"B","837-Q1","1","0050","","","","","","","1","0050","390","E","ST*837*987654*005010X222A2~"
"B","837-Q1","1","0050","","","","","","","1","0050","2","A","Transaction Set Header"
"C","837-Q1","1","0050","ST","01","","","","","1","0050","","F","Transaction Set Identifier Code"
"C","837-Q1","1","0050","ST","02","","","","","1","0050","3","","The Transaction Set Control Number in ST02 and SE02 must be identical. The number must be unique within a specific interchange (ISA-IEA), but can repeat in other interchanges."
"C","837-Q1","1","0050","ST","02","","","","","1","0050","","F","Transaction Set Control Number"
"C","837-Q1","1","0050","ST","03","","","","","1","0050","4","","This element must be populated with the guide identifier named in Section 1.2."
"C","837-Q1","1","0050","ST","03","","","","","1","0050","391","","This field contains the same value as GS08. Some translator products strip off the ISA and GS segments prior to application (ST-SE) processing. Providing the information from the GS08 at this level will ensure that the appropriate application mapping is used at translation time."
"C","837-Q1","1","0050","ST","03","","","","","1","0050","","F","Implementation Guide Version Name"
"B","837-Q1","1","0100","","","","","","","1","0100","392","E","BHT*0019*00*0123*20040618*0932*CH~"
"B","837-Q1","1","0100","","","","","","","1","0100","5","","The second example denotes the case where the entire transaction set contains ENCOUNTERS."
"B","837-Q1","1","0100","","","","","","","1","0100","393","E","BHT*0019*00*44445*20040213*0345*RP~"
"B","837-Q1","1","0100","","","","","","","1","0100","394","A","Beginning of Hierarchical Transaction"
"C","837-Q1","1","0100","BHT","01","","","","","1","0100","","F","Hierarchical Structure Code"
"C","837-Q1","1","0100","BHT","02","","","","","1","0100","7","","BHT02 is intended to convey the electronic transmission status of the 837 batch contained in this ST-SE envelope. The terms ""original"" and ""reissue"" refer to the electronic transmission status of the 837 batch, not the billing status."
"C","837-Q1","1","0100","BHT","02","","","","","1","0100","","F","Transaction Set Purpose Code"
"E","837-Q1","1","0100","BHT","02","","","353","00","1","0100","8","","Original transmissions are transmissions which have never been sent to the receiver."
"E","837-Q1","1","0100","BHT","02","","","353","18","1","0100","9","","If a transmission was disrupted and the receiver requests a retransmission, the sender uses ""Reissue"" to indicate the transmission has been previously sent."
"C","837-Q1","1","0100","BHT","03","","","","","1","0100","10","","The inventory file number of the transmission assigned by the submitter's system. This number operates as a batch control number."
"C","837-Q1","1","0100","BHT","03","","","","","1","0100","11","","This field is limited to 30 characters."
"C","837-Q1","1","0100","BHT","03","","","","","1","0100","","F","Originator Application Transaction Identifier"
"C","837-Q1","1","0100","BHT","04","","","","","1","0100","12","","This is the date that the original submitter created the claim file from their business application system."
"C","837-Q1","1","0100","BHT","04","","","","","1","0100","","F","Transaction Set Creation Date"
"C","837-Q1","1","0100","BHT","05","","","","","1","0100","13","","This is the time that the original submitter created the claim file from their business application system."
"C","837-Q1","1","0100","BHT","05","","","","","1","0100","","F","Transaction Set Creation Time"
"C","837-Q1","1","0100","BHT","06","","","","","1","0100","","F","Claim or Encounter Identifier"
"E","837-Q1","1","0100","BHT","06","","","640","31","1","0100","395","","The subrogation demand code is only for use by state Medicaid agencies performing post payment recovery claiming with willing trading partners.
<BI>NOTE: <B>At the time of this writing, Subrogation Demand is not a HIPAA mandated use of the 837 transaction."
"E","837-Q1","1","0100","BHT","06","","","640","CH","1","0100","396","","Use CH when the transaction contains only fee for service claims or claims with at least one chargeable line item. If it is not clear whether a transaction contains claims or capitated encounters, or if the transaction contains a mix of claims and capitated encounters, use CH."
"E","837-Q1","1","0100","BHT","06","","","640","RP","1","0100","397","","Use RP when the entire ST-SE envelope contains only capitated encounters.<R>Use RP when the transaction is being sent to an entity (usually not a payer or a normal provider payer transmission intermediary) for purposes other than adjudication of a claim. Such an entity could be a state health data agency which is using the 837 for health data reporting purposes."
"B","837-Q1","1","0200","","","","","","","1","0200","14","E","NM1*41*2*ABC SUBMITTER*****46*999999999~"
"B","837-Q1","1","0200","","","","","","","1","0200","15","A","Submitter Name"
"B","837-Q1","1","0200","","","","","","","1","0200","16","","The submitter is the entity responsible for the creation and formatting of this transaction."
"C","837-Q1","1","0200","NM1","01","","","","","1","0200","","F","Entity Identifier Code"
"C","837-Q1","1","0200","NM1","02","","","","","1","0200","","F","Entity Type Qualifier"
"C","837-Q1","1","0200","NM1","03","","","","","1","0200","","F","Submitter Last or Organization Name"
"C","837-Q1","1","0200","NM1","04","","","","","1","0200","17","D","Required when NM102 = 1 (person) and the person has a first name. If not required by this implementation guide, do not send."
"C","837-Q1","1","0200","NM1","04","","","","","1","0200","","F","Submitter First Name"
"C","837-Q1","1","0200","NM1","05","","","","","1","0200","18","D","Required when NM102 = 1 (person) and the middle name or initial of the person is needed to identify the individual. If not required by this implementation guide, do not send."
"C","837-Q1","1","0200","NM1","05","","","","","1","0200","","F","Submitter Middle Name or Initial"
"C","837-Q1","1","0200","NM1","08","","","","","1","0200","","F","Identification Code Qualifier"
"E","837-Q1","1","0200","NM1","08","","","66","46","1","0200","19","","Established by trading partner agreement"
"C","837-Q1","1","0200","NM1","09","","","","","1","0200","","F","Submitter Identifier"
"B","837-Q1","1","0450","","","","","","","1","0450","24","","When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number must always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as <169>1<170>, in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as <169>ext<170> or <169>x-<170>."
"B","837-Q1","1","0450","","","","","","","1","0450","450","E","PER*IC*JOHN SMITH*TE*5555551234*EX*123~"
"B","837-Q1","1","0450","","","","","","","1","0450","26","","The contact information in this segment identifies the person in the submitter organization who deals with data transmission issues. If data transmission problems arise, this is the person to contact in the submitter organization."
"B","837-Q1","1","0450","","","","","","","1","0450","23","A","Submitter EDI Contact Information"
"B","837-Q1","1","0450","","","","","","","1","0450","27","","There are 2 repetitions of the PER segment to allow for six possible combinations of communication numbers including extensions."
"C","837-Q1","1","0450","PER","01","","","","","1","0450","","F","Contact Function Code"
"C","837-Q1","1","0450","PER","02","","","","","1","0450","28","D","Required when the contact name is different than the name contained in  the Submitter Name (NM1) segment of this loop<R>AND<R>it is the first iteration of the Submitter EDI Contact Information (PER) segment.<R>If not required by this implementation guide, do not send."
"C","837-Q1","1","0450","PER","02","","","","","1","0450","","F","Submitter Contact Name"
"C","837-Q1","1","0450","PER","03","","","","","1","0450","","F","Communication Number Qualifier"
"C","837-Q1","1","0450","PER","04","","","","","1","0450","","F","Communication Number"
"C","837-Q1","1","0450","PER","05","","","","","1","0450","29","D","Required when this information is deemed necessary by the submitter. If not required by this implementation guide, do not send."
"C","837-Q1","1","0450","PER","05","","","","","1","0450","","F","Communication Number Qualifier"
"C","837-Q1","1","0450","PER","06","","","","","1","0450","29","D","Required when this information is deemed necessary by the submitter. If not required by this implementation guide, do not send."
"C","837-Q1","1","0450","PER","06","","","","","1","0450","","F","Communication Number"
"C","837-Q1","1","0450","PER","07","","","","","1","0450","29","D","Required when this information is deemed necessary by the submitter. If not required by this implementation guide, do not send."
"C","837-Q1","1","0450","PER","07","","","","","1","0450","","F","Communication Number Qualifier"
"C","837-Q1","1","0450","PER","08","","","","","1","0450","29","D","Required when this information is deemed necessary by the submitter. If not required by this implementation guide, do not send."
"C","837-Q1","1","0450","PER","08","","","","","1","0450","","F","Communication Number"
"B","837-Q1","1","0500","","","","","","","1","0200","30","A","Receiver Name"
"B","837-Q1","1","0500","","","","","","","1","0200","31","E","NM1*40*2*XYZ RECEIVER*****46*111222333~"
"C","837-Q1","1","0500","NM1","01","","","","","1","0200","","F","Entity Identifier Code"
"C","837-Q1","1","0500","NM1","02","","","","","1","0200","","F","Entity Type Qualifier"
"C","837-Q1","1","0500","NM1","03","","","","","1","0200","398","B","Receiver Name"
"C","837-Q1","1","0500","NM1","03","","","","","1","0200","","F","Receiver Name"
"C","837-Q1","1","0500","NM1","08","","","","","1","0200","","F","Identification Code Qualifier"
"C","837-Q1","1","0500","NM1","09","","","","","1","0200","","F","Receiver Primary Identifier"
"B","837-Q1","2","0010","","","","","","","2","0010","32","E","HL*1**20*1~"
"B","837-Q1","2","0010","","","","","","","2","0010","399","A","Billing Provider Hierarchical Level"
"C","837-Q1","2","0010","HL","01","","","","","2","0010","34","","The first HL01 within each ST-SE envelope must begin with <169>1<170>, and be incremented by one each time an HL is used in the transaction.  Only numeric values are allowed in HL01."
"C","837-Q1","2","0010","HL","01","","","","","2","0010","","F","Hierarchical ID Number"
"C","837-Q1","2","0010","HL","03","","","","","2","0010","","F","Hierarchical Level Code"
"C","837-Q1","2","0010","HL","04","","","","","2","0010","","F","Hierarchical Child Code"
"B","837-Q1","2","0030","","","","","","","2","0030","400","E","PRV*BI*PXC*207Q00000X~"
"B","837-Q1","2","0030","","","","","","","2","0030","401","","Required when the payer's adjudication is known to be impacted by the provider taxonomy code.<R>If not required by this implementation guide, do not send."
"B","837-Q1","2","0030","","","","","","","2","0030","402","A","Billing Provider Specialty Information"
"C","837-Q1","2","0030","PRV","01","","","","","2","0030","","F","Provider Code"
"C","837-Q1","2","0030","PRV","02","","","","","2","0030","","F","Reference Identification Qualifier"
"C","837-Q1","2","0030","PRV","03","","","","","2","0030","","F","Provider Taxonomy Code"
"B","837-Q1","2","0100","","","","","","","2","0100","403","E","CUR*85*CAD~"
"B","837-Q1","2","0100","","","","","","","2","0100","404","A","Foreign Currency Information"
"B","837-Q1","2","0100","","","","","","","2","0100","405","","Required when the amounts represented in this transaction are currencies other than the United States dollar. If not required by this implementation guide, do not send."
"B","837-Q1","2","0100","","","","","","","2","0100","406","","It is REQUIRED that all amounts reported within the transaction are of the currency named in this segment. If this segment is not used, then it is required that all amounts in this transaction be expressed in US dollars."
"C","837-Q1","2","0100","CUR","01","","","","","2","0100","","F","Entity Identifier Code"
"C","837-Q1","2","0100","CUR","02","","","","","2","0100","407","","The submitter must use the Currency Code, not the Country Code, for this element. For example the Currency Code CAD = Canadian dollars would be valid, while CA = Canada would be invalid."
"C","837-Q1","2","0100","CUR","02","","","","","2","0100","","F","Currency Code"
"B","837-Q1","2","0150","","","","","","","2","0150","408","A","Billing Provider Name"
"B","837-Q1","2","0150","","","","","","","2","0150","409","E","NM1*85*2*ABC Group Practice*****XX*1234567890~"
"B","837-Q1","2","0150","","","","","","","2","0150","410","","Beginning on the NPI compliance date: When the Billing Provider is an organization health care provider, the organization health care provider's NPI or its subpart's NPI is reported in NM109. When a health care provider organization has determined that it needs to enumerate its subparts, it will report the NPI of a subpart as the Billing Provider. The subpart reported as the Billing Provider MUST always represent the most detailed level of enumeration as determined by the organization health care provider and MUST be the same identifier sent to any trading partner. For additional explanation, see section 1.10.3 Organization Health Care Provider Subpart Presentation."
"B","837-Q1","2","0150","","","","","","","2","0150","38","","Prior to the NPI compliance date, proprietary identifiers necessary for the receiver to identify the Billing Provider entity are to be reported in the REF segment of Loop ID-2010BB."
"B","837-Q1","2","0150","","","","","","","2","0150","39","","The Taxpayer Identifying Number (TIN) of the Billing Provider to be used for 1099 purposes must be reported in the REF segment of this loop."
"B","837-Q1","2","0150","","","","","","","2","0150","411","","The Billing Provider may be an individual only when the health care provider performing services is an independent, unincorporated entity. In these cases, the Billing Provider is the individual whose social security number is used for 1099 purposes. That individual's NPI is reported in NM109, and the individual's Tax Identification Number must be reported in the REF segment of this loop. The individual's NPI must be reported when the individual provider is eligible for an NPI. See section 1.10.1 (Providers who are Not Eligible for Enumeration)."
"B","837-Q1","2","0150","","","","","","","2","0150","40","","When the individual or the organization is not a health care provider and, thus, not eligible to receive an NPI (For example, personal care services, carpenters, etc), the Billing Provider should be the legal entity. However, willing trading partners may agree upon varying definitions. Proprietary identifiers necessary for the receiver to identify the entity are to be reported in the Loop ID-2010BB REF, Billing Provider Secondary Identification segment. The TIN to be used for 1099 purposes must be reported in the REF (Tax Identification Number) segment of this loop."
"C","837-Q1","2","0150","NM1","01","","","","","2","0150","","F","Entity Identifier Code"
"C","837-Q1","2","0150","NM1","02","","","","","2","0150","","F","Entity Type Qualifier"
"C","837-Q1","2","0150","NM1","03","","","","","2","0150","","F","Billing Provider Last or Organizational Name"
"C","837-Q1","2","0150","NM1","04","","","","","2","0150","17","D","Required when NM102 = 1 (person) and the person has a first name. If not required by this implementation guide, do not send."
"C","837-Q1","2","0150","NM1","04","","","","","2","0150","","F","Billing Provider First Name"
"C","837-Q1","2","0150","NM1","05","","","","","2","0150","18","D","Required when NM102 = 1 (person) and the middle name or initial of the person is needed to identify the individual. If not required by this implementation guide, do not send."
"C","837-Q1","2","0150","NM1","05","","","","","2","0150","","F","Billing Provider Middle Name or Initial"
"C","837-Q1","2","0150","NM1","07","","","","","2","0150","80","D","Required when NM102 = 1 (person) and the name suffix of the person is needed to identify the individual. If not required by this implementation guide, do not send."
