Com1SoftwareInc.

X12 Utility

Model : C1D0N497
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Table of Contents

Section 1. - Overview X12 Utility
Section 2. - Features Specifications X12 Utility
Section 3. - Using the X12 Utility
Section 4. - 837P to CMS-1500
Section 5. - 837I to CMS-1450
Section 6. - 837D to ADA Form
Section 7. - 837 Field Descriptions
Section 8. - 837 Field Descriptions
Section 9. - 837 Field Descriptions
Section 10. - 835 Field Descriptions

Updated:07/31/17



Section 1

Overview X12 Utility

[Table of Contents]

X12 Utility
Model C1D0U497 64 bit
Model C1D0N497 32 bit
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
Email: information@com1software.com



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

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

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

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




Section 2

Features Specifications X12 Utility

[Table of Contents]

BASIC CONCEPT

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


270 Eligibility Inquiry
271 Eligibility Response
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.

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

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


Claims software of the users choice can be run from 
within the X12 Utility. The X12 file created by the 
claims software is detected and can processed by the
X12 Utility. 

837 Health Care Claims and 835 Remittances can be 
scanned into a database.


FEATURES
 - HIPAA Compliant X12 Versions 5010 and 4010
 - 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
 - Load 997 transactions on top of 837 claims transactions
   for Line Level Identificartion of error information. 
 - Tracks X12 837 files and their associated X12
   responses.
 - Creates 276 Claim Status Inquiry from an 837 file.
 - Export X12 files to CSV or XML.


SYSTEM SPECIFICATIONS

   Requires a Microsoft Windows Operating System. 
  



Section 3

Using the X12 Utility

[Table of Contents]

The X12 Utility can be used in two basic ways. 

The first use for the X12 Utility is as a file reader that can format
and export x12 files into other formats like XML or CSV.

The second use for the X12 Utility is as an analytic and tracking tool
for your x12 files. 837 and 835 X12 files in a directory can be scanned
into the X12 Utilities database. Once your x12 files have been scanned you 
can locate claims by patient/subscriber name or by claim number. A listing of
totals by date can be generated as well as an export to CSV of the database.


                     - - - - 

The X12 Utility will handle transactions that it recognizes
automatically and displays the data for that format in a
manner that is appropriate for that individual transaction 
type.


The supported transaction types are:

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


Data can also be displayed and printed in a formatted raw data
dump of the x12 transaction it self.

A file can be loaded into the X12 Utility either by:

  - Selecting the file through the menu of the program. 

Once a particular file has been loaded by the Utility, it will display
the appropriate screen for the transaction set.

If a file contains multiple X12 batches within it, that is
to say that there are multiple ISA's within a single file, the X12
Utility will ask the user, which batch to select. 

If a batch contains multiple transaction sets or groups, the user 
will be asked which set they wish to view.


- 837 Health Care Claim

When an 837 Health Care Claim file is loaded into the Utility, the 
View X12 837 selection screen is displayed. Data within the
transaction set is displayed using the name of the subscriber,
the amount of the claim, and the ID of the subscriber.

Within this screen the user has the option selecting one of the claims
within the list for additional detail, listing the data to a printer, 
viewing the data in segment form, and loading a 997 on top of the
already loaded 837 file.


The Listing button will preview before print a listing that is similar
to that of the View X12 837 screen.


The Select button is used to select the highlighted claim in the claim 
list. Once selected, the Claim Data screen is displayed. This screen
will display, in a dynamic list, any supported claim elements that
it can detect and identify. Print a form of this screen and Exits
are options. 

Data detail displayed in this screen are the Subscriber, Patient
demographic information, Claim Totals, Referring and Rendering Physician 
Data, and Individual Service line Data.


Once a 997 has been loaded on top of its appropriate 837, the View Data
can be used to look at the data in a segment format with any errors
in the 837 being identified by a * or ** to the left of the segments
data,indicating an error in association with that particular line.


                     - - - - 



To use the X12 Utility to help you track and locate claims data.


Click on the SCAN button and the 837 and 835 X12 files 
in the specified directory and will be read and indexed
into the X12 Utilities database. 

Once the process of scanning has been completed,
you can go to Locate and search for claims by either subscriber
using last name, first name middle initial or by claim ID.

Partial searches work with locate by subscriber name. 

The claim can be selected for viewing in formated fashion as well 
as by raw data segments.


                     - - - - 


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 utility. 

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.




Section 4

837P to CMS-1500

[Table of Contents]

CMS-1500 Form Location to Mapping Field
and 837P Segment/Element

   Form Locator Carrier Information Block
           Loop 2010BB
           PAYERNAME - NM103
           PAYERADDR1 - N301
           PAYERADDR2 - N302
           PAYERCITY - N401
           PAYERSTATE - N402
           PAYERZIP - N403


   Form Locator 1 - Health Insurance Coverage
            Claim Filing Inicator
            Loop 200B
            SUBCLMTYPECODE -SBR09

   Form Locator 1a - Insured's I.D. Number
             Loop 2010BA
             SUBID - NM109

   Form Locator 2 - Patient's Name
            Loop 2010CA, 2010BA
            PATLNAME - NM103
            PATFNAME - NM104
            PATMI - NM105
                  - NM107

   Form Locator 3 - Patient's Birthdate,Sex
            Loop 2010CA, 2010BA
            PATDOB - DMG02
            PATSEX - DMG03

   Form Locator 4 - Insured's Name
            Loop 2010BA
            SUBLNAME - NM103
            SUBFNAME - NM104
            SUBMI - NM105
                  - NM107



   Form Locator 5 - Patient's Address
            Loop 2010CA
            PATADDR1 - N301
                       N401
                       N402
                       N403

           
   Form Locator 6 - Patient's Relationship to Insured
            Loop 2000B,2000C
            SUBREL - SBR02
            PATREL - PAT01

   Form Locator 7 - Insured's Address
            Loop 2010BA
            SUBADDR1 - N301
                       N401
                       N402
                       N403

           

   Form Locator 8 - Patient Status


   Form Locator 9 - Other Insured's Name
            Loop 2330A
            SUBLNAME - NM103
            SUBFNAME - NM104
            SUBMI - NM105
                  - NM107

            

       9a - Other Insured's Policy or Group Number
            Loop 2320
              SBR03

       9b - Other Insured's Date of Birth
            SUBDOB - DMG02
            SUBSEX - DMG03

       9c - Employers Name or School Name
            Loop 2320

       9d - Insured's plan or program name
              SBR04


  Form Locator 10 - Is Patient's Condition Related to:
       Loop 2300

       10a- Employment
            Field RELATEDCAUSECODE = EM
            CLM11

       10b- Auto Accident
            Field RELATEDCAUSECODE = AA
            CLM11

       10c- Other
            Field RELATEDCAUSECODE = OA
            CLM11

       10d- Local Use 
            
                  
  Form Locator 11 - Insured's Policy Group or FECA Number
            Loop 2000B

            SBR03

       11a- Insured's Date of Birth
            Loop 2010BA
            SUBDOB - DMG02
            SUBSEX - DMG03

       11b- Employer's Name or School Name
            REF01
            REF02

       11c  Insured's plan name or program name
            SBR04


       11d- Is there another health benefit plan?
            Yes if Loop 2320 Present

  Form Locator 12   Patient's or Authorized Person's Signature
            CLM09

  Form Locator 13   Insured's or Authorized Person's Signature
            CLM08

  Form Locator 14   Date of Onset
            DTP03

  Form Locator 15   Other Date
            DTP03
       
  Form Locator 16   Dates patient unable to work in current occupation.
            DTP03

