Section 1
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
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
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
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
CMS-1470 Form Location to Mapping Field and 837I Segment/Element Form Locator 1 - Form Locator 2 - Form Locator 3 - Form Locator 4 - Form Locator 5 - Form Locator 6 - Form Locator 7 - Form Locator 8 - Form Locator 9 - Form Locator 1 - Form Locator 1 - Form Locator 10 - Form Locator 11 - Form Locator 1 - Form Locator 12 - Form Locator 13 - Form Locator 14 - Form Locator 15 - Form Locator 16 - Form Locator 17 - Form Locator 18 - Form Locator 19 - Form Locator 20 - Form Locator 21 - Form Locator 22 - Form Locator 23 - Form Locator 24 - Form Locator 25 - Form Locator 26 - Form Locator 27 - Form Locator 28 - Form Locator 29 - Form Locator 30 - Form Locator 31 - Form Locator 32 - Form Locator 33 - Form Locator 34 - Form Locator 35 - Form Locator 36 - Form Locator 37 - Form Locator 38 - Form Locator 39 - Form Locator 40 - Form Locator 41 - Form Locator 42 - Form Locator 43 - Form Locator 44 - Form Locator 45 - Form Locator 46 - Form Locator 47 - Form Locator 48 - Form Locator 49 - Form Locator 50 - Form Locator 51 - Form Locator 52 - Form Locator 53 - Form Locator 54 - Form Locator 55 - Form Locator 56 - Form Locator 57 - Form Locator 58 - Form Locator 59 - Form Locator 60 - Form Locator 61 - Form Locator 62 - Form Locator 63 - Form Locator 64 - Form Locator 65 - Form Locator 66 - Form Locator 67 - Form Locator 68 - Form Locator 69 - Form Locator 70 - Form Locator 71 - Form Locator 72 - Form Locator 73 - Form Locator 74 - Form Locator 75 - Form Locator 76 - Form Locator 77 - Form Locator 78 - Form Locator 79 - Form Locator 80 - Form Locator 81 - Form Locator 82 - Form Locator 83 - Form Locator 84 - Form Locator 85 -
Section 6
ADA Form Location to Mapping Field and 837D Segment/Element Form Locator 1 - Form Locator 2 - Form Locator 3 - Form Locator 4 - Form Locator 5 - Form Locator 6 - Form Locator 7 - Form Locator 8 - Form Locator 9 - Form Locator 1 - Form Locator 1 - Form Locator 10 - Form Locator 11 - Form Locator 1 - Form Locator 12 - Form Locator 13 - Form Locator 14 - Form Locator 15 - Form Locator 16 - Form Locator 17 - Form Locator 18 - Form Locator 19 - Form Locator 20 - Form Locator 21 - Form Locator 22 - Form Locator 23 - Form Locator 24 - Form Locator 25 - Form Locator 26 - Form Locator 27 - Form Locator 28 - Form Locator 29 - Form Locator 30 - Form Locator 31 - Form Locator 32 - Form Locator 33 - Form Locator 34 - Form Locator 35 - Form Locator 36 - Form Locator 37 - Form Locator 38 - Form Locator 39 - Form Locator 40 - Form Locator 41 - Form Locator 42 - Form Locator 43 - Form Locator 44 - Form Locator 45 - Form Locator 46 - Form Locator 47 - Form Locator 48 - Form Locator 49 - Form Locator 50 - Form Locator 51 - Form Locator 52 - Form Locator 53 - Form Locator 54 - Form Locator 55 - Form Locator 56 -
Section 7
This is a list of the fields supported for mapping and are stored in an XML file called: C1837I.XML for Institutional C1837P.XML for Professional C1837D.XML for Dental Field names are placed inside the field tags of the xml. Example :CLAIMID CLAIMAMTDDDDDD_CC CLAIMAMT - - - - - - - - - - - - - - - - - - CLAIMID Claim ID Location : CLM Segment, Element 1 CLAIMAMTDDDDDD_CC Claim Amount Location : CLM Segment, Element 2 CLAIMAMT Claim Amount Location : CLM Segment, Element 2 CLEARINGIDNUMBER Clearing Service ID Location : REF Segment, Element 2 Qualifier D9 MULTICLAIMTOTAL Multi Claim Total Amount Location : CLM Segment, Element 2 ICNDCN Internal Document Number Document Control Number Location : REF Segment, Element 3 Qualifier F8 TAXONOMYCODE Taxonomy Code Location : PRV Segment, Element 4 Qualifier PE EMPLOYERIDNUM Employer Identification Number Location : REF Segment, Element 3 Qualifier EI PRIORAUTHORIZATIONNUMBER Prior Authorization Number Location : REF Segment, Element 3 Qualifier G1 ORDERDATE Order Date Location : DTP Segment, Element 3 Qualifier 938 INITIALTREATMENTDATE Initial Treatment Date Location : DTP Segment, Element 3 Qualifier 454 REFERRALDATE Referral Date Location : DTP Segment, Element 3 Qualifier 330 DATELASTSEEN Date last Seen Location : DTP Segment, Element 3 Qualifier 304 ONSETOFILLNESDATE Onset of Current Symptoms or Illness Date Location : DTP Segment, Element 3 Qualifier 431 ACUTEMANIFESTATIONDATE Acute Manifestation of a Chronic Condition Date Location : DTP