"C","837-Q1","2","0150","NM1","07","","","","","2","0150","","F","Billing Provider Name Suffix"
"C","837-Q1","2","0150","NM1","08","","","","","2","0150","44","D","Required for providers in the United States or its territories on or  after the mandated HIPAA National Provider Identifier (NPI)  implementation date when the provider is eligible to receive an  NPI.<R>OR<R>Required for providers not in the United States or its territories on or after the mandated HIPAA National Provider Identifier (NPI) implementation date when the provider has received an NPI.<R>OR<R>Required for providers prior to the mandated NPI implementation date when the provider has received an NPI and the submitter has the capability to send it.<R>If not required by this implementation guide, do not send."
"C","837-Q1","2","0150","NM1","08","","","","","2","0150","","F","Identification Code Qualifier"
"C","837-Q1","2","0150","NM1","09","","","","","2","0150","44","D","Required for providers in the United States or its territories on or  after the mandated HIPAA National Provider Identifier (NPI)  implementation date when the provider is eligible to receive an  NPI.<R>OR<R>Required for providers not in the United States or its territories on or after the mandated HIPAA National Provider Identifier (NPI) implementation date when the provider has received an NPI.<R>OR<R>Required for providers prior to the mandated NPI implementation date when the provider has received an NPI and the submitter has the capability to send it.<R>If not required by this implementation guide, do not send."
"C","837-Q1","2","0150","NM1","09","","","","","2","0150","","F","Billing Provider Identifier"
"B","837-Q1","2","0250","","","","","","","2","0250","84","E","N3*123 MAIN STREET~"
"B","837-Q1","2","0250","","","","","","","2","0250","412","A","Billing Provider Address"
"B","837-Q1","2","0250","","","","","","","2","0250","1074","","The Billing Provider Address must be a street address. Post Office Box or Lock Box addresses are to be sent in the Pay-To Address Loop (Loop ID-2010AB), if necessary."
"C","837-Q1","2","0250","N3","01","","","","","2","0250","","F","Billing Provider Address Line"
"C","837-Q1","2","0250","N3","02","","","","","2","0250","87","D","Required when there is a second address line. If not required by this implementation guide, do not send."
"C","837-Q1","2","0250","N3","02","","","","","2","0250","","F","Billing Provider Address Line"
"B","837-Q1","2","0300","","","","","","","2","0300","413","A","Billing Provider City, State, ZIP Code"
"B","837-Q1","2","0300","","","","","","","2","0300","1548","E","N4*KANSAS CITY*MO*64108~"
"C","837-Q1","2","0300","N4","01","","","","","2","0300","","F","Billing Provider City Name"
"C","837-Q1","2","0300","N4","02","","","","","2","0300","1549","D","Required when the address is in the United States of America, including its territories, or Canada. If not required by this implementation guide, do not send."
"C","837-Q1","2","0300","N4","02","","","","","2","0300","","F","Billing Provider State or Province Code"
"C","837-Q1","2","0300","N4","03","","","","","2","0300","1550","D","Required when the address is in the United States of America, including its territories, or Canada, or when a postal code exists for the country in N404. If not required by this implementation guide, do not send."
"C","837-Q1","2","0300","N4","03","","","","","2","0300","1594","","When reporting the ZIP code for U.S. addresses, the full nine digit ZIP code must be provided."
"C","837-Q1","2","0300","N4","03","","","","","2","0300","","F","Billing Provider Postal Zone or ZIP Code"
"C","837-Q1","2","0300","N4","04","","","","","2","0300","1551","D","Required when the address is outside the United States of America. If not required by this implementation guide, do not send."
"C","837-Q1","2","0300","N4","04","","","","","2","0300","1552","","Use the alpha-2 country codes from Part 1 of ISO 3166."
"C","837-Q1","2","0300","N4","04","","","","","2","0300","","F","Country Code"
"C","837-Q1","2","0300","N4","07","","","","","2","0300","1553","D","Required when the address is not in the United States of America, including its territories, or Canada, and the country in N404 has administrative subdivisions such as but not limited to states, provinces, cantons, etc. If not required by this implementation guide, do not send."
"C","837-Q1","2","0300","N4","07","","","","","2","0300","1554","","Use the country subdivision codes from Part 2 of ISO 3166."
"C","837-Q1","2","0300","N4","07","","","","","2","0300","","F","Country Subdivision Code"
"B","837-Q1","2","0350","","","","","","","2","0350","415","","This is the tax identification number (TIN) of the entity to be paid for the submitted services."
"B","837-Q1","2","0350","","","","","","","2","0350","416","E","REF*EI*123456789~"
"B","837-Q1","2","0350","","","","","","","2","0350","1487","A","Billing Provider Tax Identification"
"C","837-Q1","2","0350","REF","01","","","","","2","0350","","F","Reference Identification Qualifier"
"E","837-Q1","2","0350","REF","01","","","128","EI","2","0350","112","","The Employer's Identification Number must be a string of exactly nine numbers with no separators.<R><R>For example, <169>001122333<170> would be valid, while sending <169>001-12-2333<170> or <169>00-1122333<170> would be invalid."
"E","837-Q1","2","0350","REF","01","","","128","SY","2","0350","327","","The Social Security Number must be a string of exactly nine numbers with no separators. For example, sending <169>111002222<170> would be valid, while sending <169>111-00-2222<170> would be invalid."
"C","837-Q1","2","0350","REF","02","","","","","2","0350","","F","Billing Provider Tax Identification Number"
"B","837-Q1","2","0360","","","","","","","2","0350","1489","A","Billing Provider UPIN/License Information"
"B","837-Q1","2","0360","","","","","","","2","0350","1490","","Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when a UPIN and/or license number is necessary for the receiver to identify the provider.<R>OR<R>Required on or after the mandated NPI implementation date when NM109 of this loop is not used and a UPIN or license number is necessary for the receiver to identify the provider.<R>If not required by this implementation guide, do not send."
"B","837-Q1","2","0360","","","","","","","2","0350","1491","","Payer specific secondary identifiers are reported in the Loop ID-2010BB REF, Billing Provider Secondary Identification."
"B","837-Q1","2","0360","","","","","","","2","0350","1492","E","REF*0B*654321~"
"C","837-Q1","2","0360","REF","01","","","","","2","0350","","F","Reference Identification Qualifier"
"E","837-Q1","2","0360","REF","01","","","128","1G","2","0350","1555","","UPINs must be formatted as either X99999 or XXX999."
"C","837-Q1","2","0360","REF","02","","","","","2","0350","","F","Billing Provider License and/or UPIN Information"
"B","837-Q1","2","0400","","","","","","","2","0400","450","E","PER*IC*JOHN SMITH*TE*5555551234*EX*123~"
"B","837-Q1","2","0400","","","","","","","2","0400","419","A","Billing Provider Contact Information"
"B","837-Q1","2","0400","","","","","","","2","0400","420","","Required when this information is different than that contained in the Loop ID-1000A - Submitter PER segment. If not required by this implementation guide, do not send.;"
"B","837-Q1","2","0400","","","","","","","2","0400","24","","When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number must always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as <169>1<170>, in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as <169>ext<170> or <169>x-<170>."
"B","837-Q1","2","0400","","","","","","","2","0400","27","","There are 2 repetitions of the PER segment to allow for six possible combinations of communication numbers including extensions."
"C","837-Q1","2","0400","PER","01","","","","","2","0400","","F","Contact Function Code"
"C","837-Q1","2","0400","PER","02","","","","","2","0400","421","D","Required in the first iteration of the Billing Provider Contact Information segment. If not required by this implementation guide, do not send."
"C","837-Q1","2","0400","PER","02","","","","","2","0400","","F","Billing Provider Contact Name"
"C","837-Q1","2","0400","PER","03","","","","","2","0400","","F","Communication Number Qualifier"
"C","837-Q1","2","0400","PER","04","","","","","2","0400","","F","Communication Number"
"C","837-Q1","2","0400","PER","05","","","","","2","0400","29","D","Required when this information is deemed necessary by the submitter. If not required by this implementation guide, do not send."
"C","837-Q1","2","0400","PER","05","","","","","2","0400","","F","Communication Number Qualifier"
"C","837-Q1","2","0400","PER","06","","","","","2","0400","29","D","Required when this information is deemed necessary by the submitter. If not required by this implementation guide, do not send."
"C","837-Q1","2","0400","PER","06","","","","","2","0400","","F","Communication Number"
"C","837-Q1","2","0400","PER","07","","","","","2","0400","29","D","Required when this information is deemed necessary by the submitter. If not required by this implementation guide, do not send."
"C","837-Q1","2","0400","PER","07","","","","","2","0400","","F","Communication Number Qualifier"
"C","837-Q1","2","0400","PER","08","","","","","2","0400","29","D","Required when this information is deemed necessary by the submitter. If not required by this implementation guide, do not send."
"C","837-Q1","2","0400","PER","08","","","","","2","0400","","F","Communication Number"
"B","837-Q1","3","0150","","","","","","","2","0150","422","E","NM1*87*2~"
"B","837-Q1","3","0150","","","","","","","2","0150","423","","Required when the address for payment is different than that of the Billing Provider. If not required by this implementation guide, do not send.;"
"B","837-Q1","3","0150","","","","","","","2","0150","424","","The purpose of Loop ID-2010AB has changed from previous versions. Loop ID-2010AB only contains address information when different from the Billing Provider Address. There are no applicable identifiers for Pay-To Address information."
"B","837-Q1","3","0150","","","","","","","2","0150","425","A","Pay-to Address Name"
"C","837-Q1","3","0150","NM1","01","","","","","2","0150","","F","Entity Identifier Code"
"C","837-Q1","3","0150","NM1","02","","","","","2","0150","","F","Entity Type Qualifier"
"B","837-Q1","3","0250","","","","","","","2","0250","84","E","N3*123 MAIN STREET~"
"B","837-Q1","3","0250","","","","","","","2","0250","426","A","Pay-to Address - ADDRESS"
"C","837-Q1","3","0250","N3","01","","","","","2","0250","","F","Pay-To Address Line"
"C","837-Q1","3","0250","N3","02","","","","","2","0250","87","D","Required when there is a second address line. If not required by this implementation guide, do not send."
"C","837-Q1","3","0250","N3","02","","","","","2","0250","","F","Pay-To Address Line"
"B","837-Q1","3","0300","","","","","","","2","0300","427","A","Pay-To Address City, State, ZIP Code"
"B","837-Q1","3","0300","","","","","","","2","0300","1548","E","N4*KANSAS CITY*MO*64108~"
"C","837-Q1","3","0300","N4","01","","","","","2","0300","","F","Pay-to Address City Name"
"C","837-Q1","3","0300","N4","02","","","","","2","0300","1549","D","Required when the address is in the United States of America, including its territories, or Canada. If not required by this implementation guide, do not send."
"C","837-Q1","3","0300","N4","02","","","","","2","0300","","F","Pay-to Address State Code"
"C","837-Q1","3","0300","N4","03","","","","","2","0300","1550","D","Required when the address is in the United States of America, including its territories, or Canada, or when a postal code exists for the country in N404. If not required by this implementation guide, do not send."
"C","837-Q1","3","0300","N4","03","","","","","2","0300","","F","Pay-to Address Postal Zone or ZIP Code"
"C","837-Q1","3","0300","N4","04","","","","","2","0300","1551","D","Required when the address is outside the United States of America. If not required by this implementation guide, do not send."
"C","837-Q1","3","0300","N4","04","","","","","2","0300","1552","","Use the alpha-2 country codes from Part 1 of ISO 3166."
"C","837-Q1","3","0300","N4","04","","","","","2","0300","","F","Country Code"
"C","837-Q1","3","0300","N4","07","","","","","2","0300","1553","D","Required when the address is not in the United States of America, including its territories, or Canada, and the country in N404 has administrative subdivisions such as but not limited to states, provinces, cantons, etc. If not required by this implementation guide, do not send."
"C","837-Q1","3","0300","N4","07","","","","","2","0300","1554","","Use the country subdivision codes from Part 2 of ISO 3166."
"C","837-Q1","3","0300","N4","07","","","","","2","0300","","F","Country Subdivision Code"
"B","837-Q1","3","0450","","","","","","","2","0150","428","A","Pay-To Plan Name"
"B","837-Q1","3","0450","","","","","","","2","0150","429","E","NM1*PE*2*ANY STATE MEDICAID*****PI*12345~"
"B","837-Q1","3","0450","","","","","","","2","0150","430","","Required when willing trading partners agree to use this implementation for their subrogation payment requests."
"B","837-Q1","3","0450","","","","","","","2","0150","1453","","This loop may only be used when BHT06 = 31."
"C","837-Q1","3","0450","NM1","01","","","","","2","0150","","F","Entity Identifier Code"
"E","837-Q1","3","0450","NM1","01","","","98","PE","2","0150","431","","PE is used to indicate the subrogated payee."
"C","837-Q1","3","0450","NM1","02","","","","","2","0150","","F","Entity Type Qualifier"
"C","837-Q1","3","0450","NM1","03","","","","","2","0150","","F","Pay-To Plan Organizational Name"
"C","837-Q1","3","0450","NM1","08","","","","","2","0150","301710","","Use code value ""PI"" when reporting Payor Identification.<R>Use code value ""XV"" when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID).<R><R>Prior to the mandated implementation date for Health Plan Identifier, willing trading partners may agree to:<R>1. Follow a dual use approach in which both the HPID or OEID and the Payor Identification are sent. Send XV qualifier in NM108 with HPID or OEID in NM109 and the Payor Identification, that would have been sent using qualifier PI, in the corresponding REF segment using qualifier 2U (Payer Identification Number).<R>OR<R>2. Follow an early implementation approach in which the HPID or OEID is sent in NM109."
"C","837-Q1","3","0450","NM1","08","","","","","2","0150","","F","Identification Code Qualifier"
"C","837-Q1","3","0450","NM1","09","","","","","2","0150","","F","Pay-To Plan Primary Identifier"
"B","837-Q1","3","0550","","","","","","","2","0250","432","A","Pay-to Plan Address"
"B","837-Q1","3","0550","","","","","","","2","0250","84","E","N3*123 MAIN STREET~"
"C","837-Q1","3","0550","N3","01","","","","","2","0250","","F","Pay-To Plan Address Line"
"C","837-Q1","3","0550","N3","02","","","","","2","0250","87","D","Required when there is a second address line. If not required by this implementation guide, do not send."
"C","837-Q1","3","0550","N3","02","","","","","2","0250","","F","Pay-To Plan Address Line"
"B","837-Q1","3","0600","","","","","","","2","0300","433","A","Pay-To Plan City, State, ZIP Code"
"B","837-Q1","3","0600","","","","","","","2","0300","1548","E","N4*KANSAS CITY*MO*64108~"
"C","837-Q1","3","0600","N4","01","","","","","2","0300","","F","Pay-To Plan City Name"
"C","837-Q1","3","0600","N4","02","","","","","2","0300","1549","D","Required when the address is in the United States of America, including its territories, or Canada. If not required by this implementation guide, do not send."
"C","837-Q1","3","0600","N4","02","","","","","2","0300","","F","Pay-To Plan State or Province Code"
"C","837-Q1","3","0600","N4","03","","","","","2","0300","1550","D","Required when the address is in the United States of America, including its territories, or Canada, or when a postal code exists for the country in N404. If not required by this implementation guide, do not send."