  Form Locator 17   Name of referring physician
            Fields REFLNAME,REFFNAME,REFMI
            NM103
            NM104
            NM105
            NM107


  Form Locator 17a  I.D. number of referring physician
               REF02


  Form Locator 17b  NPI Number
                    Field REFID
                    NM109
              

  Form Locator 18   Hospitalization dates related to current services
                    DTP03

  Form Locator 19   Reserved for local use
                    NTE
                    PWK

  Form Locator 20   Outside Lab Charges
                    PS102

  Form Locator 21   Diagnosis or nature of illness
                    Fields DX1,DX2,DX3,DX4
                    HI01-2
                    HI02-2
                    HI03-2
                    HI03-2


  Form Locator 22   Medicaid resubmission code
                    CLM05-3 Claim Frequency Code
                    REF02 Claim Control Number

  Form Locator 23    Prior authorization number
                     REF02

  Form Locator 24A   Date(s) of service
                     Fields MM_DD_YY_DOSF1 - 99
                            MM_DD_YY_DOST1 - 99
                     DTP03

  Form Locator 24B   Place of service
                     Fields POSCODE1 - 99
                     CLM05-1
                     SV105

  Form Locator 24C   EMG
                     TOSCODE1 - 99
                     SV109


  Form Locator 24D   Procedures, services, or supplies
                     Field PROC1 - 99
                     SV101 2-6

  Form Locator 24E   Diagnosis Pointer
                     Field DXLINK1 - 99
                     SV107 1-4

  Form Locator 24F   Charges
                     Fields AMT1 - 99
                     SV102

  Form Locator 24G   Days or units
                     Fields UNITS1 - 99
                     SV104

  Form Locator 24H   EPSDT family plan
                     SV111
                     SV112

  Form Locator 24I   ID Qualifier
                     PRV02
                     REF01

  Form Locator 24J   Rendering Provider ID
                     Loop 2310B and 2420A
                     NM109

  Form Locator 25    Federal tax I.D. number
                     Loop 2010AA
                     Field HIERARCHIALCLAIMBILLINGPROVIDERIDCODE=34
                           HIERARCHIALCLAIMBILLINGPROVIDERIDCODE=24
                     REF02

  Form Locator 26    Patient's account number
                     Loop 2300
                     Field CLAIMID
                     CLM01

  Form Locator 27    Accept assignment
                     Loop 2300
                     CLM07

  Form Locator 28    Total charges
                     Loop 2300 
                     Field CLAIMAMT
                     CLM02

  Form Locator 29    Amount paid
                     Loop 2300,2320
                     AMT02

  Form Locator 30    Balance due
                     

  Form Locator 31    Signature credentials
                     Loop 2300
                     CLM06

  Form Locator 32    Name and address of facility where services were
                     rendered
                     Loop 2310C
                     Fields FACILITYNAME
                            FACILITYADDR1
                            FACILITYCITY
                            FACILITYSTATE
                            FACILITYZIP
                            SERVICELOCATIONNAME
                            SERVICELOCATIONADDR1
                            SERVICELOCATIONCITY
                            SERVICELOCATIONSTATE
                            SERVICELOCATIONZIP
                     NM103
                     N301
                     N401
                     N402
                     N403

 Form Locator 33     Physician's, supplier's billing name, address, zip
                     code and telephone number
                     Loop 2010AA
                     Fields HIERARCHIALCLAIMBILLINGPROVIDERNAME
                            HIERARCHIALCLAIMBILLINGPROVIDERADDR1
                            HIERARCHIALCLAIMBILLINGPROVIDERCITY
                            HIERARCHIALCLAIMBILLINGPROVIDERST
                            HIERARCHIALCLAIMBILLINGPROVIDERZIP
                            HIERARCHIALCLAIMBILLINGPROVIDERID
                            HIERARCHIALCLAIMBILLINGPROVIDERIDTYPE = National Provider ID
                            HIERARCHIALCLAIMBILLINGPROVIDERSECONDARYIDCODE
                            HIERARCHIALCLAIMBILLINGPROVIDERSECONDARYID
                     NM103
                     NM104
                     NM105
                     NM107
                     N301
                     N401
                     N402
                     N403

                         



Section 5

837I to CMS-1450

[Table of Contents]

CMS-1470 Form Location to Mapping Field
and 837I Segment/Element


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Section 6

837D to ADA Form

[Table of Contents]

ADA Form Location to Mapping Field
and 837D Segment/Element


Form Locator 1 -

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Section 7

837 Field Descriptions

[Table of Contents]

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

C1837I.XML for Institutional

C1837P.XML for Professional 

C1837D.XML for Dental

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

Example :

CLAIMID
CLAIMAMTDDDDDD_CC
CLAIMAMT


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





CLAIMID
      Claim ID
        Location :  CLM Segment, Element 1


CLAIMAMTDDDDDD_CC
      Claim Amount
        Location :  CLM Segment, Element 2


CLAIMAMT
      Claim Amount
        Location :  CLM Segment, Element 2


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


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



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


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


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



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


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


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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



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







PROVSIGNATUREONFILE
      Provider Signature
        Location :  CLM Segment, Element 6


PROVACCEPTASSIGNMENTCODE
      Provider Assignment 
        Location :  CLM Segment, Element 7



BENEFITINDICATOR
      Benefit Indicator
        Location :  CLM Segment, Element 8



RELEASEOFINFORMATION
      Release of Information
        Location :  CLM Segment, Element 9



RELATEDCAUSECODE
      Related Cause
        Location :  CLM Segment, Element 11



RELATEDCAUSE
      Related Cause
        Location :  CLM Segment, Element 11


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


DISCHARGEDATE
      Discharge Date
        Location :  CR6 Segment, Element 5



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

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



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



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



ADMISSIONSOURCECODE
      Addmission Source Code
        Location :  CL1 Segment, Element 2



ADMISSIONSOURCE
      Addmission Source
        Location :  CL1 Segment, Element 2



PATIENTSTATUSCODE
      Patient Status Code
        Location :  CL1 Segment, Element 3



PATIENTSTATUS
      Patient Status
        Location :  CL1 Segment, Element 3


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


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

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



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


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


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


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


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


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


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


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


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



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



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



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

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

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

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

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

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

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

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

SEGMENTNOTE
      Segment Note
        Location :  DMG Segment, Element 3


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


FACILITYCODEVALUE
      Facility Code Value
        Location :  CLM Segment, Element 6


FREQUENCYTYPECODE
      Frequency Type Code 
        Location :  CLM Segment, Element 6

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

K3DATA
      K3 Data
        Location :  K3 Segment, Element 1

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

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

NDCUNITS
      NDC Units
        Location :  CTP Segment, Element 4

TYPEOFBILL
      Type of Bill
        Location :  CLM Segment, Element 6


FREQUENCYCODE
      Frequency Type Code 
        Location :  CLM Segment, Element 6

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

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

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


DRG
      DRG
        Location :  HI Segment, Element 1
                    Qualifier DR

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


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



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


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


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

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



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

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



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

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


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

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



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


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


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

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


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


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


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


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


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

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


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

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



SUBCLMTYPECODE
      Subscriber Claim Type
        Location :  SBR Segment, Element 9