Segment, Element 3 Qualifier 453 SIMILARILLNESSONSETDATE Onset of Similar Symptoms or Illness Date Location : DTP Segment, Element 3 Qualifier 438 ACCIDENTDATE Accident Date Location : DTP Segment, Element 3 Qualifier 439 LMPDATE Last Menstrual Period Date Location : DTP Segment, Element 3 Qualifier 484 LASTXRAYDATE Last X-Ray Date Location : DTP Segment, Element 3 Qualifier 455 ESTIMATEDDATEOFBIRTH Estimated Date of Birth Location : DTP Segment, Element 3 Qualifier ABC HEARINGVISIONPRESCRIPTIONDATE Hearing and Vision Prescription Date Location : DTP Segment, Element 3 Qualifier 471 DISABILITYBEGINDATE Disability Begin Date Location : DTP Segment, Element 3 Qualifier 360 DISABILITYENDDATE Disability End Date Location : DTP Segment, Element 3 Qualifier 361 DATELASTWORKED Date Last Worked Location : DTP Segment, Element 3 Qualifier 297 RETURNTOWORKDATE Return to Work Date Location : DTP Segment, Element 3 Qualifier 296 ASSUMEDCAREDATE Assumed Care Start Date Location : DTP Segment, Element 3 Qualifier 090 RELINQUISHEDCAREDATE Relinquished Care End Date Location : DTP Segment, Element 3 Qualifier 091 PROVSIGNATUREONFILE Provider Signature Location : CLM Segment, Element 6 PROVACCEPTASSIGNMENTCODE Provider Assignment Location : CLM Segment, Element 7 BENEFITINDICATOR Benefit Indicator Location : CLM Segment, Element 8 RELEASEOFINFORMATION Release of Information Location : CLM Segment, Element 9 RELATEDCAUSECODE Related Cause Location : CLM Segment, Element 11 RELATEDCAUSE Related Cause Location : CLM Segment, Element 11 DISCHARGEHOUR Discharge Hour Location : DTP Segment, Element 3 Qualifier 069 DISCHARGEDATE Discharge Date Location : CR6 Segment, Element 5 STATEMENTDATE Statement Date Location : DTP Segment, Element 3 Qualifier 434 ADMISSIONDATETIME Addmission Date Time Location : DTP Segment, Element 3 Qualifier 435 ADMISSIONTYPECODE Addmission Type Code Location : CL1 Segment, Element 1 Qualifier 435 ADMISSIONTYPE Addmission Type Location : CL1 Segment, Element 1 Qualifier 435 ADMISSIONSOURCECODE Addmission Source Code Location : CL1 Segment, Element 2 ADMISSIONSOURCE Addmission Source Location : CL1 Segment, Element 2 PATIENTSTATUSCODE Patient Status Code Location : CL1 Segment, Element 3 PATIENTSTATUS Patient Status Location : CL1 Segment, Element 3 MEDICALRECORDNUMBER Medical Record Number Location : REF Segment, Element 2 Qualifier EA PATIENTAMOUNTPAID Patient Amount Paid Location : AMT Segment, Element 2 Qualifier F5 TOTALPURCHASEDSERVICEAMOUNT Total Purchased Service Amount Location : AMT Segment, Element 2 Qualifier NE PAYERPRIORPAY Payer Prior Pay Location : AMT Segment, Element 2 Qualifier C4 CLAIMNOTEADD Claim Note Additional Information Location : NTE Segment, Element 2 Qualifier ADD CLAIMNOTECER Claim Note Certification Narrative Location : NTE Segment, Element 2 Qualifier CER CLAIMNOTEDCP Claim Note Goals /Discharge Plan Location : NTE Segment, Element 2 Qualifier DCP CLAIMNOTEDGN Claim Note Diagnosis Description Location : NTE Segment, Element 2 Qualifier DGN CLAIMNOTEPMT Claim Note Payment Location : NTE Segment, Element 2 Qualifier PMT CLAIMNOTETPO Claim Note Third party Org Location : NTE Segment, Element 2 Qualifier TPO OISUBORDER Other Insurance Subscriber Order Location : NM1 Segment, Element 1 OISUBID Other Insurance Subscriber ID Location : NM1 Segment, Element 9 Qualifier IL OISUBLNAME Other Insurance Subscriber Last Name Location : NM1 Segment, Element 3 Qualifier IL OISUBFNAME Other Insurance Subscriber First Name Location : NM1 Segment, Element 4 Qualifier IL OISUBMI Other Insurance Subscriber Middle Initial Location : NM1 Segment, Element 5 Qualifier IL OIPAYERADDR1 Other Insurance Subscriber Address 1 Location : N3 Segment, Element 1 OIPAYERADDR2 Other Insurance Subscriber Address 2 Location : N3 Segment, Element 2 OIPAYERCITY Other Insurance Subscriber City Location : N4 Segment, Element 1 OIPAYERSTATE Other Insurance Subscriber State Location : N4 Segment, Element 2 OIPAYERZIP Other Insurance Subscriber Zip Code Location : N4 Segment, Element 3 OIPAYERID Other Insurance Payer ID Location : NM1 Segment, Element 9 Qualifier PR OIPAYERNAME Other Insurance Payer Name Location : NM1 Segment, Element 3 Qualifier PR SEGMENTNOTE Segment Note Location : DMG Segment, Element 3 POSDESC Place of Service Description Location : CLM Segment, Element 6 FACILITYCODEVALUE Facility Code Value Location : CLM Segment, Element 6 FREQUENCYTYPECODE Frequency Type Code Location : CLM Segment, Element 6 POSCODE