"C","837-Q1","3","0600","N4","03","","","","","2","0300","","F","Pay-To Plan Postal Zone or ZIP Code"
"C","837-Q1","3","0600","N4","04","","","","","2","0300","1551","D","Required when the address is outside the United States of America. If not required by this implementation guide, do not send."
"C","837-Q1","3","0600","N4","04","","","","","2","0300","1552","","Use the alpha-2 country codes from Part 1 of ISO 3166."
"C","837-Q1","3","0600","N4","04","","","","","2","0300","","F","Country Code"
"C","837-Q1","3","0600","N4","07","","","","","2","0300","1553","D","Required when the address is not in the United States of America, including its territories, or Canada, and the country in N404 has administrative subdivisions such as but not limited to states, provinces, cantons, etc. If not required by this implementation guide, do not send."
"C","837-Q1","3","0600","N4","07","","","","","2","0300","1554","","Use the country subdivision codes from Part 2 of ISO 3166."
"C","837-Q1","3","0600","N4","07","","","","","2","0300","","F","Country Subdivision Code"
"B","837-Q1","3","0650","","","","","","","2","0350","434","A","Pay-to Plan Secondary Identification"
"B","837-Q1","3","0650","","","","","","","2","0350","435","E","REF*2U*98765~"
"B","837-Q1","3","0650","","","","","","","2","0350","301711","","Required when an additional identification number to that provided in the NM109 of this loop is necessary to identify the entity.<R>If not required by this implementation guide, do not send."
"C","837-Q1","3","0650","REF","01","","","","","2","0350","","F","Reference Identification Qualifier"
"E","837-Q1","3","0650","REF","01","","","128","2U","2","0350","301712","","This code is only allowed when the qualifier XV is reported in NM108 of this loop."
"C","837-Q1","3","0650","REF","02","","","","","2","0350","","F","Pay-to Plan Secondary Identifier"
"B","837-Q1","3","0655","","","","","","","2","0350","1556","A","Pay-To Plan Tax Identification Number"
"B","837-Q1","3","0655","","","","","","","2","0350","416","E","REF*EI*123456789~"
"C","837-Q1","3","0655","REF","01","","","","","2","0350","","F","Reference Identification Qualifier"
"E","837-Q1","3","0655","REF","01","","","128","EI","2","0350","112","","The Employer's Identification Number must be a string of exactly nine numbers with no separators.<R><R>For example, <169>001122333<170> would be valid, while sending <169>001-12-2333<170> or <169>00-1122333<170> would be invalid."
"C","837-Q1","3","0655","REF","02","","","","","2","0350","","F","Pay-To Plan Tax Identification Number"
"B","837-Q1","4","0010","","","","","","","2","0010","55","E","HL*2*1*22*1~"
"B","837-Q1","4","0010","","","","","","","2","0010","54","A","Subscriber Hierarchical Level"
"B","837-Q1","4","0010","","","","","","","2","0010","56","","If a patient can be uniquely identified to the destination payer in Loop ID-2010BB by a unique Member Identification Number, then the patient is the subscriber or is considered to be the subscriber and is identified at this level, and the patient HL in Loop ID-2000C is not used."
"B","837-Q1","4","0010","","","","","","","2","0010","57","","If the patient is not the subscriber and cannot be identified to the destination payer by a unique Member Identification Number or it is not known to the sender if the Member Identification number is unique, both this HL and the patient HL in Loop ID- 2000C are required."
"C","837-Q1","4","0010","HL","01","","","","","2","0010","34","","The first HL01 within each ST-SE envelope must begin with <169>1<170>, and be incremented by one each time an HL is used in the transaction.  Only numeric values are allowed in HL01."
"C","837-Q1","4","0010","HL","01","","","","","2","0010","","F","Hierarchical ID Number"
"C","837-Q1","4","0010","HL","02","","","","","2","0010","","F","Hierarchical Parent ID Number"
"C","837-Q1","4","0010","HL","03","","","","","2","0010","","F","Hierarchical Level Code"
"C","837-Q1","4","0010","HL","04","","","","","2","0010","58","","The claim (Loop ID-2300) can be used when HL04 has no subordinate levels (HL04 = 0) or when HL04 has subordinate levels indicated (HL04 = 1)."
"C","837-Q1","4","0010","HL","04","","","","","2","0010","59","","In the first case (HL04 = 0), the subscriber is the patient and there are no dependent claims."
"C","837-Q1","4","0010","HL","04","","","","","2","0010","60","","The second case (HL04 = 1) happens when claims for one or more dependents of the subscriber are being sent under the same billing provider HL (for example, a spouse and son are both treated by the same provider). In that case, the subscriber HL04 = 1 because there is at least one dependent to this subscriber. The dependent HL (spouse) would then be sent followed by the Loop ID-2300 for the spouse. The next HL would be the dependent HL for the son followed by the Loop ID-2300 for the son."
"C","837-Q1","4","0010","HL","04","","","","","2","0010","61","","In order to send claims for the subscriber and one or more dependents,  the Subscriber HL, with Relationship Code SBR02=18 (Self), would be  followed by the Subscriber's Loop ID-2300 for the Subscriber's claims.  Then the Subscriber HL would be repeated, followed by one or more  Patient HL loops for the dependents, with the proper Relationship Code  in PAT01, each followed by their respective Loop ID-2300 for each  dependent's claims."
"C","837-Q1","4","0010","HL","04","","","","","2","0010","","F","Hierarchical Child Code"
"B","837-Q1","4","0050","","","","","","","2","0050","63","E","SBR*P**GRP01020102******CI~"
"B","837-Q1","4","0050","","","","","","","2","0050","62","A","Subscriber Information"
"C","837-Q1","4","0050","SBR","01","","","","","2","0050","64","","Within a given claim, the various values for the Payer Responsibility Sequence Number Code (other than value ""U"") may occur no more than once."
"C","837-Q1","4","0050","SBR","01","","","","","2","0050","","F","Payer Responsibility Sequence Number Code"
"E","837-Q1","4","0050","SBR","01","","","1138","U","2","0050","65","","This code may only be used in payer to payer COB claims when the original payer determined the presence of this coverage from eligibility files received from this payer or when the original claim did not provide the responsibility sequence for this payer."
"C","837-Q1","4","0050","SBR","02","","","","","2","0050","66","D","Required when the patient is the subscriber or is considered to be the subscriber. If not required by this implementation guide, do not send."
"C","837-Q1","4","0050","SBR","02","","","","","2","0050","","F","Individual Relationship Code"
"C","837-Q1","4","0050","SBR","03","","","","","2","0050","68","D","Required when the subscriber's identification card for the destination  payer (Loop ID-2010BB) shows a group number. If not required by this  implementation guide, do not send."
"C","837-Q1","4","0050","SBR","03","","","","","2","0050","67","","This is not the number uniquely identifying the subscriber. The unique  subscriber number is submitted in Loop ID-2010BA-NM109."
"C","837-Q1","4","0050","SBR","03","","","","","2","0050","","F","Subscriber Group or Policy Number"
"C","837-Q1","4","0050","SBR","04","","","","","2","0050","313","D","Required when SBR03 is not used and the group name is available. If not required by this implementation guide, do not send.;"
"C","837-Q1","4","0050","SBR","04","","","","","2","0050","","F","Subscriber Group Name"
"C","837-Q1","4","0050","SBR","05","","","","","2","0050","437","D","Required when the destination payer (Loop ID-2010BB) is Medicare and Medicare is not the primary payer (SBR01 does not equal ""P""). If not required by this implementation guide, do not send."
"C","837-Q1","4","0050","SBR","05","","","","","2","0050","","F","Insurance Type Code"
"C","837-Q1","4","0050","SBR","09","","","","","2","0050","","F","Claim Filing Indicator Code"
"E","837-Q1","4","0050","SBR","09","","","1032","OF","2","0050","1484","","Use code OF when submitting Medicare Part D claims."
"E","837-Q1","4","0050","SBR","09","","","1032","ZZ","2","0050","71","","Use Code ZZ when Type of Insurance is not known."
"B","837-Q1","4","0070","","","","","","","2","0070","74","A","Patient Information"
"B","837-Q1","4","0070","","","","","","","2","0070","438","E","PAT*****D8*19970314~
PAT*******01*146~"
"B","837-Q1","4","0070","","","","","","","2","0070","439","","Required when the patient is the subscriber or considered to be the subscriber and at least one of the element requirements are met. If not required by this implementation guide, do not send."
"C","837-Q1","4","0070","PAT","05","","","","","2","0070","440","D","Required when patient is known to be deceased and the date of death is available to the provider billing system. If not required by this implementation guide, do not send."
"C","837-Q1","4","0070","PAT","05","","","","","2","0070","","F","Date Time Period Format Qualifier"
"C","837-Q1","4","0070","PAT","06","","","","","2","0070","440","D","Required when patient is known to be deceased and the date of death is available to the provider billing system. If not required by this implementation guide, do not send."
"C","837-Q1","4","0070","PAT","06","","","","","2","0070","","F","Patient Death Date"
"C","837-Q1","4","0070","PAT","07","","","","","2","0070","442","D","Required when claims involve Medicare Durable Medical Equipment Regional Carriers Certificate of Medical Necessity (DMERC CMN) 02.03, 10.02, or DME MAC 10.03.<R>If not required by this implementation guide, do not send."
"C","837-Q1","4","0070","PAT","07","","","","","2","0070","","F","Unit or Basis for Measurement Code"
"C","837-Q1","4","0070","PAT","08","","","","","2","0070","442","D","Required when claims involve Medicare Durable Medical Equipment Regional Carriers Certificate of Medical Necessity (DMERC CMN) 02.03, 10.02, or DME MAC 10.03.<R>If not required by this implementation guide, do not send."
"C","837-Q1","4","0070","PAT","08","","","","","2","0070","","F","Patient Weight"
"C","837-Q1","4","0070","PAT","09","","","","","2","0070","443","D","Required when mandated by law. The determination of pregnancy shall be completed in compliance with applicable law. The ""Y"" code indicates that the patient is pregnant. If PAT09 is not used, it means that the patient is not pregnant or that the pregnancy indicator is not mandated by law.<R>If not required by this implementation guide, do not send."
"C","837-Q1","4","0070","PAT","09","","","","","2","0070","858","","For this implementation, the listed value takes precedence over the semantic note."
"C","837-Q1","4","0070","PAT","09","","","","","2","0070","","F","Pregnancy Indicator"
"B","837-Q1","4","0150","","","","","","","2","0150","78","E","NM1*IL*1*DOE*JOHN*T**JR*MI*123456~"
"B","837-Q1","4","0150","","","","","","","2","0150","77","A","Subscriber Name"
"B","837-Q1","4","0150","","","","","","","2","0150","79","","In worker's compensation or other property and casualty claims, the ""subscriber"" may be a non-person entity (for example, the employer). However, this varies by state."
"C","837-Q1","4","0150","NM1","01","","","","","2","0150","","F","Entity Identifier Code"
"C","837-Q1","4","0150","NM1","02","","","","","2","0150","","F","Entity Type Qualifier"
"C","837-Q1","4","0150","NM1","03","","","","","2","0150","","F","Subscriber Last Name"
"C","837-Q1","4","0150","NM1","04","","","","","2","0150","17","D","Required when NM102 = 1 (person) and the person has a first name. If not required by this implementation guide, do not send."
"C","837-Q1","4","0150","NM1","04","","","","","2","0150","","F","Subscriber First Name"
"C","837-Q1","4","0150","NM1","05","","","","","2","0150","18","D","Required when NM102 = 1 (person) and the middle name or initial of the person is needed to identify the individual. If not required by this implementation guide, do not send."
"C","837-Q1","4","0150","NM1","05","","","","","2","0150","","F","Subscriber Middle Name or Initial"
"C","837-Q1","4","0150","NM1","07","","","","","2","0150","81","","Examples: I, II, III, IV, Jr, Sr
This data element is used only to indicate generation or patronymic."
"C","837-Q1","4","0150","NM1","07","","","","","2","0150","80","D","Required when NM102 = 1 (person) and the name suffix of the person is needed to identify the individual. If not required by this implementation guide, do not send."
"C","837-Q1","4","0150","NM1","07","","","","","2","0150","","F","Subscriber Name Suffix"
"C","837-Q1","4","0150","NM1","08","","","","","2","0150","301118","D","Required when NM102 = 1 (person). If not required by this implementation guide, do not send."
"C","837-Q1","4","0150","NM1","08","","","","","2","0150","","F","Identification Code Qualifier"
"E","837-Q1","4","0150","NM1","08","","","66","II","2","0150","1540","","Required if the HIPAA Individual Patient Identifier is mandated use.  If not required, use value `MI' instead."
"E","837-Q1","4","0150","NM1","08","","","66","MI","2","0150","82","","The code MI is intended to be the subscriber's identification number as assigned by the payer. (For example, Insured's ID, Subscriber's ID, Health Insurance Claim Number (HIC), etc.)<R><R>MI is also intended to be used in claims submitted to the Indian Health Service/Contract Health Services (IHS/CHS) Fiscal Intermediary for the purpose of reporting the Tribe Residency Code (Tribe County State). In the event that a Social Security Number (SSN) is also available on an IHS/CHS claim, put the SSN in REF02.<R><R>When sending the Social Security Number as the Member ID, it must be a string of exactly nine numbers with no separators. For example, sending <169>111002222<170> would be valid, while sending <169>111-00-2222<170> would be invalid."
"C","837-Q1","4","0150","NM1","09","","","","","2","0150","301118","D","Required when NM102 = 1 (person). If not required by this implementation guide, do not send."
"C","837-Q1","4","0150","NM1","09","","","","","2","0150","","F","Subscriber Primary Identifier"
"B","837-Q1","4","0250","","","","","","","2","0250","84","E","N3*123 MAIN STREET~"
"B","837-Q1","4","0250","","","","","","","2","0250","85","A","Subscriber Address"
"B","837-Q1","4","0250","","","","","","","2","0250","86","","Required when the patient is the subscriber or considered to be the  subscriber. If not required by this implementation guide, do not send."
"C","837-Q1","4","0250","N3","01","","","","","2","0250","","F","Subscriber Address Line"
"C","837-Q1","4","0250","N3","02","","","","","2","0250","87","D","Required when there is a second address line. If not required by this implementation guide, do not send."
"C","837-Q1","4","0250","N3","02","","","","","2","0250","","F","Subscriber Address Line"
"B","837-Q1","4","0300","","","","","","","2","0300","89","A","Subscriber City, State, ZIP Code"
"B","837-Q1","4","0300","","","","","","","2","0300","1548","E","N4*KANSAS CITY*MO*64108~"
"B","837-Q1","4","0300","","","","","","","2","0300","86","","Required when the patient is the subscriber or considered to be the  subscriber. If not required by this implementation guide, do not send."
"C","837-Q1","4","0300","N4","01","","","","","2","0300","","F","Subscriber City Name"
"C","837-Q1","4","0300","N4","02","","","","","2","0300","1549","D","Required when the address is in the United States of America, including its territories, or Canada. If not required by this implementation guide, do not send."
"C","837-Q1","4","0300","N4","02","","","","","2","0300","","F","Subscriber State Code"
"C","837-Q1","4","0300","N4","03","","","","","2","0300","1550","D","Required when the address is in the United States of America, including its territories, or Canada, or when a postal code exists for the country in N404. If not required by this implementation guide, do not send."