SUBCLMTYPE
      Subscriber Claim Type
        Location :  SBR Segment, Element 9


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


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


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


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



SUBADDR1
      Subscriber Address 1
        Location :  N3 Segment, Element 1



SUBADDR2
      Subscriber Address 2
        Location :  N3 Segment, Element 2


SUBCITY
      Subscriber City
        Location :  N4 Segment, Element 1


SUBST
      Subscriber State
        Location :  N4 Segment, Element 2


SUBZIP
      Subscriber Zip 
        Location :  N4 Segment, Element 3


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



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


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


SUBMSTATUS
      Subscriber Prefix
        Location :  DMG Segment, Element 4



SUBORDER
      Subscriber Coverage Order
        Location :  SBR Segment, Element 1


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



SUBGROUPNAME
      Subscriber Group Name
        Location :  SBR Segment, Element 3



SUBSEX
      Subscriber Gender
        Location :  DMG Segment, Element 3





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





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

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

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


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


PAYERCITY
      Payer City
        Location :  N4 Segment, Element 1

PAYERSTATE
      Payer State
        Location :  N4 Segment, Element 2

PAYERZIP
      Payer Zip Code
        Location :  N4 Segment, Element 3





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


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


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


PATADDR1
      Patient Address 1
        Location :  N3 Segment, Element 1
          



PATADDR2
      Patient Address 2
        Location :  N3 Segment, Element 2
          

PATCITY
      Patient City
        Location :  N4 Segment, Element 1
          


PATST
      Patient State
        Location :  N4 Segment, Element 2

PATZIP
      Patient Zip
        Location :  N4 Segment, Element 3


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

PATSEX
      Patient Gender
        Location :  DMG Segment, Element 3



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


PATSIGNATURESOURCE
      Patient Signature Source
        Location :  CLM Segment, Element 10



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

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

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

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


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

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



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


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


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

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

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


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


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


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

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

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


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


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

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

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


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



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


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


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

FACILITYCITY
      Facility City
        Location :  N4 Segment, Element 1


FACILITYST
      Facility State
        Location :  N4 Segment, Element 2

FACILITYZIP
      Facility Zip Code
        Location :  N4 Segment, Element 3


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


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


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


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


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


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


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


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


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


SERVICELOCATIONCITY
      Service Localtion City
        Location :  N4 Segment, Element 1


SERVICELOCATIONST
      Service Localtion State
        Location :  N4 Segment, Element 2


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


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


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

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


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


ILABCITY
     Independent LAB City
        Location :  N4 Segment, Element 1


ILABST
     Independent LAB State
        Location :  N4 Segment, Element 2

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


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

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


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

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


TLABCITY
     Testing LAB City
        Location :  N4 Segment, Element 1

TLABST
     Testing LAB State
        Location :  N4 Segment, Element 2


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


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


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

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

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

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



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

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

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

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

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




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

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


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



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


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



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


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



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


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


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


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



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


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




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


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


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


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


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



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



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


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


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





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




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


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




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





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


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



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



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


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




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



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



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


PRIMARYSUBCITY
      Primary Subscriber City
        Location :  N4 Segment, Element 1


PRIMARYSUBSTATE
      Primary Subscriber State
        Location :  N4 Segment, Element 2


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


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



PRIMARYSUBSEX
      Primary Subscriber Gender
        Location :  DMG Segment, Element 3


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



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


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



PRIMARYPAYERCITY
      Primary Payer City
        Location :  N4 Segment, Element 1



PRIMARYPAYERSTATE
      Primary Payer State
        Location :  N4 Segment, Element 2



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



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







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


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



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



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


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




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



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



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


SECONDARYSUBCITY
      Secondary Subscriber City
        Location :  N4 Segment, Element 1


SECONDARYSUBSTATE
      Secondary Subscriber State
        Location :  N4 Segment, Element 2


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


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



SECONDARYSUBSEX
      Secondary Subscriber Gender
        Location :  DMG Segment, Element 3


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



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


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



SECONDARYPAYERCITY
      Secondary Payer City
        Location :  N4 Segment, Element 1



SECONDARYPAYERSTATE
      Secondary Payer State
        Location :  N4 Segment, Element 2



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



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







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


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



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



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


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




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



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



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


TERTIARYSUBCITY
      Tertiary Subscriber City
        Location :  N4 Segment, Element 1


TERTIARYSUBSTATE
      Tertiary Subscriber State
        Location :  N4 Segment, Element 2


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


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



TERTIARYSUBSEX
      Tertiary Subscriber Gender
        Location :  DMG Segment, Element 3


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



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


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



TERTIARYPAYERCITY
      Tertiary Payer City
        Location :  N4 Segment, Element 1



TERTIARYPAYERSTATE
      Tertiary Payer State
        Location :  N4 Segment, Element 2



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



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















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

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


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

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


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



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



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


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


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


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



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


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



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



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



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



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



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


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



TSCONTROLNUMBER
   Batch Conrol Number 
        Location :  ST Segment, Element 2


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


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



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


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



SUBMITTERCITY
    Submitter City
        Location :  N4 Segment, Element 1


SUBMITTERST
    Submitter State
        Location :  N4 Segment, Element 2



SUBMITTERZIP
    Submitter Zip Code
        Location :  N4 Segment, Element 3



SUBMITTERCONTACT
    Submitter Contact
        Location :  PER Segment, Element 2


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



SUBMITTERCONTACT
   Submitter ID
        Location :  PER Segment, Element 3


SUBMITTERCOMMQUALA
   Submitter ID
        Location :  PER Segment, Element 4


SUBMITTERCOMMNUMBERA
   Submitter ID
        Location :  PER Segment, Element 5


SUBMITTERCOMMQUALB
   Submitter ID
        Location :  PER Segment, Element 6


SUBMITTERCOMMNUMBERB
   Submitter ID
        Location :  PER Segment, Element 7

SUBMITTERCOMMQUALC
   Submitter ID
        Location :  PER Segment, Element 8


SUBMITTERCOMMNUMBERC
   Submitter ID
        Location :  PER Segment, Element 9


         


RECEIVERID
   Receiver
        Location :  NM1 Segment, Element 9
                    Qualifier 41


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


RECEIVERADDITIONALNAME
   Receiver Additional Name
        Location :  N2 Segment, Element 1


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



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


RECEIVERCITY
   Receiver Address City
        Location :  N4 Segment, Element 1

RECEIVERST
   Receiver Address State
        Location :  N4 Segment, Element 2


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



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


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


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


BILLINGPROVIDERCITY
    Billing Provider City
        Location :  N4 Segment, Element 1


BILLINGPROVIDERST
    Billing Provider State
        Location :  N4 Segment, Element 2



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


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


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


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



BILLINGPROVIDERCONTACT
   BILLINGPROVIDER ID
        Location :  PER Segment, Element 3


BILLINGPROVIDERCOMMQUALA
   BILLINGPROVIDER ID
        Location :  PER Segment, Element 4


BILLINGPROVIDERCOMMNUMBERA
   BILLINGPROVIDER ID
        Location :  PER Segment, Element 5


BILLINGPROVIDERCOMMQUALB
   BILLINGPROVIDER ID
        Location :  PER Segment, Element 6


BILLINGPROVIDERCOMMNUMBERB
   BILLINGPROVIDER ID
        Location :  PER Segment, Element 7