Place of Service Description Location : CLM Segment, Element 6 K3DATA K3 Data Location : K3 Segment, Element 1 NDCCODE National Drug Code Location : LIN Segment, Element 3 Qualifier N4 NDCUNITPRICE NDC Drug Unit Price Location : CTP Segment, Element 3 NDCUNITS NDC Units Location : CTP Segment, Element 4 TYPEOFBILL Type of Bill Location : CLM Segment, Element 6 FREQUENCYCODE Frequency Type Code Location : CLM Segment, Element 6 PRINCIPALDX Principle Diagnosis Location : HI Segment, Element 1 Qualifier BK ADMITDX Admitting Diagnosis Location : HI Segment, Element 2 Qualifier BJ ECODE Vital Statistics E-Code Location : HI Segment, Element 3 Qualifier BN DRG DRG Location : HI Segment, Element 1 Qualifier DR OTHERDX01 thru OTHERDX12 Other Diagnosis 1 thru 12 Location : HI Segment, Element 1 Qualifier BF OTHERDXA01 thru OTHERDXY12 Other Diagnosis 1 thru 12 Multi Segment Location : HI Segment, Element 1 Qualifier BF PRINCIPLEPROCDATE Principle Procedure Date Location : HI Segment, Element 1 Qualifier BP,BR PRINCIPLEPROC Principle Procedure Date Location : HI Segment, Element 1 Qualifier BP,BR OTHERPROC01 thru OTHERPROC12 Other Procedures 1 thru 12 Location : HI Segment, Element 1 Qualifier BO,BQ OTHERPROCA01 thru OTHERPROCY12 Other Procedures 1 thru 12 Multi Segment Location : HI Segment, Element 1 Qualifier BO,BQ OCCURRENCESPAN01 thru OCCURRENCESPAN12 Occurance Span 1 thru 12 Location : HI Segment, Element 1 Qualifier BI OCCURRENCESPANA01 thru OCCURRENCESPANY12 Occurance Span 1 thru 12 Multi Segment Location : HI Segment, Element 1 Qualifier BI OCCURRENCECODE01 thru OCCURRENCECODE12 Occurance Code 1 thru 12 Location : HI Segment, Element 1 Qualifier BH OCCURRENCECODEA01 thru OCCURRENCECODEY12 Occurance Code 1 thru 12 Multi Segment Location : HI Segment, Element 1 Qualifier BH OCCURRENCEDATE01 thru OCCURRENCEDATE12 Occurance Date 1 thru 12 Location : HI Segment, Element 1 Qualifier BH OCCURRENCEDATEA01 thru OCCURRENCEDATEY12 Occurance Date 1 thru 12 Multi Segment Location : HI Segment, Element 1 Qualifier BH VALUECODE01 thru VALUECODE12 Value Codes 1 thru 12 Location : HI Segment, Element 1 Qualifier BE VALUECODEA01 thru VALUECODEY12 Value Codes 1 thru 12 Multi Segment Location : HI Segment, Element 1 Qualifier BE VALUEAMOUNT01 thru VALUEAMOUNT12 Value Amounts 1 thru 12 Location : HI Segment, Element 1 Qualifier BE VALUEAMOUNTA01 thru VALUEAMOUNTY12 Value Amounts 1 thru 12 Multi Segment Location : HI Segment, Element 1 Qualifier BE VALUEQTY01 thru VALUEQTY12 Value Quantity 1 thru 12 Location : HI Segment, Element 1 Qualifier BE VALUEQTYA01 thru VALUEQTYY12 Value Quantity 1 thru 12 Multi segment Location : HI Segment, Element 1 Qualifier BE CONDITIONCODE01 thru CONDITIONCODE12 Condition Codes 1 thru 12 Location : HI Segment, Element 1 Qualifier BG CONDITIONCODEA01 thru CONDITIONCODEY12 Condition Codes 1 thru 12 Multi Segment Location : HI Segment, Element 1 Qualifier BG CONDITIONDATE01 thru CONDITIONDATE12 Condition Dates 1 thru 12 Location : HI Segment, Element 1 Qualifier BG CONDITIONDATEA01 thru CONDITIONDATEY12 Condition Dates 1 thru 12 Multi Segment Location : HI Segment, Element 1 Qualifier BG TREATMENTCODE01 thru TREATMENTCODE12 Treatment Codes 1 thru 12 Location : HI Segment, Element 1 Qualifier TC TREATMENTCODEA01 thru TREATMENTCODEY12 Treatment Codes 1 thru 12 Multi Segment Location : HI Segment, Element 1 Qualifier TC SUBCLMTYPECODE Subscriber Claim Type Location : SBR Segment, Element 9 SUBCLMTYPE Subscriber Claim Type Location : SBR Segment, Element 9 SUBID Subscriber ID Location : NM1 Segment, Element 9 Qualifier IL SUBLNAME Subscriber Last Name Location : NM1 Segment, Element 3 Qualifier IL SUBFNAME Subscriber First Name Location : NM1 Segment, Element 4 Qualifier IL SUBMI Subscriber Middle Initial Location : NM1 Segment, Element 5 Qualifier IL SUBADDR1 Subscriber Address 1 Location : N3 Segment, Element 1 SUBADDR2 Subscriber Address 2 Location : N3 Segment, Element 2 SUBCITY Subscriber City Location : N4 Segment, Element 1 SUBST Subscriber State Location : N4 Segment, Element 2 SUBZIP Subscriber Zip Location : N4 Segment, Element 3 SUBDOB Subscriber Date of Birth Location : DMG Segment, Element 2 SUBNAMEPREFIX Subscriber Prefix Location : NM1 Segment, Element 6 Qualifier IL SUBNAMESUFIX Subscriber Suffix Location : NM1 Segment, Element 6 Qualifier IL SUBMSTATUS Subscriber Prefix Location : DMG Segment, Element 4 SUBORDER Subscriber Coverage Order Location : SBR Segment, Element 1 SUBREL Subscriber Relationship