reason Code
        Location :  PLB Segment, Element 7
                    SubValue 1                       
PROVADJREASONID3
    Provider Adjustment Reason ID
        Location :  PLB Segment, Element 7
                    SubValue 2                    
PROVADJAMT3
    Provider Adjustment Amount
        Location :  PLB Segment, Element 8


PROVADJRESONCODE4
    Provider Adjustment Reason Code
        Location :  PLB Segment, Element 9
                    SubValue 1                       
PROVADJREASONID4
    Provider Adjustment Reason ID
        Location :  PLB Segment, Element 9
                    SubValue 2                    
PROVADJAMT4
    Provider Adjustment Amount
        Location :  PLB Segment, Element 10

PROVADJRESONCODE5
    Provider Adjustment Reason Code
        Location :  PLB Segment, Element 11
                    SubValue 1                       
PROVADJREASONID5
    Provider Adjustment Reason ID
        Location :  PLB Segment, Element 11
                    SubValue 2                    
PROVADJAMT5
    Provider Adjustment Amount
        Location :  PLB Segment, Element 12

PROVADJRESONCODE6
    Provider Adjustment Reason Code
        Location :  PLB Segment, Element 13
                    SubValue 1                       
PROVADJREASONID6
    Provider Adjustment Reason ID
        Location :  PLB Segment, Element 13
                    SubValue 2                    
PROVADJAMT6
    Provider Adjustment Amount
        Location :  PLB Segment, Element 14




            - - - - - - - - - - - - - - 



          Medicare Inpatient Adjudication



            - - - - - - - - - - - - - - 




MIACOVDVC 
    Covered Days or Visits Count
         Location : MIA Segment, Element 1


MIAOPOUTAMT
    PPS Operating Outlier Amount
         Location : MIA Segment, Element 2 


MIALIFPSYDAYS
    Lifetime Psychiatric Days Count
         Location : MIA Segment, Element 3


MIADRGAMT
    Claim DRG Amount
         Location : MIA Segment, Element 4


MIAREMARK1
     Remark Code
         Location : MIA Segment, Element 5


MIASHAREAMT
     Claim Disproportionate Share Amount
         Location : MIA Segment, Element 6


MIAMSPPASSAMT
     Claim MSP Pass-through Amount
         Location : MIA Segment, Element 7


MIAPPSCAPAMT
      Claim PPS Capital Amount
         Location : MIA Segment, Element 8


MIAFSPDRGAMT
      PPS-Capital FSP DRG Amount
         Location : MIA Segment, Element 9


MIAHSPDRGAMT
      PPS-Capital HSP DRG Amount 10
         Location : MIA Segment, Element 


MIADHSDRGAMT
      PPS-Capital DSH DRG Amount
         Location : MIA Segment, Element 11


MIAOLDCAPAMT
      Old Capital Amount
         Location : MIA Segment, Element 12


MIAIMEAMT
      PPS-Capital IME amount
         Location : MIA Segment, Element 13


MIAOHSDRG
      PPS-Operating Hospital Specific DRG Amount
         Location : MIA Segment, Element 14


MIACOSTRPTDATCNT
      Cost Report Day Count
         Location : MIA Segment, Element 15


MIAOFSDRG
      PPS-Operating Federal Specific DRG Amount
         Location : MIA Segment, Element 16


MIAPPSCAPOUTAMT
      Claim PPS Capital Outlier Amount
         Location : MIA Segment, Element 17


MIAINDTEACHAMT
      Claim Indirect Teaching Amount
          Location : MIA Segment, Element 18


MIANONPAYPROAMT
      Nonpayable Professional Component Amount
          Location : MIA Segment, Element 19


MIAREMARK2
      Remark Code
           Location : MIA Segment, Element 20


MIAREMARK3
      Remark Code
           Location : MIA Segment, Element 21

MIAREMARK4
      Remark Code
           Location : MIA Segment, Element 22


MIAREMARK5
      Remark Code
           Location : MIA Segment, Element 23


MIACAPEXCPAMT
      PPS-Capital Exception Amount
           Location : MIA Segment, Element 24