BILLINGPROVIDERCOMMQUALC
   BILLINGPROVIDER ID
        Location :  PER Segment, Element 8


BILLINGPROVIDERCOMMNUMBERC
   BILLINGPROVIDER ID
        Location :  PER Segment, Element 9


         





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



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



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


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


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



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



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




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



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




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

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

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



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

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


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


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


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

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

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

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

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

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


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

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


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


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


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

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


ILINE01

IPROCTYPE01

IPROC01

IMODA01

IMODB01

IMODC01

IMODD01

IAMT01

IUNITSTYPE01

IUNITSQTY01

IUNITSRATE01

IUNITS01

IDOS01

NDCCODE01

NDCUNITPRICE01

NDCUNITS01

IADJUDDATE01

IADJUDID01

IADJUDAMT01



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

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


PPROC01

MODA01

MODB01

MODC01

MODD01

DOS01

MM_DD_YY_DOSF01

MM_DD_YY_DOST01

AMT01

DDDDDD_CC01

POSLINECODE01

UNITS01

DXLINK01

SUPDXLINKA01

SUPDXLINKB01

SUPDXLINKC01

SUPDXLINKD01


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

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

DPROC01

DMODA01

DMODB01

DMODC01

DMODD01

DAMT01

TOOTHSURFACE

TOOTH01

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

General Service Line Level Fields

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

LINEITEMCONTROLNUMBER01



Section 8

837 Field Descriptions

[Table of Contents]

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

C1837I.XML for Institutional

C1837P.XML for Professional 

C1837D.XML for Dental

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

Example :

CLAIMID
CLAIMAMTDDDDDD_CC
CLAIMAMT


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





CLAIMID
      Claim ID
        Location :  CLM Segment, Element 1


CLAIMAMTDDDDDD_CC
      Claim Amount
        Location :  CLM Segment, Element 2


CLAIMAMT
      Claim Amount
        Location :  CLM Segment, Element 2


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


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



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


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


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



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


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


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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



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







PROVSIGNATUREONFILE
      Provider Signature
        Location :  CLM Segment, Element 6


PROVACCEPTASSIGNMENTCODE
      Provider Assignment 
        Location :  CLM Segment, Element 7



BENEFITINDICATOR
      Benefit Indicator
        Location :  CLM Segment, Element 8



RELEASEOFINFORMATION
      Release of Information
        Location :  CLM Segment, Element 9



RELATEDCAUSECODE
      Related Cause
        Location :  CLM Segment, Element 11



RELATEDCAUSE
      Related Cause
        Location :  CLM Segment, Element 11


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


DISCHARGEDATE
      Discharge Date
        Location :  CR6 Segment, Element 5



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

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



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



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



ADMISSIONSOURCECODE
      Addmission Source Code
        Location :  CL1 Segment, Element 2



ADMISSIONSOURCE
      Addmission Source
        Location :  CL1 Segment, Element 2



PATIENTSTATUSCODE
      Patient Status Code
        Location :  CL1 Segment, Element 3



PATIENTSTATUS
      Patient Status
        Location :  CL1 Segment, Element 3


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


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

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



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


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


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


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


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


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


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


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


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



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



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



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

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

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

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

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

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

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

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

SEGMENTNOTE
      Segment Note
        Location :  DMG Segment, Element 3


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


FACILITYCODEVALUE
      Facility Code Value
        Location :  CLM Segment, Element 6


FREQUENCYTYPECODE
      Frequency Type Code 
        Location :  CLM Segment, Element 6

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

K3DATA
      K3 Data
        Location :  K3 Segment, Element 1

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

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

NDCUNITS
      NDC Units
        Location :  CTP Segment, Element 4

TYPEOFBILL
      Type of Bill
        Location :  CLM Segment, Element 6


FREQUENCYCODE
      Frequency Type Code 
        Location :  CLM Segment, Element 6

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

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

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


DRG
      DRG
        Location :  HI Segment, Element 1
                    Qualifier DR

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


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



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


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


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

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



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

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



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

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


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

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



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


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


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

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


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


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


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


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


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

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


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

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



SUBCLMTYPECODE
      Subscriber Claim Type
        Location :  SBR Segment, Element 9


SUBCLMTYPE
      Subscriber Claim Type
        Location :  SBR Segment, Element 9


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


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


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


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



SUBADDR1
      Subscriber Address 1
        Location :  N3 Segment, Element 1



SUBADDR2
      Subscriber Address 2
        Location :  N3 Segment, Element 2


SUBCITY
      Subscriber City
        Location :  N4 Segment, Element 1


SUBST
      Subscriber State
        Location :  N4 Segment, Element 2


SUBZIP
      Subscriber Zip 
        Location :  N4 Segment, Element 3


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



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


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


SUBMSTATUS
      Subscriber Prefix
        Location :  DMG Segment, Element 4



SUBORDER
      Subscriber Coverage Order
        Location :  SBR Segment, Element 1


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



SUBGROUPNAME
      Subscriber Group Name
        Location :  SBR Segment, Element 3



SUBSEX
      Subscriber Gender
        Location :  DMG Segment, Element 3





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





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

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

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


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


PAYERCITY
      Payer City
        Location :  N4 Segment, Element 1

PAYERSTATE
      Payer State
        Location :  N4 Segment, Element 2

PAYERZIP
      Payer Zip Code
        Location :  N4 Segment, Element 3





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


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


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


PATADDR1
      Patient Address 1
        Location :  N3 Segment, Element 1
          



PATADDR2
      Patient Address 2
        Location :  N3 Segment, Element 2
          

PATCITY
      Patient City
        Location :  N4 Segment, Element 1
          


PATST
      Patient State
        Location :  N4 Segment, Element 2

PATZIP
      Patient Zip
        Location :  N4 Segment, Element 3


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

PATSEX
      Patient Gender
        Location :  DMG Segment, Element 3



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


PATSIGNATURESOURCE
      Patient Signature Source
        Location :  CLM Segment, Element 10



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

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

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

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


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

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



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


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


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

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

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


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


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


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

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

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


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


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

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

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


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



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


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


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

FACILITYCITY
      Facility City
        Location :  N4 Segment, Element 1


FACILITYST
      Facility State
        Location :  N4 Segment, Element 2

FACILITYZIP
      Facility Zip Code
        Location :  N4 Segment, Element 3


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


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


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


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


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


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


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


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


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


SERVICELOCATIONCITY
      Service Localtion City
        Location :  N4 Segment, Element 1


SERVICELOCATIONST
      Service Localtion State
        Location :  N4 Segment, Element 2


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


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


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

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


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


ILABCITY
     Independent LAB City
        Location :  N4 Segment, Element 1


ILABST
     Independent LAB State
        Location :  N4 Segment, Element 2

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


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

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


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

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


TLABCITY
     Testing LAB City
        Location :  N4 Segment, Element 1

TLABST
     Testing LAB State
        Location :  N4 Segment, Element 2


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


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


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

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

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

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



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

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

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

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

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




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

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


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



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


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



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


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



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


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


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


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



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


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




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


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


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


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


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



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



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


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


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





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




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


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




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





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


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



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



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


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




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



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



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


PRIMARYSUBCITY
      Primary Subscriber City
        Location :  N4 Segment, Element 1


PRIMARYSUBSTATE
      Primary Subscriber State
        Location :  N4 Segment, Element 2


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


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



PRIMARYSUBSEX
      Primary Subscriber Gender
        Location :  DMG Segment, Element 3