"C","837-Q1","4","0300","N4","03","","","","","2","0300","","F","Subscriber Postal Zone or ZIP Code"
"C","837-Q1","4","0300","N4","04","","","","","2","0300","1551","D","Required when the address is outside the United States of America. If not required by this implementation guide, do not send."
"C","837-Q1","4","0300","N4","04","","","","","2","0300","1552","","Use the alpha-2 country codes from Part 1 of ISO 3166."
"C","837-Q1","4","0300","N4","04","","","","","2","0300","","F","Country Code"
"C","837-Q1","4","0300","N4","07","","","","","2","0300","1553","D","Required when the address is not in the United States of America, including its territories, or Canada, and the country in N404 has administrative subdivisions such as but not limited to states, provinces, cantons, etc. If not required by this implementation guide, do not send."
"C","837-Q1","4","0300","N4","07","","","","","2","0300","1554","","Use the country subdivision codes from Part 2 of ISO 3166."
"C","837-Q1","4","0300","N4","07","","","","","2","0300","","F","Country Subdivision Code"
"B","837-Q1","4","0320","","","","","","","2","0320","93","A","Subscriber Demographic Information"
"B","837-Q1","4","0320","","","","","","","2","0320","86","","Required when the patient is the subscriber or considered to be the  subscriber. If not required by this implementation guide, do not send."
"B","837-Q1","4","0320","","","","","","","2","0320","94","E","DMG*D8*19690815*M~"
"C","837-Q1","4","0320","DMG","01","","","","","2","0320","","F","Date Time Period Format Qualifier"
"C","837-Q1","4","0320","DMG","02","","","","","2","0320","","F","Subscriber Birth Date"
"C","837-Q1","4","0320","DMG","03","","","","","2","0320","","F","Subscriber Gender Code"
"B","837-Q1","4","0350","","","","","","","2","0350","100","A","Subscriber Secondary Identification"
"B","837-Q1","4","0350","","","","","","","2","0350","326","","Required when an additional identification number to that provided in NM109 of this loop is necessary for the claim processor to identify the entity. If not required by this implementation guide, do not send."
"B","837-Q1","4","0350","","","","","","","2","0350","101","E","REF*SY*123456789~"
"C","837-Q1","4","0350","REF","01","","","","","2","0350","","F","Reference Identification Qualifier"
"E","837-Q1","4","0350","REF","01","","","128","SY","2","0350","327","","The Social Security Number must be a string of exactly nine numbers with no separators. For example, sending <169>111002222<170> would be valid, while sending <169>111-00-2222<170> would be invalid."
"C","837-Q1","4","0350","REF","02","","","","","2","0350","","F","Subscriber Supplemental Identifier"
"B","837-Q1","4","0360","","","","","","","2","0350","444","A","Property and Casualty Claim Number"
"B","837-Q1","4","0360","","","","","","","2","0350","445","E","REF*Y4*4445555~"
"B","837-Q1","4","0360","","","","","","","2","0350","446","","Required when the services included in this claim are to be considered as part of a property and casualty claim. If not required by this implementation guide, do not send."
"B","837-Q1","4","0360","","","","","","","2","0350","447","","This is a property and casualty payer-assigned claim number. Providers receive this number from the property and casualty payer during eligibility determinations or some other communication with that payer. See Section 1.4.2, Property and Casualty, for additional information about property and casualty claims.;"
"B","837-Q1","4","0360","","","","","","","2","0350","448","","This segment is not a HIPAA requirement as of this writing."
"C","837-Q1","4","0360","REF","01","","","","","2","0350","","F","Reference Identification Qualifier"
"C","837-Q1","4","0360","REF","02","","","","","2","0350","","F","Property Casualty Claim Number"
"B","837-Q1","4","0400","","","","","","","2","0400","449","A","Property and Casualty Subscriber Contact Information"
"B","837-Q1","4","0400","","","","","","","2","0400","450","E","PER*IC*JOHN SMITH*TE*5555551234*EX*123~"
"B","837-Q1","4","0400","","","","","","","2","0400","451","","Required for Property and Casualty claims when this information is deemed necessary by the submitter. If not required by this implementation guide, do not send."
"B","837-Q1","4","0400","","","","","","","2","0400","24","","When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number must always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as <169>1<170>, in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as <169>ext<170> or <169>x-<170>."
"C","837-Q1","4","0400","PER","01","","","","","2","0400","","F","Contact Function Code"
"C","837-Q1","4","0400","PER","02","","","","","2","0400","452","D","Required when the Subscriber contact is a person other than the person identified in the Subscriber Name NM1 (Loop ID-2000BA). If not required by this implementation guide, do not send."
"C","837-Q1","4","0400","PER","02","","","","","2","0400","","F","Name"
"C","837-Q1","4","0400","PER","03","","","","","2","0400","","F","Communication Number Qualifier"
"C","837-Q1","4","0400","PER","04","","","","","2","0400","","F","Communication Number"
"C","837-Q1","4","0400","PER","05","","","","","2","0400","29","D","Required when this information is deemed necessary by the submitter. If not required by this implementation guide, do not send."
"C","837-Q1","4","0400","PER","05","","","","","2","0400","","F","Communication Number Qualifier"
"C","837-Q1","4","0400","PER","06","","","","","2","0400","29","D","Required when this information is deemed necessary by the submitter. If not required by this implementation guide, do not send."
"C","837-Q1","4","0400","PER","06","","","","","2","0400","","F","Communication Number"
"B","837-Q1","5","0150","","","","","","","2","0150","104","E","NM1*PR*2*ABC INSURANCE CO*****PI*11122333~"
"B","837-Q1","5","0150","","","","","","","2","0150","106","","This is the destination payer."
"B","837-Q1","5","0150","","","","","","","2","0150","105","A","Payer Name"
"B","837-Q1","5","0150","","","","","","","2","0150","1485","","For the purposes of this implementation the term payer is synonymous with several other terms, such as, repricer and third party administrator."
"C","837-Q1","5","0150","NM1","01","","","","","2","0150","","F","Entity Identifier Code"
"C","837-Q1","5","0150","NM1","02","","","","","2","0150","","F","Entity Type Qualifier"
"C","837-Q1","5","0150","NM1","03","","","","","2","0150","","F","Payer Name"
"C","837-Q1","5","0150","NM1","08","","","","","2","0150","301710","","Use code value ""PI"" when reporting Payor Identification.<R>Use code value ""XV"" when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID).<R><R>Prior to the mandated implementation date for Health Plan Identifier, willing trading partners may agree to:<R>1. Follow a dual use approach in which both the HPID or OEID and the Payor Identification are sent. Send XV qualifier in NM108 with HPID or OEID in NM109 and the Payor Identification, that would have been sent using qualifier PI, in the corresponding REF segment using qualifier 2U (Payer Identification Number).<R>OR<R>2. Follow an early implementation approach in which the HPID or OEID is sent in NM109."
"C","837-Q1","5","0150","NM1","08","","","","","2","0150","","F","Identification Code Qualifier"
"C","837-Q1","5","0150","NM1","09","","","","","2","0150","","F","Payer Identifier"
"B","837-Q1","5","0250","","","","","","","2","0250","84","E","N3*123 MAIN STREET~"
"B","837-Q1","5","0250","","","","","","","2","0250","453","A","Payer Address"
"B","837-Q1","5","0250","","","","","","","2","0250","792","","Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send."
"C","837-Q1","5","0250","N3","01","","","","","2","0250","","F","Payer Address Line"
"C","837-Q1","5","0250","N3","02","","","","","2","0250","87","D","Required when there is a second address line. If not required by this implementation guide, do not send."
"C","837-Q1","5","0250","N3","02","","","","","2","0250","","F","Payer Address Line"
"B","837-Q1","5","0300","","","","","","","2","0300","455","A","Payer City, State, ZIP Code"
"B","837-Q1","5","0300","","","","","","","2","0300","1548","E","N4*KANSAS CITY*MO*64108~"
"B","837-Q1","5","0300","","","","","","","2","0300","301119","","Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send."
"C","837-Q1","5","0300","N4","01","","","","","2","0300","","F","Payer City Name"
"C","837-Q1","5","0300","N4","02","","","","","2","0300","1549","D","Required when the address is in the United States of America, including its territories, or Canada. If not required by this implementation guide, do not send."
"C","837-Q1","5","0300","N4","02","","","","","2","0300","","F","Payer State or Province Code"
"C","837-Q1","5","0300","N4","03","","","","","2","0300","1550","D","Required when the address is in the United States of America, including its territories, or Canada, or when a postal code exists for the country in N404. If not required by this implementation guide, do not send."
"C","837-Q1","5","0300","N4","03","","","","","2","0300","","F","Payer Postal Zone or ZIP Code"
"C","837-Q1","5","0300","N4","04","","","","","2","0300","1551","D","Required when the address is outside the United States of America. If not required by this implementation guide, do not send."
"C","837-Q1","5","0300","N4","04","","","","","2","0300","1552","","Use the alpha-2 country codes from Part 1 of ISO 3166."
"C","837-Q1","5","0300","N4","04","","","","","2","0300","","F","Country Code"
"C","837-Q1","5","0300","N4","07","","","","","2","0300","1553","D","Required when the address is not in the United States of America, including its territories, or Canada, and the country in N404 has administrative subdivisions such as but not limited to states, provinces, cantons, etc. If not required by this implementation guide, do not send."
"C","837-Q1","5","0300","N4","07","","","","","2","0300","1554","","Use the country subdivision codes from Part 2 of ISO 3166."
"C","837-Q1","5","0300","N4","07","","","","","2","0300","","F","Country Subdivision Code"
"B","837-Q1","5","0350","","","","","","","2","0350","456","E","REF*FY*435261708~"
"B","837-Q1","5","0350","","","","","","","2","0350","108","A","Payer Secondary Identification"
"B","837-Q1","5","0350","","","","","","","2","0350","301711","","Required when an additional identification number to that provided in the NM109 of this loop is necessary to identify the entity.<R>If not required by this implementation guide, do not send."
"C","837-Q1","5","0350","REF","01","","","","","2","0350","","F","Reference Identification Qualifier"
"E","837-Q1","5","0350","REF","01","","","128","2U","2","0350","301712","","This code is only allowed when the qualifier XV is reported in NM108 of this loop."
"E","837-Q1","5","0350","REF","01","","","128","EI","2","0350","112","","The Employer's Identification Number must be a string of exactly nine numbers with no separators.<R><R>For example, <169>001122333<170> would be valid, while sending <169>001-12-2333<170> or <169>00-1122333<170> would be invalid."
"C","837-Q1","5","0350","REF","02","","","","","2","0350","","F","Payer Secondary Identifier"
"B","837-Q1","5","0370","","","","","","","2","0350","414","A","Billing Provider Secondary Identification"
"B","837-Q1","5","0370","","","","","","","2","0350","369","E","REF*G2*12345~"
"B","837-Q1","5","0370","","","","","","","2","0350","1486","","Required prior to the mandated NPI Implementation Date when an additional identification number is necessary for the receiver to identify the provider.<R>OR<R>Required on or after the mandated NPI Implementation Date when NM109 in Loop 2010AA is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.<R>If not required by this implementation guide, do not send."
"C","837-Q1","5","0370","REF","01","","","","","2","0350","","F","Reference Identification Qualifier"
"E","837-Q1","5","0370","REF","01","","","128","G2","2","0350","1464","","This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc."
"C","837-Q1","5","0370","REF","02","","","","","2","0350","","F","Billing Provider Secondary Identifier"
"B","837-Q1","8","0010","","","","","","","2","0010","114","E","HL*3*2*23*0~"
"B","837-Q1","8","0010","","","","","","","2","0010","113","A","Patient Hierarchical Level"
"B","837-Q1","8","0010","","","","","","","2","0010","115","","Required when the patient is a dependent of the subscriber identified in Loop ID-2000B and cannot be uniquely identified to the payer using the subscriber's identifier in the Subscriber Level. If not required by this implementation guide, do not send."
"B","837-Q1","8","0010","","","","","","","2","0010","116","","There are no HLs subordinate to the Patient HL."
"B","837-Q1","8","0010","","","","","","","2","0010","117","","If a patient is a dependent of a subscriber and can be uniquely identified to the payer by a unique Identification Number, then the patient is considered the subscriber and is to be identified in the Subscriber Level."
"C","837-Q1","8","0010","HL","01","","","","","2","0010","","F","Hierarchical ID Number"
"C","837-Q1","8","0010","HL","02","","","","","2","0010","","F","Hierarchical Parent ID Number"
"C","837-Q1","8","0010","HL","03","","","","","2","0010","","F","Hierarchical Level Code"
"E","837-Q1","8","0010","HL","03","","","735","23","2","0010","118","","The code DEPENDENT conveys that the information in this HL applies to the patient when the subscriber and the patient are not the same person."
"C","837-Q1","8","0010","HL","04","","","","","2","0010","","F","Hierarchical Child Code"
"B","837-Q1","8","0070","","","","","","","2","0070","74","A","Patient Information"
"B","837-Q1","8","0070","","","","","","","2","0070","474","E","PAT*01~"
"C","837-Q1","8","0070","PAT","01","","","","","2","0070","1289","","Specifies the patient's relationship to the person insured."
"C","837-Q1","8","0070","PAT","01","","","","","2","0070","","F","Individual Relationship Code"
"C","837-Q1","8","0070","PAT","05","","","","","2","0070","440","D","Required when patient is known to be deceased and the date of death is available to the provider billing system. If not required by this implementation guide, do not send."
"C","837-Q1","8","0070","PAT","05","","","","","2","0070","","F","Date Time Period Format Qualifier"
"C","837-Q1","8","0070","PAT","06","","","","","2","0070","440","D","Required when patient is known to be deceased and the date of death is available to the provider billing system. If not required by this implementation guide, do not send."
"C","837-Q1","8","0070","PAT","06","","","","","2","0070","","F","Patient Death Date"
"C","837-Q1","8","0070","PAT","07","","","","","2","0070","442","D","Required when claims involve Medicare Durable Medical Equipment Regional Carriers Certificate of Medical Necessity (DMERC CMN) 02.03, 10.02, or DME MAC 10.03.<R>If not required by this implementation guide, do not send."
"C","837-Q1","8","0070","PAT","07","","","","","2","0070","","F","Unit or Basis for Measurement Code"
"C","837-Q1","8","0070","PAT","08","","","","","2","0070","442","D","Required when claims involve Medicare Durable Medical Equipment Regional Carriers Certificate of Medical Necessity (DMERC CMN) 02.03, 10.02, or DME MAC 10.03.<R>If not required by this implementation guide, do not send."
"C","837-Q1","8","0070","PAT","08","","","","","2","0070","","F","Patient Weight"
"C","837-Q1","8","0070","PAT","09","","","","","2","0070","443","D","Required when mandated by law. The determination of pregnancy shall be completed in compliance with applicable law. The ""Y"" code indicates that the patient is pregnant. If PAT09 is not used, it means that the patient is not pregnant or that the pregnancy indicator is not mandated by law.<R>If not required by this implementation guide, do not send."
"C","837-Q1","8","0070","PAT","09","","","","","2","0070","858","","For this implementation, the listed value takes precedence over the semantic note."