            - - - - - - - - - - - - - - 



          Medicare Outpatient Adjudication



            - - - - - - - - - - - - - - 





MOAPERCENT
    Medicare Outpatient Adjudication Percent
        Location :  MOA Segment, Element 1



MOAMOUNTPAYABLE"
    Medicare Outpatient Adjudication Amount
        Location :  MOA Segment, Element 2


MOAREMARK1
    Medicare Outpatient Adjudication Remark 1
        Location :  MOA Segment, Element 3

MOAREMARK2
    Medicare Outpatient Adjudication Remark 2
        Location :  MOA Segment, Element 4

MOAREMARK3
    Medicare Outpatient Adjudication Remark 3
        Location :  MOA Segment, Element 5

MOAREMARK4
    Medicare Outpatient Adjudication Remark 4
        Location :  MOA Segment, Element 6

MOAREMARK5
    Medicare Outpatient Adjudication Remark 5
        Location :  MOA Segment, Element 7

MOAPAYMENT
    Medicare Outpatient Adjudication Payment Amount
        Location :  MOA Segment, Element 8

MOANONPAYABLE
    Medicare Outpatient Adjudication Non Payable Amount
        Location :  MOA Segment, Element 9






Section 10

277 Field Descriptions

[Table of Contents]

This is a list of the fields supported for mapping and are
stored in an XML file called:

C1277.XML for Claim Status


Field names are placed inside the field tags of the xml.

Example :

SUBFNAME
SUBLNAME
SUBMI


- - - - - - - - - - - - - - - - - -





SUBFNAME
Subscribers First Name
Location : NM1 Segment, Element 4
Element 1 Qualifier IL

SUBLNAME
Subscribers Last Name
Location : NM1 Segment, Element 3
Element 1 Qualifier IL

SUBMI
Subscribers Middle Initial
Location : NM1 Segment, Element 5
Element 1 Qualifier IL

SUBIDCODE
Subscribers ID
Location : NM1 Segment, Element 9
Element 1 Qualifier IL


SUBSEX
Subscriber Gender
Location : DMG Segment, Element 3

SUBDOB
Subscriber Date of Birth
Location : DMG Segment, Element 4


PATFNAME
Patient First Name
Location : NM1 Segment, Element 4
Element 1 Qualifier QC

PATLNAME
Patient Last Name
Location : NM1 Segment, Element 3
Element 1 Qualifier QC

PATMI
Patient Middle Initial
Location : NM1 Segment, Element 5
Element 1 Qualifier QC

PATSEX
Patient Gender
Location : DMG Segment, Element 3

PATDOB
Patient Date of Birth
Location : DMG Segment, Element 4


DATEOFSERVICE
Date of Service
Location : DTP Segment, Element 3
Element 1 Qualifier 472

CLAIMPERIODDATESTART
Claim Period Start Date
Location : DTP Segment, Element 3
Element 1 Qualifier 232

DATERECEIVED
Date Received 
Location : DTP Segment, Element 3
Element 1 Qualifier 050

TRACEID
Trace ID
Location : TRN Segment, Element 2

CLAIMPAYMENTMETHODCODE
Claim Payment Method Code 
Location : STC Segment, Element 7


CLAIMCHECKDATE
Claim Check Date
Location : STC Segment, Element 8

CLAIMCHECKNUMBER
Claim Check Number
Location : STC Segment, Element 9

CLAIMTOTALAMOUNT
Claim Total Amount
Location : STC Segment, Element 5


CLAIMPAYMENTAMOUNT
Claim Payment Amount
Location : STC Segment, Element 6

CLAIMSTATUS1
Claim Status 
Location : STC Segment, Element 6


CLAIMSTATUSCODE1

CLAIMSTATUS2

CLAIMSTATUSCODE2

CLAIMSTATUS3

CLAIMSTATUSCODE3



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