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



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


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



PRIMARYPAYERCITY
      Primary Payer City
        Location :  N4 Segment, Element 1



PRIMARYPAYERSTATE
      Primary Payer State
        Location :  N4 Segment, Element 2



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



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







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


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



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



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


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




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



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



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


SECONDARYSUBCITY
      Secondary Subscriber City
        Location :  N4 Segment, Element 1


SECONDARYSUBSTATE
      Secondary Subscriber State
        Location :  N4 Segment, Element 2


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


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



SECONDARYSUBSEX
      Secondary Subscriber Gender
        Location :  DMG Segment, Element 3


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



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


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



SECONDARYPAYERCITY
      Secondary Payer City
        Location :  N4 Segment, Element 1



SECONDARYPAYERSTATE
      Secondary Payer State
        Location :  N4 Segment, Element 2



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



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







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


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



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



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


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




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



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



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


TERTIARYSUBCITY
      Tertiary Subscriber City
        Location :  N4 Segment, Element 1


TERTIARYSUBSTATE
      Tertiary Subscriber State
        Location :  N4 Segment, Element 2


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


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



TERTIARYSUBSEX
      Tertiary Subscriber Gender
        Location :  DMG Segment, Element 3


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



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


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



TERTIARYPAYERCITY
      Tertiary Payer City
        Location :  N4 Segment, Element 1



TERTIARYPAYERSTATE
      Tertiary Payer State
        Location :  N4 Segment, Element 2



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



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















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

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


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

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


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



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



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


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


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


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



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


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



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



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



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



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



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


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



TSCONTROLNUMBER
   Batch Conrol Number 
        Location :  ST Segment, Element 2


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


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



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


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



SUBMITTERCITY
    Submitter City
        Location :  N4 Segment, Element 1


SUBMITTERST
    Submitter State
        Location :  N4 Segment, Element 2



SUBMITTERZIP
    Submitter Zip Code
        Location :  N4 Segment, Element 3



SUBMITTERCONTACT
    Submitter Contact
        Location :  PER Segment, Element 2


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



SUBMITTERCOMMQUALA
   Submitter ID
        Location :  PER Segment, Element 3


SUBMITTERCOMMNUMBERA
   Submitter ID
        Location :  PER Segment, Element 4


SUBMITTERCOMMQUALB
   Submitter ID
        Location :  PER Segment, Element 5


SUBMITTERCOMMNUMBERB
   Submitter ID
        Location :  PER Segment, Element 6

SUBMITTERCOMMQUALC
   Submitter ID
        Location :  PER Segment, Element 7


SUBMITTERCOMMNUMBERC
   Submitter ID
        Location :  PER Segment, Element 8


         


RECEIVERID
   Receiver
        Location :  NM1 Segment, Element 9
                    Qualifier 41


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


RECEIVERADDITIONALNAME
   Receiver Additional Name
        Location :  N2 Segment, Element 1


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



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


RECEIVERCITY
   Receiver Address City
        Location :  N4 Segment, Element 1

RECEIVERST
   Receiver Address State
        Location :  N4 Segment, Element 2


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



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


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


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


BILLINGPROVIDERCITY
    Billing Provider City
        Location :  N4 Segment, Element 1


BILLINGPROVIDERST
    Billing Provider State
        Location :  N4 Segment, Element 2



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


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


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


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



BILLINGPROVIDERCONTACT
   BILLINGPROVIDER ID
        Location :  PER Segment, Element 3


BILLINGPROVIDERCOMMQUALA
   BILLINGPROVIDER ID
        Location :  PER Segment, Element 4


BILLINGPROVIDERCOMMNUMBERA
   BILLINGPROVIDER ID
        Location :  PER Segment, Element 5


BILLINGPROVIDERCOMMQUALB
   BILLINGPROVIDER ID
        Location :  PER Segment, Element 6


BILLINGPROVIDERCOMMNUMBERB
   BILLINGPROVIDER ID
        Location :  PER Segment, Element 7

BILLINGPROVIDERCOMMQUALC
   BILLINGPROVIDER ID
        Location :  PER Segment, Element 8


BILLINGPROVIDERCOMMNUMBERC
   BILLINGPROVIDER ID
        Location :  PER Segment, Element 9


         





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



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



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


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


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



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



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




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



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




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

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

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



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

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


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


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


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

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

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

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

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

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


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

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


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


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


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

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


ILINE01

IPROCTYPE01

IPROC01

IMODA01

IMODB01

IMODC01

IMODD01

IAMT01

IUNITSTYPE01

IUNITSQTY01

IUNITSRATE01

IUNITS01

IDOS01

NDCCODE01

NDCUNITPRICE01

NDCUNITS01

IADJUDDATE01

IADJUDID01

IADJUDAMT01



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

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


PPROC01

MODA01

MODB01

MODC01

MODD01

DOS01

MM_DD_YY_DOSF01

MM_DD_YY_DOST01

AMT01

DDDDDD_CC01

POSLINECODE01

UNITS01

DXLINK01

SUPDXLINKA01

SUPDXLINKB01

SUPDXLINKC01

SUPDXLINKD01


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

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

DPROC01

DMODA01

DMODB01

DMODC01

DMODD01

DAMT01

TOOTHSURFACE

TOOTH01

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

General Service Line Level Fields

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

LINEITEMCONTROLNUMBER01


SBS00684b



Section 10

835 Field Descriptions

[Table of Contents]

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

 Example :

         CLAIMPATCTL
         CLAIMSTATUSCODE
         CLAIMTOTALCHARGE
         CLAIMTOTALPAID


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


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



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



CLAIMSTATUSCODE
     Claim Staus Code
        Location :  CLP Segment, Element 2


CLAIMSTATUSDESC
     Claim Status Description
        Location :  CLP Segment, Element 2


CLAIMTOTALCHARGE
     Claim Total Charge
        Location :  CLP Segment, Element 3


CLAIMTOTALPAID
     Claim Total Paid
        Location :  CLP Segment, Element 4


PATRESPONSIBLE
     Patient Responsibility
        Location :  CLP Segment, Element 5


FILIND
     Filing Indicator
        Location :  CLP Segment, Element 6


FILINDDESC
     Filing Indicator Description
        Location :  CLP Segment, Element 6

PAYERCLAIMCODE
  Payer Claim Code
        Location :  CLP Segment, Element 7


FACILITYTYPECODE
     Facility Type Code
        Location :  CLP Segment, Element 8


PAYERCLAIMCODE
     Payer Claim Code
        Location :  CLP Segment, Element 8


CLAIMFREQ
     Claim Frequency Code
        Location :  CLP Segment, Element 9


PATSTATCODE
     Patient Status Code
        Location : CLP Segment, Element 10


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


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


DISCHGPCT
     Discharge Fraction
        Location : CLP Segment, Element 13


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


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


CLMADJCODE
        Location :  CAS Segment, Element 2
        Loop 2100        
 

CLMADJAMT
        Location :  CAS Segment, Element 3
        Loop 2100        



CLMADJQTY
        Location :  CAS Segment, Element 4
        Loop 2100        



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

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


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




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


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


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


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




TRANSHANDCODE
    Transaction Handling Code
        Location :  BPR Segment, Element 1




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



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




TRANSPAYMETHOD
    Transaction Payment Method
        Location :  BPR Segment, Element 4