to Patient Location : SBR Segment, Element 2 SUBGROUPNAME Subscriber Group Name Location : SBR Segment, Element 3 SUBSEX Subscriber Gender Location : DMG Segment, Element 3 PROPERYCASUALTYCLAIMNUMBER Added Property Casuality Claim Number Location : REF Segment, Element 2 Qualifier Y4 PAYERID Payer ID Location : NM1 Segment, Element 9 Qualifier PR PAYERNAME Payer Name Location : NM1 Segment, Element 3 Qualifier PR PAYERADDR1 Payer Address Line 1 Location : N3 Segment, Element 1 PAYERADDR2 Payer Address Line 2 Location : N3 Segment, Element 2 PAYERCITY Payer City Location : N4 Segment, Element 1 PAYERSTATE Payer State Location : N4 Segment, Element 2 PAYERZIP Payer Zip Code Location : N4 Segment, Element 3 PATLNAME Patient Last Name Location : NM1 Segment, Element 3 Qualifier QC PATFNAME Patient First Name Location : NM1 Segment, Element 4 Qualifier QC PATMI Patient Middle Initial Location : NM1 Segment, Element 5 Qualifier QC PATADDR1 Patient Address 1 Location : N3 Segment, Element 1 PATADDR2 Patient Address 2 Location : N3 Segment, Element 2 PATCITY Patient City Location : N4 Segment, Element 1 PATST Patient State Location : N4 Segment, Element 2 PATZIP Patient Zip Location : N4 Segment, Element 3 PATDOB Patient Date of Birth Location : DMG Segment, Element 2 PATSEX Patient Gender Location : DMG Segment, Element 3 PATREL Patient Relationship to Subscriber Location : PAT Segment, Element 2 PATSIGNATURESOURCE Patient Signature Source Location : CLM Segment, Element 10 REFLNAME Referring Provider Last Name Location : NM1 Segment, Element 3 Qualifier DN REFFNAME Referring Provider First Name Location : NM1 Segment, Element 4 Qualifier DN REFID Referring Provider ID Location : NM1 Segment, Element 9 Qualifier DN REFIDTYPE Referring Provider ID Type Location : NM1 Segment, Element 8 Qualifier DN REFSECONDARYID Referring Provider Secondary ID Location : REF Segment, Element 3 REFSECONDARYIDCODE Referring Provider Secondary ID Code Location : REF Segment, Element 2 ATTENDLNAME Attending Provider Last Name Location : NM1 Segment, Element 3 Qualifier 71 ATTENDFNAME Attending Provider First Name Location : NM1 Segment, Element 4 Qualifier 71 ATTENDID Attending Provider ID Location : NM1 Segment, Element 9 Qualifier 71 ATTENDSECONDARYID Attending Provider Secondary ID Location : REF Segment, Element 2 ATTENDSECONDARYIDCODE Attending Provider Secondary ID Code Location : REF Segment, Element 1 OPERATELNAME Operating Provider Last Name Location : NM1 Segment, Element 3 Qualifier 72 OPERATEFNAME Operating Provider First Name Location : NM1 Segment, Element 4 Qualifier 72 OPERATEID Operating Provider Last Name Location : NM1 Segment, Element 3 Qualifier 72 OPERATESECONDARYID Operating Provider Secondary ID Location : REF Segment, Element 2 OPERATESECONDARYIDCODE Operating Provider Secondary ID Code Location : REF Segment, Element 1 RENLNAME Rendering Provider Last Name Location : NM1 Segment, Element 3 Qualifier 82 RENFNAME Rendering Provider First Name Location : NM1 Segment, Element 4 Qualifier 82 RENIDTYPECODE Rendering Provider ID Type Code Location : NM1 Segment, Element 8 Qualifier 82 RENIDTYPE Rendering Provider ID Type Location : NM1 Segment, Element 8 Qualifier 82 RENID Rendering Provider ID Location : NM1 Segment, Element 9 Qualifier 82 FACILITYNAME Facility Name Location : NM1 Segment, Element 3 Qualifier FA FACILITYADDR1 Facility Address Line 1 Location : N3 Segment, Element 1 FACILITYADDR2 Facility Address Line 2 Location : N3 Segment, Element 2 FACILITYCITY Facility City Location : N4 Segment, Element 1 FACILITYST Facility State Location : N4 Segment, Element 2 FACILITYZIP Facility Zip Code Location : N4 Segment, Element 3 FACILITYIDTYPE Facility ID Type Location : NM1 Segment, Element 8 Qualifier FA FACILITYIDCODE Facility ID Code Location : NM1 Segment, Element 8 Qualifier FA FACILITYID Facility ID Location : NM1 Segment, Element 9 Qualifier FA FACILITYSECONDARYIDTYPE Facility Secondary ID Type Location : REF Segment, Element 1 FACILITYSECONDARYIDCODE Facility Secondary ID CODE Location : REF Segment, Element 1 FACILITYSECONDARYID Facility Secondary ID Type Location : REF Segment, Element 2 SERVICELOCATIONNAME Service Location Name Location : NM1 Segment, Element 3 Qualifier 77 SERVICELOCATIONADDR1 Service Localtion Address Line 1 Location : N3 Segment, Element 1 SERVICELOCATIONADDR2 Service Localtion Address Line 2 Location : N3 Segment, Element 2 SERVICELOCATIONCITY Service Localtion City Location : N4 Segment, Element 