"C","837-Q1","8","0070","PAT","09","","","","","2","0070","","F","Pregnancy Indicator"
"B","837-Q1","8","0150","","","","","","","2","0150","120","E","NM1*QC*1*DOE*SALLY*J~"
"B","837-Q1","8","0150","","","","","","","2","0150","121","A","Patient Name"
"C","837-Q1","8","0150","NM1","01","","","","","2","0150","","F","Entity Identifier Code"
"C","837-Q1","8","0150","NM1","02","","","","","2","0150","","F","Entity Type Qualifier"
"C","837-Q1","8","0150","NM1","03","","","","","2","0150","","F","Patient Last Name"
"C","837-Q1","8","0150","NM1","04","","","","","2","0150","266","D","Required when the person has a first name. If not required by this implementation guide, do not send."
"C","837-Q1","8","0150","NM1","04","","","","","2","0150","","F","Patient First Name"
"C","837-Q1","8","0150","NM1","05","","","","","2","0150","1170","D","Required when the middle name or initial of the person is needed to identify the individual. If not required by this implementation guide, do not send."
"C","837-Q1","8","0150","NM1","05","","","","","2","0150","","F","Patient Middle Name or Initial"
"C","837-Q1","8","0150","NM1","07","","","","","2","0150","268","D","Required when the name suffix is needed to identify the individual. If not required by this implementation guide, do not send.;"
"C","837-Q1","8","0150","NM1","07","","","","","2","0150","","F","Patient Name Suffix"
"B","837-Q1","8","0250","","","","","","","2","0250","84","E","N3*123 MAIN STREET~"
"B","837-Q1","8","0250","","","","","","","2","0250","123","A","Patient Address"
"C","837-Q1","8","0250","N3","01","","","","","2","0250","","F","Patient Address Line"
"C","837-Q1","8","0250","N3","02","","","","","2","0250","87","D","Required when there is a second address line. If not required by this implementation guide, do not send."
"C","837-Q1","8","0250","N3","02","","","","","2","0250","","F","Patient Address Line"
"B","837-Q1","8","0300","","","","","","","2","0300","124","A","Patient City, State, ZIP Code"
"B","837-Q1","8","0300","","","","","","","2","0300","1548","E","N4*KANSAS CITY*MO*64108~"
"C","837-Q1","8","0300","N4","01","","","","","2","0300","","F","Patient City Name"
"C","837-Q1","8","0300","N4","02","","","","","2","0300","1549","D","Required when the address is in the United States of America, including its territories, or Canada. If not required by this implementation guide, do not send."
"C","837-Q1","8","0300","N4","02","","","","","2","0300","","F","Patient State Code"
"C","837-Q1","8","0300","N4","03","","","","","2","0300","1550","D","Required when the address is in the United States of America, including its territories, or Canada, or when a postal code exists for the country in N404. If not required by this implementation guide, do not send."
"C","837-Q1","8","0300","N4","03","","","","","2","0300","","F","Patient Postal Zone or ZIP Code"
"C","837-Q1","8","0300","N4","04","","","","","2","0300","1551","D","Required when the address is outside the United States of America. If not required by this implementation guide, do not send."
"C","837-Q1","8","0300","N4","04","","","","","2","0300","1552","","Use the alpha-2 country codes from Part 1 of ISO 3166."
"C","837-Q1","8","0300","N4","04","","","","","2","0300","","F","Country Code"
"C","837-Q1","8","0300","N4","07","","","","","2","0300","1553","D","Required when the address is not in the United States of America, including its territories, or Canada, and the country in N404 has administrative subdivisions such as but not limited to states, provinces, cantons, etc. If not required by this implementation guide, do not send."
"C","837-Q1","8","0300","N4","07","","","","","2","0300","1554","","Use the country subdivision codes from Part 2 of ISO 3166."
"C","837-Q1","8","0300","N4","07","","","","","2","0300","","F","Country Subdivision Code"
"B","837-Q1","8","0320","","","","","","","2","0320","94","E","DMG*D8*19690815*M~"
"B","837-Q1","8","0320","","","","","","","2","0320","125","A","Patient Demographic Information"
"C","837-Q1","8","0320","DMG","01","","","","","2","0320","","F","Date Time Period Format Qualifier"
"C","837-Q1","8","0320","DMG","02","","","","","2","0320","","F","Patient Birth Date"
"C","837-Q1","8","0320","DMG","03","","","","","2","0320","","F","Patient Gender Code"
"B","837-Q1","8","0360","","","","","","","2","0350","444","A","Property and Casualty Claim Number"
"B","837-Q1","8","0360","","","","","","","2","0350","445","E","REF*Y4*4445555~"
"B","837-Q1","8","0360","","","","","","","2","0350","446","","Required when the services included in this claim are to be considered as part of a property and casualty claim. If not required by this implementation guide, do not send."
"B","837-Q1","8","0360","","","","","","","2","0350","447","","This is a property and casualty payer-assigned claim number. Providers receive this number from the property and casualty payer during eligibility determinations or some other communication with that payer. See Section 1.4.2, Property and Casualty, for additional information about property and casualty claims.;"
"B","837-Q1","8","0360","","","","","","","2","0350","448","","This segment is not a HIPAA requirement as of this writing."
"C","837-Q1","8","0360","REF","01","","","","","2","0350","","F","Reference Identification Qualifier"
"C","837-Q1","8","0360","REF","02","","","","","2","0350","","F","Property Casualty Claim Number"
"B","837-Q1","8","0362","","","","","","","2","0350","301115","A","Property and Casualty Patient Identifier"
"B","837-Q1","8","0362","","","","","","","2","0350","301116","","Required when an identification number is needed by the receiver to identify the patient for Property and Casualty claims. If not required by this implementation guide, do not send."
"B","837-Q1","8","0362","","","","","","","2","0350","101","E","REF*SY*123456789~"
"C","837-Q1","8","0362","REF","01","","","","","2","0350","","F","Reference Identification Qualifier"
"E","837-Q1","8","0362","REF","01","","","128","1W","2","0350","301117","","This code designates a patient identification number used by the destination payer identified in the Payer Name loop, Loop ID 2010BB, associated with this claim."
"E","837-Q1","8","0362","REF","01","","","128","SY","2","0350","327","","The Social Security Number must be a string of exactly nine numbers with no separators. For example, sending <169>111002222<170> would be valid, while sending <169>111-00-2222<170> would be invalid."
"C","837-Q1","8","0362","REF","02","","","","","2","0350","","F","Property and Casualty Patient Identifier"
"B","837-Q1","8","0400","","","","","","","2","0400","475","A","Property and Casualty Patient Contact Information"
"B","837-Q1","8","0400","","","","","","","2","0400","450","E","PER*IC*JOHN SMITH*TE*5555551234*EX*123~"
"B","837-Q1","8","0400","","","","","","","2","0400","476","","Required for Property and Casualty claims when this information is different than the information provided in the Subscriber Contact Information PER segment in Loop ID-2010BA and this information is deemed necessary by the submitter. If not required by this implementation guide, do not send."
"B","837-Q1","8","0400","","","","","","","2","0400","24","","When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number must always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as <169>1<170>, in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as <169>ext<170> or <169>x-<170>."
"C","837-Q1","8","0400","PER","01","","","","","2","0400","","F","Contact Function Code"
"C","837-Q1","8","0400","PER","02","","","","","2","0400","477","D","Required when the Patient contact is a person other than the person identified in the Patient Name NM1 (Loop ID-2010CA). If not required by this implementation guide, do not send."
"C","837-Q1","8","0400","PER","02","","","","","2","0400","","F","Name"
"C","837-Q1","8","0400","PER","03","","","","","2","0400","","F","Communication Number Qualifier"
"C","837-Q1","8","0400","PER","04","","","","","2","0400","","F","Communication Number"
"C","837-Q1","8","0400","PER","05","","","","","2","0400","29","D","Required when this information is deemed necessary by the submitter. If not required by this implementation guide, do not send."
"C","837-Q1","8","0400","PER","05","","","","","2","0400","","F","Communication Number Qualifier"
"C","837-Q1","8","0400","PER","06","","","","","2","0400","29","D","Required when this information is deemed necessary by the submitter. If not required by this implementation guide, do not send."
"C","837-Q1","8","0400","PER","06","","","","","2","0400","","F","Communication Number"
"B","837-Q1","C","1300","","","","","","","2","1300","478","E","CLM*A37YH556*500***11:B:1*Y*A*Y*I*P~"
"B","837-Q1","C","1300","","","","","","","2","1300","138","A","Claim Information"
"B","837-Q1","C","1300","","","","","","","2","1300","139","","The developers of this implementation guide recommend that trading partners limit the size of the transaction (ST-SE envelope) to a maximum of 5000 CLM segments. There is no recommended limit to the number of ST-SE transactions within a GS-GE or ISA-IEA. Willing trading partners can agree to set limits higher."
"B","837-Q1","C","1300","","","","","","","2","1300","140","","For purposes of this documentation, the claim detail information is presented only in the dependent level. Specific claim detail information can be given in either the subscriber or the dependent hierarchical level. Because of this, the claim information is said to <169>float.<170> Claim information is positioned in the same hierarchical level that describes its owner-participant, either the subscriber or the dependent. In other words, the claim information, Loop ID-2300, is placed following Loop ID-2010BB in the Subscriber Hierarchical Level (HL) when patient information is sent in Loop ID-2010BA of the Subscriber HL. Claim information is placed in the Patient HL when the patient information is sent in Loop ID-2010CA of the Patient HL. When the patient is the subscriber or is considered to be the subscriber, Loop ID-2000C and Loop ID-2010CA are not sent. See Subscriber/Patient HL Segment explanation in section 1.4.3.2.2.1 for details."
"C","837-Q1","C","1300","CLM","01","","","","","2","1300","479","","The number that the submitter transmits in this position is echoed back to the submitter in the 835 and other transactions. This permits the submitter to use the value in this field as a key in the submitter's system to match the claim to the payment information returned in the 835 transaction. The two recommended identifiers are either the Patient Account Number or the Claim Number in the billing submitter's patient management system. The developers of this implementation guide strongly recommend that submitters use unique numbers for this field for each individual claim."
"C","837-Q1","C","1300","CLM","01","","","","","2","1300","480","","When Loop ID-2010AC is present, CLM01 represents the subrogated Medicaid agency's claim number (ICN/DCN) from their original 835 CLP07 - Payer Claim Control Number. See Section 1.4.1.4 of the front matter for a description of post payment recovery claims for subrogated Medicaid agencies."
"C","837-Q1","C","1300","CLM","01","","","","","2","1300","143","","The maximum number of characters to be supported for this field is `20'. Characters beyond the maximum are not required to be stored nor returned by any 837-receiving system."
"C","837-Q1","C","1300","CLM","01","","","","","2","1300","","F","Patient Control Number"
"C","837-Q1","C","1300","CLM","02","","","","","2","1300","144","","The Total Claim Charge Amount must be greater than or equal to zero."
"C","837-Q1","C","1300","CLM","02","","","","","2","1300","481","","The total claim charge amount must balance to the sum of all service line charge amounts reported in the Professional Service (SV1) segments for this claim."
"C","837-Q1","C","1300","CLM","02","","","","","2","1300","","F","Total Claim Charge Amount"
"C","837-Q1","C","1300","CLM","05","","","","","2","1300","482","","CLM05 applies to all service lines unless it is over written at the line level."
"D","837-Q1","C","1300","CLM","05","C023","01","","","2","1300","","F","Place of Service Code"
"D","837-Q1","C","1300","CLM","05","C023","02","","","2","1300","","F","Facility Code Qualifier"
"D","837-Q1","C","1300","CLM","05","C023","03","","","2","1300","","F","Claim Frequency Code"
"C","837-Q1","C","1300","CLM","06","","","","","2","1300","","F","Provider or Supplier Signature Indicator"
"C","837-Q1","C","1300","CLM","07","","","","","2","1300","1559","","Within this element the context of the word assignment is related to the relationship between the provider and the payer. This is NOT the field for reporting whether the patient has or has not assigned benefits to the provider. The benefit assignment indicator is in CLM08."
"C","837-Q1","C","1300","CLM","07","","","","","2","1300","","F","Assignment or Plan Participation Code"
"E","837-Q1","C","1300","CLM","07","","","1359","A","2","1300","1560","","Required when the provider accepts assignment and/or has a participation agreement with the destination payer.<R>OR<R>Required when the provider does not accept assignment and/or have a participation agreement, but is advising the payer to adjudicate this specific claim under participating provider benefits as allowed under certain plans."
"E","837-Q1","C","1300","CLM","07","","","1359","B","2","1300","1561","","Required when the provider accepts assignment for Clinical Lab Services only."
"E","837-Q1","C","1300","CLM","07","","","1359","C","2","1300","1562","","Required when neither codes `A' nor `B' apply."
"C","837-Q1","C","1300","CLM","08","","","","","2","1300","486","","This element answers the question whether or not the insured has authorized the plan to remit payment directly to the provider."
"C","837-Q1","C","1300","CLM","08","","","","","2","1300","","F","Benefits Assignment Certification Indicator"
"E","837-Q1","C","1300","CLM","08","","","1073","W","2","1300","1563","","Use code `W' when the patient refuses to assign benefits."
"C","837-Q1","C","1300","CLM","09","","","","","2","1300","487","","The Release of Information response is limited to the information carried in this claim."
"C","837-Q1","C","1300","CLM","09","","","","","2","1300","","F","Release of Information Code"
"E","837-Q1","C","1300","CLM","09","","","1363","I","2","1300","488","","Required when the provider has not collected a signature AND state or federal laws do not require a signature be collected."
"E","837-Q1","C","1300","CLM","09","","","1363","Y","2","1300","489","","Required when the provider has collected a signature.<R>OR<R>Required when state or federal laws require a signature be collected."
"C","837-Q1","C","1300","CLM","10","","","","","2","1300","490","D","Required when a signature was executed on the patient's behalf under state or federal law. If not required by this implementation guide, do not send."
"C","837-Q1","C","1300","CLM","10","","","","","2","1300","","F","Patient Signature Source Code"
"E","837-Q1","C","1300","CLM","10","","","1351","P","2","1300","1497","","Signature generated by an entity other than the patient according to State or Federal law."
"C","837-Q1","C","1300","CLM","11","","","","","2","1300","146","D","Required when the services provided are employment related or the result of an accident. If not required by this implementation guide, do not send."
"C","837-Q1","C","1300","CLM","11","","","","","2","1300","147","","If DTP - Date of Accident (DTP01=439) is used, then CLM11 is required."
"D","837-Q1","C","1300","CLM","11","C024","01","","","2","1300","","F","Related Causes Code"
"D","837-Q1","C","1300","CLM","11","C024","02","","","2","1300","148","D","Required when more than one related cause code applies. See CLM11-1 for valid values. If not required by this implementation guide, do not send."
"D","837-Q1","C","1300","CLM","11","C024","02","","","2","1300","","F","Related Causes Code"
"D","837-Q1","C","1300","CLM","11","C024","04","","","2","1300","149","D","Required when CLM11-1 or CLM11-2 has a value of `AA' to identify the state, province or sub-country code in which the automobile accident occurred. If accident occurred in a country or location that does not have states, provinces or sub-country codes named in Code Source 22, do not use.<R>If not required by this implementation guide, do not send."