TRANSDATE
    Transaction Date
        Location :  BPR Segment, Element 16



TRACEREFRENCEID
    Trace Reference Identification
        Location :  TRN Segment, Element 4


TRACEREFID
    Trace Reference Identification
        Location :  TRN Segment, Element 2


TRACEORGID
    Trace Originating Identifier
        Location :  TRN Segment, Element 4


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



PAYEEADID
    PAYEE ADDITIONAL IDENTIFICATION
        Location :  REF Segment, Element 2


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


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


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


PAYERADDRESS1
    Payer Address 1
        Location :  N3 Segment, Element 1


PAYERADDRESS2
    Payer Address 2
        Location :  N3 Segment, Element 2


PAYERCITY
    Payer City
        Location :  N4 Segment, Element 1


PAYERSTATE
    Payer State
        Location :  N4 Segment, Element 2


PAYERZIPCODE
    Payer Zip Code
        Location :  N4 Segment, Element 3



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


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


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


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


PAYEENAME
    Payee Name
        Location :  N1 Segment, Element 2


PAYEEADDRESS1
    Payee Address 1
        Location :  N3 Segment, Element 1

PAYEEADDRESS2
    Payee Address 2
        Location :  N3 Segment, Element 3

PAYEECITY
    Payee City
        Location :  N4 Segment, Element 1

PAYEESTATE
    Payee State
        Location :  N4 Segment, Element 2

PAYEEZIPCODE
    Payee Zip Code
        Location :  N4 Segment, Element 3

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

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

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




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



PRIMARYCLAIMSTATUSCODE
     Claim Staus Code
        Location :  CLP Segment, Element 2


PRIMARYCLAIMSTATUSDESC
     Claim Status Description
        Location :  CLP Segment, Element 2


PRIMARYCLAIMTOTALCHARGE
     Claim Total Charge
        Location :  CLP Segment, Element 3


PRIMARYCLAIMTOTALPAID
     Claim Total Paid
        Location :  CLP Segment, Element 4


PRIMARYPATRESPONSIBLE
     Patient Responsibility
        Location :  CLP Segment, Element 5


PRIMARYFILIND
     Filing Indicator
        Location :  CLP Segment, Element 6


PRIMARYFILINDDESC
     Filing Indicator Description
        Location :  CLP Segment, Element 6

PRIMARYPAYERCLAIMCODE
  Payer Claim Code
        Location :  CLP Segment, Element 7


PRIMARYFACILITYTYPECODE
     Facility Type Code
        Location :  CLP Segment, Element 8


PRIMARYPAYERCLAIMCODE
     Payer Claim Code
        Location :  CLP Segment, Element 8


PRIMARYCLAIMFREQ
     Claim Frequency Code
        Location :  CLP Segment, Element 9



PRIMARYPATSTATCODE
     Patient Status Code
        Location : CLP Segment, Element 10


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


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


PRIMARYDISCHGPCT
     Discharge Fraction
        Location : CLP Segment, Element 13


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


SECONDARYCLAIMSTATUSCODE
     Claim Staus Code
        Location :  CLP Segment, Element 2


SECONDARYCLAIMSTATUSDESC
     Claim Status Description
        Location :  CLP Segment, Element 2


SECONDARYCLAIMTOTALCHARGE
     Claim Total Charge
        Location :  CLP Segment, Element 3


SECONDARYCLAIMTOTALPAID
     Claim Total Paid
        Location :  CLP Segment, Element 4


SECONDARYPATRESPONSIBLE
     Patient Responsibility
        Location :  CLP Segment, Element 5


SECONDARYFILIND
     Filing Indicator
        Location :  CLP Segment, Element 6


SECONDARYFILINDDESC
     Filing Indicator Description
        Location :  CLP Segment, Element 6

SECONDARYPAYERCLAIMCODE
  Payer Claim Code
        Location :  CLP Segment, Element 7


SECONDARYFACILITYTYPECODE
     Facility Type Code
        Location :  CLP Segment, Element 8


SECONDARYPAYERCLAIMCODE
     Payer Claim Code
        Location :  CLP Segment, Element 8


SECONDARYCLAIMFREQ
     Claim Frequency Code
        Location :  CLP Segment, Element 9


SECONDARYPATSTATCODE
     Patient Status Code
        Location : CLP Segment, Element 10


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


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


SECONDARYDISCHGPCT
     Discharge Fraction
        Location : CLP Segment, Element 13


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



TERTIARYCLAIMSTATUSCODE
     Claim Staus Code
        Location :  CLP Segment, Element 2


TERTIARYCLAIMSTATUSDESC
     Claim Status Description
        Location :  CLP Segment, Element 2


TERTIARYCLAIMTOTALCHARGE
     Claim Total Charge
        Location :  CLP Segment, Element 3


TERTIARYCLAIMTOTALPAID
     Claim Total Paid
        Location :  CLP Segment, Element 4


TERTIARYPATRESPONSIBLE
     Patient Responsibility
        Location :  CLP Segment, Element 5


TERTIARYFILIND
     Filing Indicator
        Location :  CLP Segment, Element 6


TERTIARYFILINDDESC
     Filing Indicator Description
        Location :  CLP Segment, Element 6

TERTIARYPAYERCLAIMCODE
  Payer Claim Code
        Location :  CLP Segment, Element 7


TERTIARYFACILITYTYPECODE
     Facility Type Code
        Location :  CLP Segment, Element 8


TERTIARYPAYERCLAIMCODE
     Payer Claim Code
        Location :  CLP Segment, Element 8


TERTIARYCLAIMFREQ
     Claim Frequency Code
        Location :  CLP Segment, Element 9


TERTIARYPATSTATCODE
      Patient Status Code
        Location : CLP Segment, Element 10


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


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


TERTIARYDISCHGPCT
      Discharge Fraction
         Location : CLP Segment, Element 13



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

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

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

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

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





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

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

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

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

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



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


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


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


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


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


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


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


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


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


PRIORAUTHORIZATIONMUMBER
    OTHER CLAIM RELATED IDENTIFICATION
    Prior Authorization Number
        Location :  REF Segment, Element 2
                    Element 1 Qualifier G1


BENEFITIDNUMBER
    OTHER CLAIM RELATED IDENTIFICATION
    Predetermination of Benefits Identification Number
        Location :  REF Segment, Element 2
                    Element 1 Qualifier G3


INSURANCEPOLICYNUMBER
    OTHER CLAIM RELATED IDENTIFICATION
    Insurance Policy Number
        Location :  REF Segment, Element 2
                    Element 1 Qualifier IG

SSN
    OTHER CLAIM RELATED IDENTIFICATION
    Social Security Number
        Location :  REF Segment, Element 2
                    Element 1 Qualifier SY



RENPROVBLUECROSSID
    RENDERING PROVIDER INFORMATION
    Blue Cross Provider Number
        Location :  REF Segment, Element 2
                    Element 1 Qualifier 1A


RENPROVBLUESHIELDID
    RENDERING PROVIDER INFORMATION
    Blue Shield Provider Number
        Location :  REF Segment, Element 2
                    Element 1 Qualifier 1B

RENPROVMEDICAREID
    RENDERING PROVIDER INFORMATION
    Medicare Provider Number
        Location :  REF Segment, Element 2
                    Element 1 Qualifier 1C

RENPROVMEDICAIDID
    RENDERING PROVIDER INFORMATION
    Medicaid Provider Number
        Location :  REF Segment, Element 2
                    Element 1 Qualifier 1D