1 SERVICELOCATIONST Service Localtion State Location : N4 Segment, Element 2 SERVICELOCATIONZIP Service Localtion Zip Code Location : N4 Segment, Element 4 SERVICELOCATIONID Service Location Name Location : NM1 Segment, Element 9 Qualifier 77 ILABNAME Independent LAB Name Location : NM1 Segment, Element 3 Qualifier LI ILABADDR1 Independent LAB Address Line 1 Location : N3 Segment, Element 1 ILABADDR2 Independent LAB Address Line 2 Location : N3 Segment, Element 2 ILABCITY Independent LAB City Location : N4 Segment, Element 1 ILABST Independent LAB State Location : N4 Segment, Element 2 ILABZIP Independent LAB Zip Code Location : N4 Segment, Element 3 ILABID Independent LAB Name Location : NM1 Segment, Element 9 Qualifier LI TLABNAME Testing LAB Name Location : NM1 Segment, Element 3 Qualifier TL TLABADDR1 Testing LAB Address Line 1 Location : N3 Segment, Element 1 TLABADDR2 Testing LAB Address Line 2 Location : N3 Segment, Element 2 TLABCITY Testing LAB City Location : N4 Segment, Element 1 TLABST Testing LAB State Location : N4 Segment, Element 2 TLABZIP Testing LAB Zip Code Location : N4 Segment, Element 3 TLABID Independent LAB Name Location : NM1 Segment, Element 9 Qualifier TL DX1_XX Diagnosis Code 1 Location : HI Segment, Element 1 Sub Element 1 DX2_XX Diagnosis Code 2 Location : HI Segment, Element 1 Sub Element 2 DX3_XX Diagnosis Code 3 Location : HI Segment, Element 1 Sub Element 3 DX4_XX Diagnosis Code 4 Location : HI Segment, Element 1 Sub Element 4 DX5_XX Diagnosis Code 5 Location : HI Segment, Element 1 Sub Element 5 DX1 Diagnosis Code 1 Location : HI Segment, Element 1 Sub Element 1 DX2 Diagnosis Code 2 Location : HI Segment, Element 1 Sub Element 2 DX3 Diagnosis Code 3 Location : HI Segment, Element 1 Sub Element 3 DX4 Diagnosis Code 4 Location : HI Segment, Element 1 Sub Element 4 DX5 Diagnosis Code 5 Location : HI Segment, Element 1 Sub Element 5 MEDICALRECORDNUMBER Medical Record Number Location : REF Segment, Element 2 Qualifier EA CLAIMBILLINGPROVIDERNAME Claim Billing Provider Name Location : NM1 Segment, Element 3 Qualifier 85 CLAIMBILLINGPROVIDERADDR1 Claim Billing Provider Address 1 Location : N3 Segment, Element 1 CLAIMBILLINGPROVIDERADDR2 Claim Billing Provider Address 2 Location : N3 Segment, Element 2 CLAIMBILLINGPROVIDERCITY Claim Billing Provider City Location : N4 Segment, Element 1 CLAIMBILLINGPROVIDERST Claim Billing Provider State Location : N4 Segment, Element 2 CLAIMBILLINGPROVIDERZIP Claim Billing Provider Zip Code Location : N4 Segment, Element 3 CLAIMBILLINGPROVIDERIDTYPE Claim Billing Provider ID Type Location : NM1 Segment, Element 8 Qualifier 85 CLAIMBILLINGPROVIDERIDCODE Claim Billing Provider ID Code Location : NM1 Segment, Element 8 Qualifier 85 CLAIMBILLINGPROVIDERID Claim Billing Provider ID Location : NM1 Segment, Element 9 Qualifier 85 CLAIMBILLINGPROVIDERSECONDARYIDTYPE Claim Billing Provider Secondary ID Type Location : REF Segment, Element 1 CLAIMBILLINGPROVIDERSECONDARYIDCODE Claim Billing Provider Secondary ID Code Location : REF Segment, Element 1 CLAIMBILLINGPROVIDERSECONDARYID Claim Billing Provider Secondary ID Location : REF Segment, Element 2 CLAIMPAYTOPROVIDERNAME Claim Pay to Provider Name Location : NM1 Segment, Element 3 Qualifier 87 CLAIMPAYTOPROVIDERADDR1 Claim Pay to Provider Address 1 Location : N3 Segment, Element 1 CLAIMPAYTOPROVIDERADDR2 Claim Pay to Provider Address 2 Location : N3 Segment, Element 2 CLAIMPAYTOPROVIDERCITY Claim Pay to Provider City Location : N4 Segment, Element 1 CLAIMPAYTOPROVIDERST Claim Pay to Provider State Location : N4 Segment, Element 2 CLAIMPAYTOPROVIDERZIP Claim Pay to Provider Zip Code Location : N4 Segment, Element 3 CLAIMPAYTOPROVIDERIDTYPE Claim Pay to Provider ID Type Location : NM1 Segment, Element 8 Qualifier 87 CLAIMPAYTOPROVIDERIDCODE Claim Pay to Provider ID Code Location : NM1 Segment, Element 8 Qualifier 87 CLAIMPAYTOPROVIDERID Claim Pay to Provider ID Location : NM1 Segment, Element 9 Qualifier 87 ADJUDDATE Claim Ajudication Date Location : DTP Segment, Element 3 Qualifier 573 IADJUDIDn Line Claim Ajudication ID Location : SVD Segment, Element 1 Qualifier 573 n=1 to 999 IADJUDAMTn Line Claim Ajudication Amount Location : SVD Segment, Element 2 n=1 to 999 IADJUDDATEn Line Claim Ajudication Date Location : DTP Segment, Element 3 Qualifier 573 n=1 to 999 PRIMARYGROUPID Primary Subscriber Group ID Location : SBR Segment, Element 2 Qualifier P PRIMARYGROUPNAME Primary Subscriber Group Name Location : SBR