"D","837-Q1","C","1300","CLM","11","C024","04","","","2","1300","","F","Auto Accident State or Province Code"
"D","837-Q1","C","1300","CLM","11","C024","05","","","2","1300","150","D","Required when CLM11-1 or CLM11-2 = AA and the accident occurred in a country other than US or Canada. If not required by this implementation guide, do not send."
"D","837-Q1","C","1300","CLM","11","C024","05","","","2","1300","","F","Country Code"
"C","837-Q1","C","1300","CLM","12","","","","","2","1300","491","D","Required when the services were rendered under one of the following circumstances, programs, or projects. If not required by this implementation guide, do not send."
"C","837-Q1","C","1300","CLM","12","","","","","2","1300","","F","Special Program Indicator"
"E","837-Q1","C","1300","CLM","12","","","1366","02","2","1300","492","","This code is used for Medicaid claims only."
"E","837-Q1","C","1300","CLM","12","","","1366","03","2","1300","492","","This code is used for Medicaid claims only."
"E","837-Q1","C","1300","CLM","12","","","1366","05","2","1300","492","","This code is used for Medicaid claims only."
"E","837-Q1","C","1300","CLM","12","","","1366","09","2","1300","492","","This code is used for Medicaid claims only."
"C","837-Q1","C","1300","CLM","20","","","","","2","1300","493","D","Required when the claim is submitted late (past contracted date of filing limitations). If not required by this implementation guide, do not send.;"
"C","837-Q1","C","1300","CLM","20","","","","","2","1300","","F","Delay Reason Code"
"B","837-Q1","C","1350","","","","","","","2","1350","494","A","Date - Onset of Current Illness or Symptom"
"B","837-Q1","C","1350","","","","","","","2","1350","495","E","DTP*431*D8*20050108~"
"B","837-Q1","C","1350","","","","","","","2","1350","496","","Required for the initial medical service or visit performed in response to a medical emergency when the date is available and is different than the date of service. If not required by this implementation guide, do not send."
"B","837-Q1","C","1350","","","","","","","2","1350","497","","This date is the onset of acute symptoms for the current illness or condition."
"C","837-Q1","C","1350","DTP","01","","","","","2","1350","","F","Date Time Qualifier"
"C","837-Q1","C","1350","DTP","02","","","","","2","1350","","F","Date Time Period Format Qualifier"
"C","837-Q1","C","1350","DTP","03","","","","","2","1350","","F","Onset of Current Illness or Injury Date"
"B","837-Q1","C","1370","","","","","","","2","1350","498","E","DTP*454*D8*20050108~"
"B","837-Q1","C","1370","","","","","","","2","1350","499","A","Date - Initial Treatment Date"
"B","837-Q1","C","1370","","","","","","","2","1350","500","","Required when the Initial Treatment Date is known to impact adjudication for claims involving spinal manipulation, physical therapy, occupational therapy, speech language pathology, dialysis, optical refractions, or pregnancy. If not required by this implementation guide, do not send."
"B","837-Q1","C","1370","","","","","","","2","1350","501","","Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in Loop ID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300 for that service line only."
"C","837-Q1","C","1370","DTP","01","","","","","2","1350","","F","Date Time Qualifier"
"C","837-Q1","C","1370","DTP","02","","","","","2","1350","","F","Date Time Period Format Qualifier"
"C","837-Q1","C","1370","DTP","03","","","","","2","1350","","F","Initial Treatment Date"
"B","837-Q1","C","1390","","","","","","","2","1350","502","E","DTP*304*D8*20050108~"
"B","837-Q1","C","1390","","","","","","","2","1350","503","A","Date - Last Seen Date"
"B","837-Q1","C","1390","","","","","","","2","1350","504","","Required when claims involve services for routine foot care and it is known to impact the payer's adjudication process. If not required by this implementation guide, do not send."
"B","837-Q1","C","1390","","","","","","","2","1350","505","","This is the date that the patient was seen by the attending or supervising physician for the qualifying medical condition related to the services performed."
"B","837-Q1","C","1390","","","","","","","2","1350","501","","Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in Loop ID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300 for that service line only."
"C","837-Q1","C","1390","DTP","01","","","","","2","1350","","F","Date Time Qualifier"
"C","837-Q1","C","1390","DTP","02","","","","","2","1350","","F","Date Time Period Format Qualifier"
"C","837-Q1","C","1390","DTP","03","","","","","2","1350","","F","Last Seen Date"
"B","837-Q1","C","13B0","","","","","","","2","1350","506","E","DTP*453*D8*20050108~"
"B","837-Q1","C","13B0","","","","","","","2","1350","507","A","Date - Acute Manifestation"
"B","837-Q1","C","13B0","","","","","","","2","1350","508","","Required when Loop ID-2300 CR208 = ""A"" or ""M"", the claim involves spinal manipulation, and the payer is Medicare. If not required by this implementation guide, do not send."
"C","837-Q1","C","13B0","DTP","01","","","","","2","1350","","F","Date Time Qualifier"
"C","837-Q1","C","13B0","DTP","02","","","","","2","1350","","F","Date Time Period Format Qualifier"
"C","837-Q1","C","13B0","DTP","03","","","","","2","1350","","F","Acute Manifestation Date"
"B","837-Q1","C","13D0","","","","","","","2","1350","509","E","DTP*439*D8*20060108~"
"B","837-Q1","C","13D0","","","","","","","2","1350","510","A","Date - Accident"
"B","837-Q1","C","13D0","","","","","","","2","1350","511","","Required when CLM11-1 or CLM11-2 has a value of `AA' or `OA'.<R>OR<R>Required when CLM11-1 or CLM11-2 has a value of `EM' and this claim is the result of an accident.<R>If not required by this implementation guide, do not send."
"C","837-Q1","C","13D0","DTP","01","","","","","2","1350","","F","Date Time Qualifier"
"C","837-Q1","C","13D0","DTP","02","","","","","2","1350","","F","Date Time Period Format Qualifier"
"C","837-Q1","C","13D0","DTP","03","","","","","2","1350","","F","Accident Date"
"B","837-Q1","C","13E0","","","","","","","2","1350","512","E","DTP*484*D8*20050108~"
"B","837-Q1","C","13E0","","","","","","","2","1350","513","A","Date - Last Menstrual Period"
"B","837-Q1","C","13E0","","","","","","","2","1350","514","","Required when, in the judgment of the provider, the services on this claim are related to the patient's pregnancy. If not required by this implementation guide, do not send."
"C","837-Q1","C","13E0","DTP","01","","","","","2","1350","","F","Date Time Qualifier"
"C","837-Q1","C","13E0","DTP","02","","","","","2","1350","","F","Date Time Period Format Qualifier"
"C","837-Q1","C","13E0","DTP","03","","","","","2","1350","","F","Last Menstrual Period Date"
"B","837-Q1","C","13F0","","","","","","","2","1350","515","E","DTP*455*D8*20050108~"
"B","837-Q1","C","13F0","","","","","","","2","1350","516","","Required when claim involves spinal manipulation and an x-ray was taken. If not required by this implementation guide, do not send."
"B","837-Q1","C","13F0","","","","","","","2","1350","517","A","Date - Last X-ray Date"
"B","837-Q1","C","13F0","","","","","","","2","1350","501","","Dates in Loop ID-2300 apply to all service lines within Loop ID-2400 unless a DTP segment occurs in Loop ID-2400 with the same value in DTP01. In that case, the DTP in Loop ID-2400 overrides the DTP in Loop ID-2300 for that service line only."
"C","837-Q1","C","13F0","DTP","01","","","","","2","1350","","F","Date Time Qualifier"
"C","837-Q1","C","13F0","DTP","02","","","","","2","1350","","F","Date Time Period Format Qualifier"
"C","837-Q1","C","13F0","DTP","03","","","","","2","1350","","F","Last X-Ray Date"
"B","837-Q1","C","13J0","","","","","","","2","1350","518","E","DTP*471*D8*20050108~"
"B","837-Q1","C","13J0","","","","","","","2","1350","519","A","Date - Hearing and Vision Prescription Date"
"B","837-Q1","C","13J0","","","","","","","2","1350","520","","Required on claims where a prescription has been written for hearing devices or vision frames and lenses and it is being billed on this claim. If not required by this implementation guide, do not send."
"C","837-Q1","C","13J0","DTP","01","","","","","2","1350","","F","Date Time Qualifier"
"C","837-Q1","C","13J0","DTP","02","","","","","2","1350","","F","Date Time Period Format Qualifier"
"C","837-Q1","C","13J0","DTP","03","","","","","2","1350","","F","Prescription Date"
"B","837-Q1","C","13L0","","","","","","","2","1350","521","E","DTP*360*D8*20050108~"
"B","837-Q1","C","13L0","","","","","","","2","1350","522","A","Date - Disability Dates"
"B","837-Q1","C","13L0","","","","","","","2","1350","523","","Required on claims involving disability where, in the judgment of the provider, the patient was or will be unable to perform the duties normally associated with his/her work.<R>OR<R>Required on non-HIPAA claims (for example workers compensation or property and casualty) when required by the claims processor.<R>If not required by this implementation guide, do not send."
"C","837-Q1","C","13L0","DTP","01","","","","","2","1350","","F","Date Time Qualifier"
"E","837-Q1","C","13L0","DTP","01","","","374","314","2","1350","1525","","Use code 314 when both disability start and end date are being reported."
"E","837-Q1","C","13L0","DTP","01","","","374","360","2","1350","1524","","Use code 360 if patient is currently disabled and disability end date is unknown."
"E","837-Q1","C","13L0","DTP","01","","","374","361","2","1350","1526","","Use code 361 if patient is no longer disabled and the start date is unknown."
"C","837-Q1","C","13L0","DTP","02","","","","","2","1350","","F","Date Time Period Format Qualifier"
"E","837-Q1","C","13L0","DTP","02","","","1250","D8","2","1350","1528","","Use code D8 when DTP01 is 360 or 361."
"E","837-Q1","C","13L0","DTP","02","","","1250","RD8","2","1350","1527","","Use code RD8 when DTP01 is 314."
"C","837-Q1","C","13L0","DTP","03","","","","","2","1350","","F","Disability From Date"
"B","837-Q1","C","13N0","","","","","","","2","1350","527","","Required on claims where this information is necessary for adjudication of the claim (for example, workers compensation claims involving absence from work). If not required by this implementation guide, do not send."
"B","837-Q1","C","13N0","","","","","","","2","1350","528","E","DTP*297*D8*20050108~"
"B","837-Q1","C","13N0","","","","","","","2","1350","529","A","Date - Last Worked"
"C","837-Q1","C","13N0","DTP","01","","","","","2","1350","","F","Date Time Qualifier"
"C","837-Q1","C","13N0","DTP","02","","","","","2","1350","","F","Date Time Period Format Qualifier"
"C","837-Q1","C","13N0","DTP","03","","","","","2","1350","","F","Last Worked Date"
"B","837-Q1","C","13O0","","","","","","","2","1350","527","","Required on claims where this information is necessary for adjudication of the claim (for example, workers compensation claims involving absence from work). If not required by this implementation guide, do not send."
"B","837-Q1","C","13O0","","","","","","","2","1350","530","E","DTP*296*D8*20050108~"
"B","837-Q1","C","13O0","","","","","","","2","1350","531","A","Date - Authorized Return to Work"
"C","837-Q1","C","13O0","DTP","01","","","","","2","1350","","F","Date Time Qualifier"
"E","837-Q1","C","13O0","DTP","01","","","374","296","2","1350","532","","This is the date the provider has authorized the patient to return to work."
"C","837-Q1","C","13O0","DTP","02","","","","","2","1350","","F","Date Time Period Format Qualifier"
"C","837-Q1","C","13O0","DTP","03","","","","","2","1350","","F","Work Return Date"
"B","837-Q1","C","13P0","","","","","","","2","1350","533","E","DTP*435*D8*20030108~"
"B","837-Q1","C","13P0","","","","","","","2","1350","534","A","Date - Admission"
"B","837-Q1","C","13P0","","","","","","","2","1350","535","","Required on all ambulance claims when the patient was known to be admitted to the hospital.<R>OR<R>Required on all claims involving inpatient medical visits.<R>If not required by this implementation guide, do not send."
"C","837-Q1","C","13P0","DTP","01","","","","","2","1350","","F","Date Time Qualifier"
"C","837-Q1","C","13P0","DTP","02","","","","","2","1350","","F","Date Time Period Format Qualifier"
"C","837-Q1","C","13P0","DTP","03","","","","","2","1350","","F","Related Hospitalization Admission Date"
"B","837-Q1","C","13Q0","","","","","","","2","1350","536","E","DTP*096*D8*20050108~"
"B","837-Q1","C","13Q0","","","","","","","2","1350","537","A","Date - Discharge"
"B","837-Q1","C","13Q0","","","","","","","2","1350","538","","Required for inpatient claims when the patient was discharged from the facility and the discharge date is known. If not required by this implementation guide, do not send."
"C","837-Q1","C","13Q0","DTP","01","","","","","2","1350","","F","Date Time Qualifier"
"C","837-Q1","C","13Q0","DTP","02","","","","","2","1350","","F","Date Time Period Format Qualifier"
"C","837-Q1","C","13Q0","DTP","03","","","","","2","1350","","F","Related Hospitalization Discharge Date"
"B","837-Q1","C","13U0","","","","","","","2","1350","539","A","Date - Assumed and Relinquished Care Dates"
"B","837-Q1","C","13U0","","","","","","","2","1350","540","E","DTP*090*D8*20050108~"
"B","837-Q1","C","13U0","","","","","","","2","1350","541","","Required to indicate ""assumed care date"" or ""relinquished care date"" when providers share post-operative care (global surgery claims). If not required by this implementation guide, do not send."
"B","837-Q1","C","13U0","","","","","","","2","1350","542","","Assumed Care Date is the date care was assumed by another provider during post-operative care. Relinquished Care Date is the date the provider filing this claim ceased post-operative care. See Medicare guidelines for further explanation of these dates.<R><R>Example: Surgeon <169>A<170> relinquished post-operative care to Physician <169>B<170> five days after surgery. When Surgeon <169>A<170> submits a claim, <169>A<170> will use code <169>091 - Report End<170> to indicate the day the surgeon relinquished care of this patient to Physician <169>B<170>. When Physician <169>B<170> submits a claim, <169>B<170> will use code <169>090 - Report Start<170> to indicate the date they assumed care of this patient from Surgeon <169>A<170>."
"C","837-Q1","C","13U0","DTP","01","","","","","2","1350","","F","Date Time Qualifier"
"E","837-Q1","C","13U0","DTP","01","","","374","090","2","1350","543","","Assumed Care Date - Use code <169>090<170> to indicate the date the provider filing this claim assumed care from another provider during post-operative care."
"E","837-Q1","C","13U0","DTP","01","","","374","091","2","1350","544","","Relinquished Care Date - Use code <169>091<170> to indicate the date the provider filing this claim relinquished post-operative care to another provider."
"C","837-Q1","C","13U0","DTP","02","","","","","2","1350","","F","Date Time Period Format Qualifier"
"C","837-Q1","C","13U0","DTP","03","","","","","2","1350","","F","Assumed or Relinquished Care Date"
"B","837-Q1","C","13W0","","","","","","","2","1350","545","A","Date - Property and Casualty Date of First Contact"
"B","837-Q1","C","13W0","","","","","","","2","1350","546","E","DTP*444*D8*20041013~"
"B","837-Q1","C","13W0","","","","","","","2","1350","547","","Required for Property and Casualty claims when state mandated. If not required by this implementation guide, do not send."