RENPROVUPINID
    RENDERING PROVIDER INFORMATION
    UPIN Provider Number
        Location :  REF Segment, Element 2
                    Element 1 Qualifier 1G

RENPROVCHAMUSID
    RENDERING PROVIDER INFORMATION
    Champus Provider Number
        Location :  REF Segment, Element 2
                    Element 1 Qualifier 1H

RENPROVFACILITYID
    RENDERING PROVIDER INFORMATION
    Facility Provider Number
        Location :  REF Segment, Element 2
                    Element 1 Qualifier 1J


RENPROVNPIID
    RENDERING PROVIDER INFORMATION
    Natioanl Provider ID Number
        Location :  REF Segment, Element 2
                    Element 1 Qualifier HPI

RENPROVTAXID
    RENDERING PROVIDER INFORMATION
    Federal Tax ID Number
        Location :  REF Segment, Element 2
                    Element 1 Qualifier TJ


CLAIMSUPPLEMENTALCA
    Claim Supplemental Quantity Information Covered - Actual
          Location :  REF Segment, Element 2
                      Element 1 Qualifier CA



CLAIMSUPPLEMENTALCD
    Claim Supplemental Quantity Information Co-insured - Actual
          Location :  REF Segment, Element 2
                      Element 1 Qualifier CD


CLAIMSUPPLEMENTALLA
    Claim Supplemental Quantity Information Life-time Reserve - Actual
          Location :  REF Segment, Element 2
                      Element 1 Qualifier LA



CLAIMSUPPLEMENTALLE
    Claim Supplemental Quantity Information Life-time Reserve - Estimated
          Location :  REF Segment, Element 2
                      Element 1 Qualifier LE



CLAIMSUPPLEMENTALNA
    Claim Supplemental Quantity Information Number of Non-covered Days
          Location :  REF Segment, Element 2
                      Element 1 Qualifier NA


CLAIMSUPPLEMENTALNE
    Claim Supplemental Quantity Information Non-Covered - Estimated
          Location :  REF Segment, Element 2
                      Element 1 Qualifier NE


CLAIMSUPPLEMENTALNR
    Claim Supplemental Quantity Information Not Replaced Blood Units
          Location :  REF Segment, Element 2
                      Element 1 Qualifier NR


CLAIMSUPPLEMENTALOU
    Claim Supplemental Quantity Information Outlier Days
          Location :  REF Segment, Element 2
                      Element 1 Qualifier OU


CLAIMSUPPLEMENTALPS
    Claim Supplemental Quantity Information Prescription
          Location :  REF Segment, Element 2
                      Element 1 Qualifier PS


CLAIMSUPPLEMENTALVS
    Claim Supplemental Quantity Information Visits
          Location :  REF Segment, Element 2
                      Element 1 Qualifier VS


CLAIMSUPPLEMENTALZK
    Claim Supplemental Quantity Information Federal
    Medicare or Medicaid Payment Mandate - Category 1
          Location :  REF Segment, Element 2
                      Element 1 Qualifier ZK


CLAIMSUPPLEMENTALZL
    Claim Supplemental Quantity Information Federal
    Medicare or Medicaid Payment Mandate - Category 2
          Location :  REF Segment, Element 2
                      Element 1 Qualifier ZL


CLAIMSUPPLEMENTALZM
    Claim Supplemental Quantity Information Federal
    Medicare or Medicaid Payment Mandate - Category 3
          Location :  REF Segment, Element 2
                      Element 1 Qualifier ZM

CLAIMSUPPLEMENTALZN
    Claim Supplemental Quantity Information Federal
    Medicare or Medicaid Payment Mandate - Category 4
          Location :  REF Segment, Element 2
                      Element 1 Qualifier ZN

CLAIMSUPPLEMENTALZO
    Claim Supplemental Quantity Information Federal
    Medicare or Medicaid Payment Mandate - Category 5
          Location :  REF Segment, Element 2
                      Element 1 Qualifier ZO



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



                Service Line Level

                     01 to 99


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


DATEOFSERVICE01
     Date of Service
        Location :  DTM Segment, Element 2
                    Element 1 Qualifier 472


PROCEDURE01
     Procedure
        Location :  SVC Segment, Element 1
                    Subvalue 2

PROCEDUREMODA01
     Procedure Modifier
        Location :  SVC Segment, Element 1
                    Subvalue 3


PROCEDUREMODB01
     Procedure Modifier
        Location :  SVC Segment, Element 1
                    Subvalue 4

PROCEDUREMODC01
     Procedure Modifier
        Location :  SVC Segment, Element 1
                    Subvalue 5

PROCEDUREMODD01
     Procedure Modifier
        Location :  SVC Segment, Element 1
                    Subvalue 6

PROCBILLEDAMT01
     Procedure Billed Amount
        Location :  SVC Segment, Element 2
                    

PROCPAYAMT01
     Procedure Paid Amount
        Location :  SVC Segment, Element 3
                    


PROCREVENUECODE01
     Procedure Revenue Code
        Location :  SVC Segment, Element 4
                    


PROCUNITSPAID01
     Procedure Units Paid
        Location :  SVC Segment, Element 5
                    


PROCUNITS01
     Procedure Original Units
        Location :  SVC Segment, Element 7
                    


PROCEDUREDESCRIPTION
     Procedure Code Description
        Location :  SVC Segment, Element 1
                    Subelement 7


PROCALLOWEDAMT01
     Procedure Allowed Amount
        Location :  AMT Segment, Element 2
                    Element 1 Qualifier B6


PROCPERDAYLIMITAMT01
     Procedure Per Day Limit
        Location :  AMT Segment, Element 2
                    Element 1 Qualifier DY


PROCDEDUCTIONAMT01
     Procedure Deduction Amount
        Location :  AMT Segment, Element 2
                    Element 1 Qualifier KH


PROCNETBILLEDAMT01
     Procedure Net Billed
        Location :  AMT Segment, Element 2
                    Element 1 Qualifier NE



PROCTAXAMT01
     Procedure Tax
        Location :  AMT Segment, Element 2
                    Element 1 Qualifier T


PROCTOTALBEFORETAXESAMT01
     Procedure Total Claim Before Taxes
        Location :  AMT Segment, Element 2
                    Element 1 Qualifier T2




PROCPAYAMT01
     Procedure Pay Amount
        Location :  CAS Segment, Element 3
                    Element 1 Qualifier PR


PROCDEDUCTAMT01
     Procedure Deductable Amount
        Location :  CAS Segment, Element 1
                    Element 1 Qualifier PR


PROCCOINSAMT01
     Procedure Coinsurance Amount Amount
        Location :  CAS Segment, Element 2
                    Element 1 Qualifier PR



PROCCOADJAMT01
        Location :  CAS Segment, Element 3
                    Element 1 Qualifier CO

PROCPROTHERAM01
        Location :  CAS Segment, Element 2,5
                    Element 1 Qualifier PR


PROCCOPAYAMT01
        Location :  CAS Segment, Element 3
                    Element 1 Qualifier PR




SERVICEDATEFROM01
      Service Date From
        Location :  DTM Segment, Element 2
                    Element 1 Qualifier 150


SERVICEDATETO01
      Service Date From
        Location :  DTM Segment, Element 2
                    Element 1 Qualifier 151


PROCPRIORAUTHNUMBER01
      Prior Auth
        Location :  REF Segment, Element 2
                    Element 1 Qualifier G1


PROCCTLNUMBER01
      Procedur Line Control Number
        Location :  REF Segment, Element 2
                    Element 1 Qualifier 6R



PROCREMARKCODE01
     Procedure Remark Code
        Location :  LQ Segment, Element 1


Note: 
     n = service line number
     s = segemet occurrence
     o = Occurrence of Field within a segement.