Segment, Element 3 Qualifier P PRIMARYSUBID Primary Subscriber ID Location : NM1 Segment, Element 9 Qualifier IL PRIMARYSUBLNAME Primary Subscriber Last Name Location : NM1 Segment, Element 3 Qualifier IL PRIMARYSUBFNAME Primary Subscriber First Name Location : NM1 Segment, Element 4 Qualifier IL PRIMARYSUBMI Primary Subscriber Middle Initial Location : NM1 Segment, Element 5 Qualifier IL PRIMARYSUBADDR1 Primary Subscriber Address Line 1 Location : N3 Segment, Element 1 PRIMARYSUBADDR2 Primary Subscriber Address Line 2 Location : N3 Segment, Element 2 PRIMARYSUBCITY Primary Subscriber City Location : N4 Segment, Element 1 PRIMARYSUBSTATE Primary Subscriber State Location : N4 Segment, Element 2 PRIMARYSUBZIP Primary Subscriber Zip Code Location : N4 Segment, Element 3 PRIMARYSUBDOB Primary Subscriber Date of Birth Location : DMG Segment, Element 2 PRIMARYSUBSEX Primary Subscriber Gender Location : DMG Segment, Element 3 PRIMARYPAYERNAME Primary Payer Name Location : NM1 Segment, Element 3 Qualifier PR PRIMARYPAYERADDR1 Primary Payer Address Line 1 Location : N3 Segment, Element 1 PRIMARYPAYERADDR2 Primary Payer Address Line 2 Location : N3 Segment, Element 2 PRIMARYPAYERCITY Primary Payer City Location : N4 Segment, Element 1 PRIMARYPAYERSTATE Primary Payer State Location : N4 Segment, Element 2 PRIMARYPAYERZIP Primary Payer Zip Code Location : N4 Segment, Element 3 PRIMARYPAYERID Primary Payer ID Location : NM1 Segment, Element 9 Qualifier PR SECONDARYGROUPID Secondary Subscriber Group ID Location : SBR Segment, Element 2 Qualifier S SECONDARYGROUPNAME Secondary Subscriber Group Name Location : SBR Segment, Element 3 Qualifier S SECONDARYSUBID Secondary Subscriber ID Location : NM1 Segment, Element 9 Qualifier IL SECONDARYSUBLNAME Secondary Subscriber Last Name Location : NM1 Segment, Element 3 Qualifier IL SECONDARYSUBFNAME Secondary Subscriber First Name Location : NM1 Segment, Element 4 Qualifier IL SECONDARYSUBMI Secondary Subscriber Middle Initial Location : NM1 Segment, Element 5 Qualifier IL SECONDARYSUBADDR1 Secondary Subscriber Address Line 1 Location : N3 Segment, Element 1 SECONDARYSUBADDR2 Secondary Subscriber Address Line 2 Location : N3 Segment, Element 2 SECONDARYSUBCITY Secondary Subscriber City Location : N4 Segment, Element 1 SECONDARYSUBSTATE Secondary Subscriber State Location : N4 Segment, Element 2 SECONDARYSUBZIP Secondary Subscriber Zip Code Location : N4 Segment, Element 3 SECONDARYSUBDOB Secondary Subscriber Date of Birth Location : DMG Segment, Element 2 SECONDARYSUBSEX Secondary Subscriber Gender Location : DMG Segment, Element 3 SECONDARYPAYERNAME Secondary Payer Name Location : NM1 Segment, Element 3 Qualifier PR SECONDARYPAYERADDR1 Secondary Payer Address Line 1 Location : N3 Segment, Element 1 SECONDARYPAYERADDR2 Secondary Payer Address Line 2 Location : N3 Segment, Element 2 SECONDARYPAYERCITY Secondary Payer City Location : N4 Segment, Element 1 SECONDARYPAYERSTATE Secondary Payer State Location : N4 Segment, Element 2 SECONDARYPAYERZIP Secondary Payer Zip Code Location : N4 Segment, Element 3 SECONDARYPAYERID Secondary Payer ID Location : NM1 Segment, Element 9 Qualifier PR TERTIARYGROUPID Tertiary Subscriber Group ID Location : SBR Segment, Element 2 Qualifier T TERTIARYGROUPNAME Tertiary Subscriber Group Name Location : SBR Segment, Element 3 Qualifier T TERTIARYSUBID Tertiary Subscriber ID Location : NM1 Segment, Element 9 Qualifier IL TERTIARYSUBLNAME Tertiary Subscriber Last Name Location : NM1 Segment, Element 3 Qualifier IL TERTIARYSUBFNAME Tertiary Subscriber First Name Location : NM1 Segment, Element 4 Qualifier IL TERTIARYSUBMI Tertiary Subscriber Middle Initial Location : NM1 Segment, Element 5 Qualifier IL TERTIARYSUBADDR1 Tertiary Subscriber Address Line 1 Location : N3 Segment, Element 1 TERTIARYSUBADDR2 Tertiary Subscriber Address Line 2 Location : N3 Segment, Element 2 TERTIARYSUBCITY Tertiary Subscriber City Location : N4 Segment, Element 1 TERTIARYSUBSTATE Tertiary Subscriber State Location : N4 Segment, Element 2 TERTIARYSUBZIP Tertiary Subscriber Zip Code Location : N4 Segment, Element 3 TERTIARYSUBDOB Tertiary Subscriber Date of Birth Location : DMG Segment, Element 2 TERTIARYSUBSEX Tertiary Subscriber Gender Location : DMG Segment, Element 3 TERTIARYPAYERNAME Tertiary Payer Name Location : NM1 Segment, Element 3 Qualifier PR TERTIARYPAYERADDR1 Tertiary Payer Address Line 1 Location : N3 Segment, Element 1 TERTIARYPAYERADDR2 Tertiary Payer Address Line 2 Location : N3 Segment, Element 2 TERTIARYPAYERCITY Tertiary Payer City Location : N4 Segment, Element 1 TERTIARYPAYERSTATE Tertiary Payer State Location : N4 Segment, Element 2 TERTIARYPAYERZIP Tertiary Payer Zip Code Location : N4 Segment, Element 3 TERTIARYPAYERID Tertiary Payer ID Location : NM1 Segment, Element 9 Qualifier PR HIERARCHIALCLAIMBILLINGPROVIDERNAME Hierarchial Claim Billing Provider Name Location : NM1 Segment, Element 3 Qualifier 85 HIERARCHIALCLAIMBILLINGPROVIDERADDR1 Hierarchial Claim Billing Provider Address Line 1 Location : N3 Segment, Element 1 HIERARCHIALCLAIMBILLINGPROVIDERADDR2 Hierarchial Claim Billing Provider Address Line 2 Location : N3 Segment, Element 2 HIERARCHIALCLAIMBILLINGPROVIDERCITY Hierarchial Claim Billing Provider City Location : N4 Segment, Element 1 HIERARCHIALCLAIMBILLINGPROVIDERST Hierarchial Claim Billing Provider State Location : N4 Segment, Element 2 HIERARCHIALCLAIMBILLINGPROVIDERZIP Hierarchial Claim Billing Provider Zip Code Location : N4 Segment, Element 3 HIERARCHIALCLAIMBILLINGPROVIDERIDTYPE Hierarchial Claim Billing Provider ID Type Location : NM1 Segment, Element 8 Qualifier 85 HIERARCHIALCLAIMBILLINGPROVIDERIDCODE Hierarchial Claim Billing Provider ID Code Location : NM1 Segment, Element 8 HIERARCHIALCLAIMBILLINGPROVIDERID Hierarchial Claim Billing Provider ID Location : NM1 Segment, Element 9 HIERARCHIALCLAIMPAYTOPROVIDERNAME Hierarchial Claim Pay to Provider Provider Name Location : NM1 Segment, Element 3 Qualifier 87 HIERARCHIALCLAIMPAYTOPROVIDERADDR1 Hierarchial Claim Pay to Provider Provider Address Line 1 Location : N3 Segment, Element 1 HIERARCHIALCLAIMPAYTOPROVIDERADDR2 Hierarchial Claim Pay to Provider Provider Address Line 2 Location : N3 Segment, Element 2 HIERARCHIALCLAIMPAYTOPROVIDERCITY Hierarchial Claim Pay to Provider Provider City Location : N4 Segment, Element 1 HIERARCHIALCLAIMPAYTOPROVIDERST Hierarchial Claim Pay to Provider Provider State Location : N4 Segment, Element 2 HIERARCHIALCLAIMPAYTOPROVIDERZIP Hierarchial Claim Pay to Provider Provider Zip Code Location : N4 Segment, Element 3 HIERARCHIALCLAIMPAYTOPROVIDERIDTYPE Hierarchial Claim Pay to Provider Provider ID Type Location : NM1 Segment, Element 8 Qualifier 87 HIERARCHIALCLAIMPAYTOPROVIDERIDCODE Hierarchial Claim Pay to Provider Provider ID Code Location : NM1 Segment, Element 8 Qualifier 87 HIERARCHIALCLAIMPAYTOPROVIDERID Hierarchial Claim Pay to Provider Provider ID Location : NM1 Segment, Element 9 Qualifier 87 TSCONTROLNUMBER Batch Conrol Number Location : ST Segment, Element 2 BHTREFID BHT Segment Reference Identification Location : BHT Segment, Element 4 SUBMITTERNAME Submitter Name Location : NM1 Segment, Element 3 Qualifier 41 SUBMITTERADDR1 Submitter Address Line 1 Location : N3 Segment, Element 1 SUBMITTERADDR2 Submitter Address Line 2 Location : N3 Segment, Element 2 SUBMITTERCITY Submitter City Location : N4 Segment, Element 1 SUBMITTERST Submitter State Location : N4 Segment, Element 2 SUBMITTERZIP Submitter Zip Code Location : N4 Segment, Element 3 SUBMITTERCONTACT Submitter Contact Location : PER Segment, Element 2 SUBMITTERID Submitter ID Location : NM1 Segment, Element 9 Qualifier 41 SUBMITTERCONTACT Submitter ID Location : PER Segment, Element 3 SUBMITTERCOMMQUALA Submitter ID Location : PER Segment, Element 4 SUBMITTERCOMMNUMBERA Submitter ID Location : PER Segment, Element 5 SUBMITTERCOMMQUALB Submitter ID Location : PER Segment, Element 6 SUBMITTERCOMMNUMBERB Submitter ID Location : PER Segment, Element 7 SUBMITTERCOMMQUALC Submitter ID Location : PER Segment, Element 8 SUBMITTERCOMMNUMBERC Submitter ID Location : PER Segment, Element 9 RECEIVERID Receiver Location : NM1 Segment, Element 9 Qualifier 41 RECEIVERNAME Receiver Name Location : NM1 Segment, Element 3 Qualifier 40 RECEIVERADDITIONALNAME Receiver Additional Name Location : N2 Segment, Element 1 RECEIVERADDR1 Receiver Address Line 1 Location : N3 Segment, Element 1 RECEIVERADDR2 Receiver Address Line 2 Location : N3 Segment, Element 2 RECEIVERCITY Receiver Address City Location : N4 Segment, Element 1 RECEIVERST Receiver Address State Location : N4 Segment, Element 2 RECEIVERZIP Receiver Address Zip Code Location : N4 Segment, Element 3 BILLINGPROVIDERNAME Billing Provider Name Location : NM1 Segment, Element 3 Qualifier 85 BILLINGPROVIDERADDR1 Billing Provider Address Line 1 Location : N3 Segment, Element 1 BILLINGPROVIDERADDR2 Billing Provider Address Line 2 Location : N3 Segment, Element 2 BILLINGPROVIDERCITY