"B","837-Q1","C","13W0","","","","","","","2","1350","548","","This is the date the patient first consulted the service provider for this condition. The date of first contact is the date the patient first consulted the provider by any means. It is not necessarily the Initial Treatment Date."
"C","837-Q1","C","13W0","DTP","01","","","","","2","1350","","F","Date Time Qualifier"
"C","837-Q1","C","13W0","DTP","02","","","","","2","1350","","F","Date Time Period Format Qualifier"
"C","837-Q1","C","13W0","DTP","03","","","","","2","1350","","F","Date Time Period"
"B","837-Q1","C","13Y0","","","","","","","2","1350","1505","A","Date - Repricer Received Date"
"B","837-Q1","C","13Y0","","","","","","","2","1350","1504","E","DTP*050*D8*20051030~"
"B","837-Q1","C","13Y0","","","","","","","2","1350","1503","","Required when a repricer is passing the claim onto the payer. If not required by this implementation guide, do not send."
"C","837-Q1","C","13Y0","DTP","01","","","","","2","1350","","F","Date Time Qualifier"
"C","837-Q1","C","13Y0","DTP","02","","","","","2","1350","","F","Date Time Period Format Qualifier"
"C","837-Q1","C","13Y0","DTP","03","","","","","2","1350","","F","Repricer Received Date"
"B","837-Q1","C","1550","","","","","","","2","1550","177","E","PWK*OZ*BM***AC*DMN0012~"
"B","837-Q1","C","1550","","","","","","","2","1550","175","A","Claim Supplemental Information"
"B","837-Q1","C","1550","","","","","","","2","1550","176","","Required when there is a paper attachment following this claim.<R>OR<R>Required when attachments are sent electronically (PWK02 = EL) but are transmitted in another functional group (for example, 275) rather than by paper. PWK06 is then used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment.<R>OR<R>Required when the provider deems it necessary to identify additional information that is being held at the provider's office and is available upon request by the payer (or appropriate entity), but the information is not being submitted with the claim. Use the value of ""AA"" in PWK02 to convey this specific use of the PWK segment.<R>If not required by this implementation guide, do not send."
"C","837-Q1","C","1550","PWK","01","","","","","2","1550","","F","Attachment Report Type Code"
"C","837-Q1","C","1550","PWK","02","","","","","2","1550","","F","Attachment Transmission Code"
"E","837-Q1","C","1550","PWK","02","","","756","AA","2","1550","179","","This means that the additional information is not being sent with the claim at this time. Instead, it is available to the payer (or appropriate entity) at their request."
"E","837-Q1","C","1550","PWK","02","","","756","EL","2","1550","180","","Indicates that the attachment is being transmitted in a separate X12 functional group."
"E","837-Q1","C","1550","PWK","02","","","756","FT","2","1550","1523","","Required when the actual attachment is maintained by an attachment warehouse or similar vendor."
"C","837-Q1","C","1550","PWK","05","","","","","2","1550","181","D","Required when PWK02 = ""BM"", ""EL"", ""EM"", ""FX"" or ""FT"". If not required by this implementation guide, do not send."
"C","837-Q1","C","1550","PWK","05","","","","","2","1550","","F","Identification Code Qualifier"
"C","837-Q1","C","1550","PWK","06","","","","","2","1550","181","D","Required when PWK02 = ""BM"", ""EL"", ""EM"", ""FX"" or ""FT"". If not required by this implementation guide, do not send."
"C","837-Q1","C","1550","PWK","06","","","","","2","1550","1494","","PWK06 is used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment."
"C","837-Q1","C","1550","PWK","06","","","","","2","1550","1495","","For the purpose of this implementation, the maximum field length is 50."
"C","837-Q1","C","1550","PWK","06","","","","","2","1550","","F","Attachment Control Number"
"B","837-Q1","C","1600","","","","","","","2","1600","549","E","CN1*02*550~"
"B","837-Q1","C","1600","","","","","","","2","1600","550","A","Contract Information"
"B","837-Q1","C","1600","","","","","","","2","1600","551","","The developers of this implementation guide note that the CN1 segment is for use only for post-adjudicated claims, which do not meet the definition of a health care claim under HIPAA. Consequently, at the time of this writing, the CN1 segment is for non-HIPAA use only."
"B","837-Q1","C","1600","","","","","","","2","1600","552","","Required when the submitter is contractually obligated to supply this information on post-adjudicated claims. If not required by this implementation guide, do not send."
"C","837-Q1","C","1600","CN1","01","","","","","2","1600","","F","Contract Type Code"
"C","837-Q1","C","1600","CN1","02","","","","","2","1600","553","D","Required when the provider is required by contract to supply this information on the claim. If not required by this implementation guide, do not send."
"C","837-Q1","C","1600","CN1","02","","","","","2","1600","","F","Contract Amount"
"C","837-Q1","C","1600","CN1","03","","","","","2","1600","553","D","Required when the provider is required by contract to supply this information on the claim. If not required by this implementation guide, do not send."
"C","837-Q1","C","1600","CN1","03","","","","","2","1600","","F","Contract Percentage"
"C","837-Q1","C","1600","CN1","04","","","","","2","1600","553","D","Required when the provider is required by contract to supply this information on the claim. If not required by this implementation guide, do not send."
"C","837-Q1","C","1600","CN1","04","","","","","2","1600","","F","Contract Code"
"C","837-Q1","C","1600","CN1","05","","","","","2","1600","553","D","Required when the provider is required by contract to supply this information on the claim. If not required by this implementation guide, do not send."
"C","837-Q1","C","1600","CN1","05","","","","","2","1600","","F","Terms Discount Percentage"
"C","837-Q1","C","1600","CN1","06","","","","","2","1600","553","D","Required when the provider is required by contract to supply this information on the claim. If not required by this implementation guide, do not send."
"C","837-Q1","C","1600","CN1","06","","","","","2","1600","","F","Contract Version Identifier"
"B","837-Q1","C","1760","","","","","","","2","1750","554","","Required when patient has made payment specifically toward this claim. If not required by this implementation guide, do not send."
"B","837-Q1","C","1760","","","","","","","2","1750","555","E","AMT*F5*152.45~"
"B","837-Q1","C","1760","","","","","","","2","1750","556","","Patient Amount Paid refers to the sum of all amounts paid on the claim by the patient or his or her representative(s)."
"B","837-Q1","C","1760","","","","","","","2","1750","557","A","Patient Amount Paid"
"C","837-Q1","C","1760","AMT","01","","","","","2","1750","","F","Amount Qualifier Code"
"C","837-Q1","C","1760","AMT","02","","","","","2","1750","","F","Patient Amount Paid"
"B","837-Q1","C","17E0","","","","","","","2","1800","563","A","Service Authorization Exception Code"
"B","837-Q1","C","17E0","","","","","","","2","1800","564","E","REF*4N*1~"
"B","837-Q1","C","17E0","","","","","","","2","1800","565","","Required when mandated by government law or regulation to obtain authorization for specific service(s) but, for the reasons listed in REF02, the service was performed without obtaining the authorization. If not required by this implementation guide, do not send."
"C","837-Q1","C","17E0","REF","01","","","","","2","1800","","F","Reference Identification Qualifier"
"C","837-Q1","C","17E0","REF","02","","","","","2","1800","566","","Allowable values for this element are:
<T>1<T>Immediate/Urgent Care
<T>2<T>Services Rendered in a Retroactive Period
<T>3<T>Emergency Care
<T>4<T>Client has Temporary Medicaid
<T>5<T>Request from County for Second Opinion to Determine
<T><T>if Recipient Can Work
<T>6<T>Request for Override Pending
<T>7<T>Special Handling"
"C","837-Q1","C","17E0","REF","02","","","","","2","1800","","F","Service Authorization Exception Code"
"B","837-Q1","C","17F0","","","","","","","2","1800","567","A","Mandatory Medicare (Section 4081) Crossover Indicator"
"B","837-Q1","C","17F0","","","","","","","2","1800","568","E","REF*F5*N~"
"B","837-Q1","C","17F0","","","","","","","2","1800","569","","Required when the submitter is Medicare and the claim is a Medigap or COB crossover claim. If not required by this implementation guide, do not send."
"C","837-Q1","C","17F0","REF","01","","","","","2","1800","","F","Reference Identification Qualifier"
"C","837-Q1","C","17F0","REF","02","","","","","2","1800","570","","The allowed values for this element are:
<T>Y<T>4081
<T>N<T>Regular crossover"
"C","837-Q1","C","17F0","REF","02","","","","","2","1800","","F","Medicare Section 4081 Indicator"
"B","837-Q1","C","17G0","","","","","","","2","1800","571","E","REF*EW*T554~"
"B","837-Q1","C","17G0","","","","","","","2","1800","572","A","Mammography Certification Number"
"B","837-Q1","C","17G0","","","","","","","2","1800","573","","Required when mammography services are rendered by a certified mammography provider. If not required by this implementation guide, do not send."
"C","837-Q1","C","17G0","REF","01","","","","","2","1800","","F","Reference Identification Qualifier"
"C","837-Q1","C","17G0","REF","02","","","","","2","1800","","F","Mammography Certification Number"
"B","837-Q1","C","17H0","","","","","","","2","1800","1496","A","Referral Number"
"B","837-Q1","C","17H0","","","","","","","2","1800","948","E","REF*9F*12345~"
"B","837-Q1","C","17H0","","","","","","","2","1800","576","","Required when a referral number is assigned by the payer or Utilization Management Organization (UMO)<R>AND<R>a referral is involved.<R>If not required by this implementation guide, do not send."
"B","837-Q1","C","17H0","","","","","","","2","1800","1320","","Numbers at this position apply to the entire claim unless they are overridden in the REF segment in Loop ID-2400. A reference identification is considered to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line."
"C","837-Q1","C","17H0","REF","01","","","","","2","1800","","F","Reference Identification Qualifier"
"C","837-Q1","C","17H0","REF","02","","","","","2","1800","","F","Referral Number"
"B","837-Q1","C","1800","","","","","","","2","1800","574","E","REF*G1*13579~"
"B","837-Q1","C","1800","","","","","","","2","1800","575","A","Prior Authorization"
"B","837-Q1","C","1800","","","","","","","2","1800","1319","","Generally, preauthorization numbers are assigned by the payer or UMO to authorize a service prior to its being performed. The UMO (Utilization Management Organization) is generally the entity empowered to make a decision regarding the outcome of a health services review or the owner of information. The prior authorization number carried in this REF is specific to the destination payer reported in the Loop ID-2010BB. If other payers have similar numbers for this claim, report that information in the Loop ID-2330 loop REF which holds that payer's information."
"B","837-Q1","C","1800","","","","","","","2","1800","1320","","Numbers at this position apply to the entire claim unless they are overridden in the REF segment in Loop ID-2400. A reference identification is considered to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line."
"B","837-Q1","C","1800","","","","","","","2","1800","1321","","Required when an authorization number is assigned by the payer or UMO<R>AND<R>the services on this claim were preauthorized.<R>If not required by this implementation guide, do not send."
"C","837-Q1","C","1800","REF","01","","","","","2","1800","","F","Reference Identification Qualifier"
"C","837-Q1","C","1800","REF","02","","","","","2","1800","","F","Prior Authorization Number"
"B","837-Q1","C","1810","","","","","","","2","1800","579","E","REF*F8*R555588~"
"B","837-Q1","C","1810","","","","","","","2","1800","580","","Required when CLM05-3 (Claim Frequency Code) indicates this claim is a replacement or void to a previously adjudicated claim. If not required by this implementation guide, do not send."
"B","837-Q1","C","1810","","","","","","","2","1800","581","A","Payer Claim Control Number"
"B","837-Q1","C","1810","","","","","","","2","1800","582","","This information is specific to the destination payer reported in Loop ID-2010BB."
"C","837-Q1","C","1810","REF","01","","","","","2","1800","","F","Reference Identification Qualifier"
"C","837-Q1","C","1810","REF","02","","","","","2","1800","","F","Payer Claim Control Number"
"B","837-Q1","C","1820","","","","","","","2","1800","583","E","REF*X4*12D4567890~"
"B","837-Q1","C","1820","","","","","","","2","1800","584","","Required for all CLIA certified facilities performing CLIA covered laboratory services. If not required by this implementation guide, do not send."
"B","837-Q1","C","1820","","","","","","","2","1800","585","","If a CLIA number is indicated at the line level (Loop ID-2400) in addition to the claim level (Loop ID-2300), that would indicate an exception to the CLIA number at the claim level for that individual line."
"B","837-Q1","C","1820","","","","","","","2","1800","586","A","Clinical Laboratory Improvement Amendment (CLIA) Number"
"B","837-Q1","C","1820","","","","","","","2","1800","587","","In cases where this claim contains both in-house and outsourced  laboratory services, the CLIA Number for laboratory services performed by the Billing or Rendering Provider is reported in this loop. The CLIA number for laboratory services which were outsourced is reported in Loop ID-2400."
"C","837-Q1","C","1820","REF","01","","","","","2","1800","","F","Reference Identification Qualifier"
"C","837-Q1","C","1820","REF","02","","","","","2","1800","","F","Clinical Laboratory Improvement Amendment Number"
"B","837-Q1","C","1830","","","","","","","2","1800","588","E","REF*9A*RJ55555~"
"B","837-Q1","C","1830","","","","","","","2","1800","589","A","Repriced Claim Number"
"B","837-Q1","C","1830","","","","","","","2","1800","590","","Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send."
"B","837-Q1","C","1830","","","","","","","2","1800","582","","This information is specific to the destination payer reported in Loop ID-2010BB."
"C","837-Q1","C","1830","REF","01","","","","","2","1800","","F","Reference Identification Qualifier"
"C","837-Q1","C","1830","REF","02","","","","","2","1800","","F","Repriced Claim Reference Number"
"B","837-Q1","C","1840","","","","","","","2","1800","591","E","REF*9C*RP44444444~"
"B","837-Q1","C","1840","","","","","","","2","1800","592","A","Adjusted Repriced Claim Number"
"B","837-Q1","C","1840","","","","","","","2","1800","590","","Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send."
"B","837-Q1","C","1840","","","","","","","2","1800","582","","This information is specific to the destination payer reported in Loop ID-2010BB."
"C","837-Q1","C","1840","REF","01","","","","","2","1800","","F","Reference Identification Qualifier"
"C","837-Q1","C","1840","REF","02","","","","","2","1800","","F","Adjusted Repriced Claim Reference Number"
"B","837-Q1","C","1850","","","","","","","2","1800","593","E","REF*LX*432907~"
"B","837-Q1","C","1850","","","","","","","2","1800","594","A","Investigational Device Exemption Number"
"B","837-Q1","C","1850","","","","","","","2","1800","595","","Required when claim involves a Food and Drug Administration (FDA) assigned investigational device exemption (IDE) number. When more than one IDE applies, they must be split into separate claims. If not required by this implementation guide, do not send."