Example : PROCADJCODE1.1
          PROCADJCODE1.2

          PROCADJCODE1.1.1
          PROCADJCODE1.1.2
          PROCADJCODE1.1.3



PROCADJGRPCODEn
PROCADJGRPCODEn.s
     Procedure Adjustment Group Code
        Location :  CAS Segment, Element 2


PROCADJCODEn
PROCADJCODEn.s
PROCADJCODEn.s.o
     Procedure Adjustment Code
        Location :  CAS Segment, Element 3

PROCADJAMTn
PROCADJAMTn.s
PROCADJAMTn.s.o
     Procedure Adjustment Amount
        Location :  CAS Segment, Element 4


PROCADJQTYn
PROCADJQTYn.s
PROCADJQTYn.s.o
     Procedure Adjustment quantity
        Location :  CAS Segment, Element 5




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



                Provider Adjustment



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




PROVADJREFID
    Provider Adjustment Provider Reference ID
        Location :  PLB Segment, Element 1


PROVADJPERIOD
    Provider Adjustment Period
        Location :  PLB Segment, Element 2


PROVADJRESONCODE1
    Provider Adjustment Reason Code
        Location :  PLB Segment, Element 3 
                    SubValue 1                       
PROVADJREASONID1
    Provider Adjustment Reason ID
        Location :  PLB Segment, Element 3 
                    SubValue 2                    
PROVADJAMT1
    Provider Adjustment Amount
        Location :  PLB Segment, Element 4

PROVADJRESONCODE2
    Provider Adjustment Reason Code
        Location :  PLB Segment, Element 5
                    SubValue 1                       
PROVADJREASONID2
    Provider Adjustment Reason ID
        Location :  PLB Segment, Element 5
                    SubValue 2                    
PROVADJAMT2
    Provider Adjustment Amount
        Location :  PLB Segment, Element 6

PROVADJRESONCODE3
    Provider Adjustment Reason Code
        Location :  PLB Segment, Element 7
                    SubValue 1                       
PROVADJREASONID3
    Provider Adjustment Reason ID
        Location :  PLB Segment, Element 7
                    SubValue 2                    
PROVADJAMT3
    Provider Adjustment Amount
        Location :  PLB Segment, Element 8


PROVADJRESONCODE4
    Provider Adjustment Reason Code
        Location :  PLB Segment, Element 9
                    SubValue 1                       
PROVADJREASONID4
    Provider Adjustment Reason ID
        Location :  PLB Segment, Element 9
                    SubValue 2                    
PROVADJAMT4
    Provider Adjustment Amount
        Location :  PLB Segment, Element 10

PROVADJRESONCODE5
    Provider Adjustment Reason Code
        Location :  PLB Segment, Element 11
                    SubValue 1                       
PROVADJREASONID5
    Provider Adjustment Reason ID
        Location :  PLB Segment, Element 11
                    SubValue 2                    
PROVADJAMT5
    Provider Adjustment Amount
        Location :  PLB Segment, Element 12

PROVADJRESONCODE6
    Provider Adjustment Reason Code
        Location :  PLB Segment, Element 13
                    SubValue 1                       
PROVADJREASONID6
    Provider Adjustment Reason ID
        Location :  PLB Segment, Element 13
                    SubValue 2                    
PROVADJAMT6
    Provider Adjustment Amount
        Location :  PLB Segment, Element 14




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



          Medicare Inpatient Adjudication



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




MIACOVDVC 
    Covered Days or Visits Count
         Location : MIA Segment, Element 1


MIAOPOUTAMT
    PPS Operating Outlier Amount
         Location : MIA Segment, Element 2 


MIALIFPSYDAYS
    Lifetime Psychiatric Days Count
         Location : MIA Segment, Element 3


MIADRGAMT
    Claim DRG Amount
         Location : MIA Segment, Element 4


MIAREMARK1
     Remark Code
         Location : MIA Segment, Element 5


MIASHAREAMT
     Claim Disproportionate Share Amount
         Location : MIA Segment, Element 6


MIAMSPPASSAMT
     Claim MSP Pass-through Amount
         Location : MIA Segment, Element 7


MIAPPSCAPAMT
      Claim PPS Capital Amount
         Location : MIA Segment, Element 8


MIAFSPDRGAMT
      PPS-Capital FSP DRG Amount
         Location : MIA Segment, Element 9


MIAHSPDRGAMT
      PPS-Capital HSP DRG Amount 10
         Location : MIA Segment, Element 


MIADHSDRGAMT
      PPS-Capital DSH DRG Amount
         Location : MIA Segment, Element 11


MIAOLDCAPAMT
      Old Capital Amount
         Location : MIA Segment, Element 12


MIAIMEAMT
      PPS-Capital IME amount
         Location : MIA Segment, Element 13


MIAOHSDRG
      PPS-Operating Hospital Specific DRG Amount
         Location : MIA Segment, Element 14


MIACOSTRPTDATCNT
      Cost Report Day Count
         Location : MIA Segment, Element 15


MIAOFSDRG
      PPS-Operating Federal Specific DRG Amount
         Location : MIA Segment, Element 16


MIAPPSCAPOUTAMT
      Claim PPS Capital Outlier Amount
         Location : MIA Segment, Element 17


MIAINDTEACHAMT
      Claim Indirect Teaching Amount
          Location : MIA Segment, Element 18


MIANONPAYPROAMT
      Nonpayable Professional Component Amount
          Location : MIA Segment, Element 19


MIAREMARK2
      Remark Code
           Location : MIA Segment, Element 20


MIAREMARK3
      Remark Code
           Location : MIA Segment, Element 21

MIAREMARK4
      Remark Code
           Location : MIA Segment, Element 22


MIAREMARK5
      Remark Code
           Location : MIA Segment, Element 23


MIACAPEXCPAMT
      PPS-Capital Exception Amount
           Location : MIA Segment, Element 24



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



          Medicare Outpatient Adjudication



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





MOAPERCENT
    Medicare Outpatient Adjudication Percent
        Location :  MOA Segment, Element 1



MOAMOUNTPAYABLE"
    Medicare Outpatient Adjudication Amount
        Location :  MOA Segment, Element 2


MOAREMARK1
    Medicare Outpatient Adjudication Remark 1
        Location :  MOA Segment, Element 3

MOAREMARK2
    Medicare Outpatient Adjudication Remark 2
        Location :  MOA Segment, Element 4

MOAREMARK3
    Medicare Outpatient Adjudication Remark 3
        Location :  MOA Segment, Element 5

MOAREMARK4
    Medicare Outpatient Adjudication Remark 4
        Location :  MOA Segment, Element 6

MOAREMARK5
    Medicare Outpatient Adjudication Remark 5
        Location :  MOA Segment, Element 7

MOAPAYMENT
    Medicare Outpatient Adjudication Payment Amount
        Location :  MOA Segment, Element 8

MOANONPAYABLE
    Medicare Outpatient Adjudication Non Payable Amount
        Location :  MOA Segment, Element 9





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