Section 1
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
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
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
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
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 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.XMLIn 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 UDFTESTST UDFTESTVER UDFTESTSUBMITTER UDFTESTRECEIVER UDFTESTK3
Section 7
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
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
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
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