Billing Provider City Location : N4 Segment, Element 1 BILLINGPROVIDERST Billing Provider State Location : N4 Segment, Element 2 BILLINGPROVIDERZIP Billing Provider Zip Code Location : N4 Segment, Element 3 BILLINGPROVIDERIDTYPE Billing Provider ID Type Location : NM1 Segment, Element 8 Qualifier 85 BILLINGPROVIDERIDCODE Billing Provider ID Code Location : NM1 Segment, Element 8 Qualifier 85 BILLINGPROVIDERID Billing Provider ID Location : NM1 Segment, Element 9 Qualifier 85 BILLINGPROVIDERCONTACT BILLINGPROVIDER ID Location : PER Segment, Element 3 BILLINGPROVIDERCOMMQUALA BILLINGPROVIDER ID Location : PER Segment, Element 4 BILLINGPROVIDERCOMMNUMBERA BILLINGPROVIDER ID Location : PER Segment, Element 5 BILLINGPROVIDERCOMMQUALB BILLINGPROVIDER ID Location : PER Segment, Element 6 BILLINGPROVIDERCOMMNUMBERB BILLINGPROVIDER ID Location : PER Segment, Element 7 BILLINGPROVIDERCOMMQUALC BILLINGPROVIDER ID Location : PER Segment, Element 8 BILLINGPROVIDERCOMMNUMBERC BILLINGPROVIDER ID Location : PER Segment, Element 9 PAYTOPROVIDERNAME Pay to Provider Name Location : NM1 Segment, Element 3 Qualifier 87 PAYTOPROVIDERADDR1 Pay to Provider Address Line 1 Location : N3 Segment, Element 1 PAYTOPROVIDERADDR2 Pay to Provider Address Line 2 Location : N3 Segment, Element 2 PAYTOPROVIDERCITY Pay to Provider City Location : N4 Segment, Element 1 PAYTOPROVIDERST Pay to Provider State Location : N4 Segment, Element 2 PAYTOPROVIDERZIP Pay to Provider Zip Code Location : N4 Segment, Element 3 PAYTOPROVIDERIDTYPE Pay to Provider ID Type Location : NM1 Segment, Element 8 Qualifier 87 PAYTOPROVIDERIDCODE Pay to Provider ID Code Location : NM1 Segment, Element 8 Qualifier 87 PAYTOPROVIDERID Pay to Provider ID Location : NM1 Segment, Element 9 Qualifier 87 PRIMARYINSURANCETYPECODE Primary Insurance Type Code Location : SBR Segment, Element 5 Qualifier P SECONDARYINSURANCETYPECODE Secondary Insurance Type Code Location : SBR Segment, Element 5 Qualifier S TERTIARYINSURANCETYPECODE Tertiary Insurance Type Code Location : SBR Segment, Element 5 Qualifier T COBPAYERPAIDAMT Coordination of Benefits Payer Paid Amount Location : AMT Segment, Element 2 Qualifier D COBAPPROVEDAMT Coordination of Benefits Payer Approved Amount Location : AMT Segment, Element 2 Qualifier AAE COBPAYERALLOWEDAMT Coordination of Benefits Payer Allowed Amount Location : AMT Segment, Element 2 Qualifier B6 COBPATRESPONSE Coordination of Benefits Patient Responsibility Location : AMT Segment, Element 2 Qualifier F2 COBCOVEREDAMT Coordination of Benefits Covered Amount Location : AMT Segment, Element 2 Qualifier AU COBDISCOUNTAMT Coordination of Benefits Discount Amount Location : AMT Segment, Element 2 Qualifier D8 COBPERDAYLIMIT Coordination of Benefits Per Day Limit Location : AMT Segment, Element 2 Qualifier DY COBPATPAIDAMT Coordination of Benefits Patient Amount Paid Location : AMT Segment, Element 2 Qualifier F5 COBTAX Coordination of Benefits Tax Location : AMT Segment, Element 2 Qualifier T COBCLMTOTTAX Coordination of Benefits Claim Total Tax Location : AMT Segment, Element 2 Qualifier T2 OIPAYERMEMNUM Other Insurance Payer Member Number Location : REF Segment, Element 2 Qualifier 1W OIPAYERCLINUM Other Insurance Payer Client Number Location : REF Segment, Element 2 Qualifier 23 OIPAYERPOLNUM Other Insurance Payer Policy Number Location : REF Segment, Element 2 Qualifier IG OIPAYERSSN Other Insurance Payer Social Security Number Location : REF Segment, Element 2 Qualifier SY - - - - - - - - - - - - - - Institutional Service Line Level Fields 01 to 999 - - - - - - - - - - - - - - ILINE01 IPROCTYPE01 IPROC01 IMODA01 IMODB01 IMODC01 IMODD01 IAMT01 IUNITSTYPE01 IUNITSQTY01 IUNITSRATE01 IUNITS01 IDOS01 NDCCODE01 NDCUNITPRICE01 NDCUNITS01 IADJUDDATE01 IADJUDID01 IADJUDAMT01 - - - - - - - - - - - - - - Professional Service Line Level Fields 01 to 99 - - - - - - - - - - - - - - PPROC01 MODA01 MODB01 MODC01 MODD01 DOS01 MM_DD_YY_DOSF01 MM_DD_YY_DOST01 AMT01 DDDDDD_CC01 POSLINECODE01 UNITS01 DXLINK01 SUPDXLINKA01 SUPDXLINKB01 SUPDXLINKC01 SUPDXLINKD01 - - - - - - - - - - - - - - Dental Service Line Level Fields 01 to 99 - - - - - - - - - - - - - - DPROC01 DMODA01 DMODB01 DMODC01 DMODD01 DAMT01 TOOTHSURFACE TOOTH01 - - - - - - - - - - - - - - General Service Line Level Fields - - - - - - - - - - - - - - LINEITEMCONTROLNUMBER01
Section 8
This is a list of the fields supported for mapping and are
stored in an XML file called 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