"C","837-Q1","C","1850","REF","01","","","","","2","1800","","F","Reference Identification Qualifier"
"C","837-Q1","C","1850","REF","02","","","","","2","1800","","F","Investigational Device Exemption Identifier"
"B","837-Q1","C","1860","","","","","","","2","1800","596","A","Claim Identifier For Transmission Intermediaries"
"B","837-Q1","C","1860","","","","","","","2","1800","597","E","REF*D9*TJ98UU321~"
"B","837-Q1","C","1860","","","","","","","2","1800","598","","Required when this information is deemed necessary by transmission intermediaries (Automated Clearinghouses, and others) who need to attach their own unique claim number. If not required by this implementation guide, do not send."
"B","837-Q1","C","1860","","","","","","","2","1800","599","","Although this REF is supplied for transmission intermediaries to attach their own unique claim number to a claim, 837-recipients are not required under HIPAA to return this number in any HIPAA transaction. Trading partners may voluntarily agree to this interaction if they wish."
"C","837-Q1","C","1860","REF","01","","","","","2","1800","600","","Number assigned by clearinghouse, van, etc."
"C","837-Q1","C","1860","REF","01","","","","","2","1800","","F","Reference Identification Qualifier"
"C","837-Q1","C","1860","REF","02","","","","","2","1800","601","","The value carried in this element is limited to a maximum of 20 positions."
"C","837-Q1","C","1860","REF","02","","","","","2","1800","","F","Value Added Network Trace Number"
"B","837-Q1","C","1890","","","","","","","2","1800","193","A","Medical Record Number"
"B","837-Q1","C","1890","","","","","","","2","1800","194","E","REF*EA*44444TH56~"
"B","837-Q1","C","1890","","","","","","","2","1800","195","","Required when the provider needs to identify for future inquiries, the  actual medical record of the patient identified in either Loop ID-2010BA or Loop ID-2010CA for this episode of care. If not required by this implementation guide, do not send."
"C","837-Q1","C","1890","REF","01","","","","","2","1800","","F","Reference Identification Qualifier"
"C","837-Q1","C","1890","REF","02","","","","","2","1800","","F","Medical Record Number"
"B","837-Q1","C","18A0","","","","","","","2","1800","602","A","Demonstration Project Identifier"
"B","837-Q1","C","18A0","","","","","","","2","1800","603","E","REF*P4*THJ1222~"
"B","837-Q1","C","18A0","","","","","","","2","1800","604","","Required when it is necessary to identify claims which are atypical in ways such as content, purpose, and/or payment, as could be the case for a demonstration or other special project, or a clinical trial. If not required by this implementation guide, do not send."
"C","837-Q1","C","18A0","REF","01","","","","","2","1800","","F","Reference Identification Qualifier"
"C","837-Q1","C","18A0","REF","02","","","","","2","1800","","F","Demonstration Project Identifier"
"B","837-Q1","C","18A1","","","","","","","2","1800","605","A","Care Plan Oversight"
"B","837-Q1","C","18A1","","","","","","","2","1800","606","E","REF*1J*12345678~"
"B","837-Q1","C","18A1","","","","","","","2","1800","607","","Required when the physician is billing Medicare for Care Plan Oversight (CPO). If not required by this implementation guide, do not send."
"B","837-Q1","C","18A1","","","","","","","2","1800","608","","This is the number of the home health agency or hospice providing Medicare covered services to the patient for the period during which CPO services were furnished.<R> Prior to the mandated HIPAA National Provider Identifier (NPI) implementation date this number is the Medicare Number.<R>On or after the mandated HIPAA National Provider Identifier (NPI) implementation date this is the NPI."
"C","837-Q1","C","18A1","REF","01","","","","","2","1800","","F","Reference Identification Qualifier"
"C","837-Q1","C","18A1","REF","02","","","","","2","1800","","F","Care Plan Oversight Number"
"B","837-Q1","C","18B0","","","","","","","2","1850","609","A","File Information"
"B","837-Q1","C","18B0","","","","","","","2","1850","199","E","K3*STATE DATA REQUIREMENT~"
"B","837-Q1","C","18B0","","","","","","","2","1850","200","","Required when ALL of the following conditions are met:<R><195> A regulatory agency concludes it must use the K3 to meet an emergency<R><_>legislative requirement;<R><195> The administering regulatory agency or other state organization has<R><_>completed each one of the following steps:<R><_><_>contacted the X12N workgroup, <R><_><_>requested a review of the K3 data requirement to ensure there is not<R><_><_><_>an existing method within the implementation guide to meet this<R><_><_><_>requirement<R><195> X12N determines that there is no method to meet the requirement.<R>If not required by this implementation guide, do not send."
"B","837-Q1","C","18B0","","","","","","","2","1850","201","","At the time of publication of this implementation, K3 segments have no specific use. The K3 segment is expected to be used only when necessary to meet the unexpected data requirement of a legislative authority. Before this segment can be used : <R>- The X12N Health Care Claim workgroup must conclude there is no other available option in the implementation guide to meet the emergency legislative requirement.<R>- The requestor must submit a proposal for approval accompanied by the relevant business documentation to the X12N Health Care Claim workgroup chairs and receive approval for the request.<R>Upon review of the request, X12N will issue an approval or denial decision to the requesting entity. Approved usage(s) of the K3 segment will be reviewed by the X12N Health Care Claim workgroup to develop a permanent change to include the business case in future transaction implementations."
"B","837-Q1","C","18B0","","","","","","","2","1850","202","","Only when all of the requirements above have been met, may the regulatory agency require the temporary use of the K3 segment."
"B","837-Q1","C","18B0","","","","","","","2","1850","203","","X12N will submit the necessary data maintenance and refer the request to the appropriate data content committee(s)."
"C","837-Q1","C","18B0","K3","01","","","","","2","1850","","F","Fixed Format Information"
"B","837-Q1","C","1900","","","","","","","2","1900","610","E","NTE*ADD*SURGERY WAS UNUSUALLY LONG BECAUSE [FILL IN REASON]~"
"B","837-Q1","C","1900","","","","","","","2","1900","204","A","Claim Note"
"B","837-Q1","C","1900","","","","","","","2","1900","611","","Required when in the judgment of the provider, the information is needed to substantiate the medical treatment and is not supported elsewhere within the claim data set.<R>If not required by this implementation guide, do not send."
"B","837-Q1","C","1900","","","","","","","2","1900","612","","Information in the NTE segment in Loop ID-2300 applies to the entire claim unless overridden by information in the NTE segment in Loop ID-2400. Information is considered to be overridden when the value in NTE01 in Loop ID-2400 is the same as the value in NTE01 in Loop ID-2300."
"B","837-Q1","C","1900","","","","","","","2","1900","206","","The developers of this implementation guide discourage using narrative information within the 837. Trading partners who use narrative information with claims are strongly encouraged to codify that information within the X12 environment.;"
"C","837-Q1","C","1900","NTE","01","","","","","2","1900","","F","Note Reference Code"
"C","837-Q1","C","1900","NTE","02","","","","","2","1900","","F","Claim Note Text"
"B","837-Q1","C","1950","","","","","","","2","1950","613","E","CR1*LB*140**A*DH*12****UNCONSCIOUS~"
"B","837-Q1","C","1950","","","","","","","2","1950","614","","Required on all claims involving ambulance transport services. If not required by this implementation guide, do not send."
"B","837-Q1","C","1950","","","","","","","2","1950","615","A","Ambulance Transport Information"
"B","837-Q1","C","1950","","","","","","","2","1950","616","","The CR1 segment in Loop ID-2300 applies to the entire claim unless overridden by a CR1 segment at the service line level in Loop ID-2400 with the same value in CR101."
"C","837-Q1","C","1950","CR1","01","","","","","2","1950","617","D","Required when it is necessary to justify the medical necessity of the level of ambulance services. If not required by this implementation guide, do not send."
"C","837-Q1","C","1950","CR1","01","","","","","2","1950","","F","Unit or Basis for Measurement Code"
"C","837-Q1","C","1950","CR1","02","","","","","2","1950","617","D","Required when it is necessary to justify the medical necessity of the level of ambulance services. If not required by this implementation guide, do not send."
"C","837-Q1","C","1950","CR1","02","","","","","2","1950","","F","Patient Weight"
"C","837-Q1","C","1950","CR1","04","","","","","2","1950","","F","Ambulance Transport Reason Code"
"E","837-Q1","C","1950","CR1","04","","","1317","A","2","1950","618","","Can be used to indicate that the patient was transferred to a residential facility."
"C","837-Q1","C","1950","CR1","05","","","","","2","1950","","F","Unit or Basis for Measurement Code"
"C","837-Q1","C","1950","CR1","06","","","","","2","1950","331","B","Transport Distance"
"C","837-Q1","C","1950","CR1","06","","","","","2","1950","619","","0 (zero) is a valid value when ambulance services do not include a charge for mileage."
"C","837-Q1","C","1950","CR1","06","","","","","2","1950","","F","Transport Distance"
"C","837-Q1","C","1950","CR1","09","","","","","2","1950","871","D","Required when the ambulance service is for a round trip. If not required by this implementation guide, do not send."
"C","837-Q1","C","1950","CR1","09","","","","","2","1950","","F","Round Trip Purpose Description"
"C","837-Q1","C","1950","CR1","10","","","","","2","1950","621","D","Required when needed to justify usage of stretcher. If not required by this implementation guide, do not send."
"C","837-Q1","C","1950","CR1","10","","","","","2","1950","","F","Stretcher Purpose Description"
"B","837-Q1","C","2000","","","","","","","2","2000","622","A","Spinal Manipulation Service Information"
"B","837-Q1","C","2000","","","","","","","2","2000","623","E","CR2********M~"
"B","837-Q1","C","2000","","","","","","","2","2000","624","","Required on chiropractic claims involving spinal manipulation when the information is known to impact the payer's adjudication process. If not required by this implementation guide, do not send."
"C","837-Q1","C","2000","CR2","08","","","","","2","2000","","F","Patient Condition Code"
"C","837-Q1","C","2000","CR2","10","","","","","2","2000","626","D","Required when this information is deemed necessary by the submitter. If not required by this implementation guide, do not send."
"C","837-Q1","C","2000","CR2","10","","","","","2","2000","","F","Patient Condition Description"
"C","837-Q1","C","2000","CR2","11","","","","","2","2000","626","D","Required when this information is deemed necessary by the submitter. If not required by this implementation guide, do not send."
"C","837-Q1","C","2000","CR2","11","","","","","2","2000","","F","Patient Condition Description"
"B","837-Q1","C","2200","","","","","","","2","2200","627","E","CRC*07*Y*01~"
"B","837-Q1","C","2200","","","","","","","2","2200","628","","Required when the claim involves ambulance transport services<R>AND<R>when reporting condition codes in any of CRC03 through CRC07. If not required by this implementation guide, do not send."
"B","837-Q1","C","2200","","","","","","","2","2200","629","A","Ambulance Certification"
"B","837-Q1","C","2200","","","","","","","2","2200","630","","The CRC segment in Loop ID-2300 applies to the entire claim unless overridden by a CRC segment at the service line level in Loop ID-2400 with the same value in CRC01."
"B","837-Q1","C","2200","","","","","","","2","2200","631","","Repeat this segment only when it is necessary to report additional unique values to those reported in CRC03 thru CRC07."
"C","837-Q1","C","2200","CRC","01","","","","","2","2200","","F","Code Category"
"C","837-Q1","C","2200","CRC","02","","","","","2","2200","","F","Certification Condition Indicator"
"C","837-Q1","C","2200","CRC","03","","","","","2","2200","632","","The codes for CRC03 also can be used for CRC04 through CRC07."
"C","837-Q1","C","2200","CRC","03","","","","","2","2200","","F","Condition Code"
"E","837-Q1","C","2200","CRC","03","","","1321","12","2","2200","633","","Use code 12 to indicate patient was bedridden during transport."
"C","837-Q1","C","2200","CRC","04","","","","","2","2200","634","D","Required when a second condition code is necessary. If not required by this implementation guide, do not send."
"C","837-Q1","C","2200","CRC","04","","","","","2","2200","635","","Use the codes listed in CRC03."
"C","837-Q1","C","2200","CRC","04","","","","","2","2200","","F","Condition Code"
"C","837-Q1","C","2200","CRC","05","","","","","2","2200","636","D","Required when a third condition code is necessary. If not required by this implementation guide, do not send."
"C","837-Q1","C","2200","CRC","05","","","","","2","2200","635","","Use the codes listed in CRC03."
"C","837-Q1","C","2200","CRC","05","","","","","2","2200","","F","Condition Code"
"C","837-Q1","C","2200","CRC","06","","","","","2","2200","637","D","Required when a fourth condition code is necessary. If not required by this implementation guide, do not send."
"C","837-Q1","C","2200","CRC","06","","","","","2","2200","635","","Use the codes listed in CRC03."
"C","837-Q1","C","2200","CRC","06","","","","","2","2200","","F","Condition Code"
"C","837-Q1","C","2200","CRC","07","","","","","2","2200","638","D","Required when a fifth condition code is necessary. If not required by this implementation guide, do not send."
"C","837-Q1","C","2200","CRC","07","","","","","2","2200","635","","Use the codes listed in CRC03."
"C","837-Q1","C","2200","CRC","07","","","","","2","2200","","F","Condition Code"
"B","837-Q1","C","2210","","","","","","","2","2200","639","A","Patient Condition Information: Vision"
"B","837-Q1","C","2210","","","","","","","2","2200","640","E","CRC*E1*Y*L1~"
"B","837-Q1","C","2210","","","","","","","2","2200","641","","Required on vision claims involving replacement lenses or frames when this information is known to impact reimbursement. If not required by this implementation guide, do not send."
"C","837-Q1","C","2210","CRC","01","","","","","2","2200","","F","Code Category"
"C","837-Q1","C","2210","CRC","02","","","","","2","2200","","F","Certification Condition Indicator"
"C","837-Q1","C","2210","CRC","03","","","","","2","2200","","F","Condition Code"
"C","837-Q1","C","2210","CRC","04","","","","","2","2200","635","","Use the codes listed in CRC03."
"C","837-Q1","C","2210","CRC","04","","","","","2","2200","634","D","Required when a second condition code is necessary. If not required by this implementation guide, do not send."
"C","837-Q1","C","2210","CRC","04","","","","","2","2200","","F","Condition Code"
"C","837-Q1","C","2210","CRC","05","","","","","2","2200","635","","Use the codes listed in CRC03."
"C","837-Q1","C","2210","CRC","05","","","","","2","2200","636","D","Required when a third condition code is necessary. If not required by this implementation guide, do not send."
"C","837-Q1","C","2210","CRC","05","","","","","2","2200","","F","Condition Code"
"C","837-Q1","C","2210","CRC","06","","","","","2","2200","635","","Use the codes listed in CRC03."
"C","837-Q1","C","2210","CRC","06","","","","","2","2200","637","D","Required when a fourth condition code is necessary. If not required by this implementation guide, do not send."
"C","837-Q1","C","2210","CRC","06","","","","","2","2200","","F","Condition Code"
"C","837-Q1","C","2210","CRC","07","","","","","2","2200","635","","Use the codes listed in CRC03."
"C","837-Q1","C","2210","CRC","07","","","","","2","2200","638","D","Required when a fifth condition code is necessary. If not required by this implementation guide, do not send."
"C","837-Q1","C","2210","CRC","07","","","","","2","2200","","F","Condition Code"
"B","837-Q1","C","2220","","","","","","","2","2200","642","E","CRC*75*Y*IH~"
"B","837-Q1","C","2220","","","","","","","2","2200","643","A","Homebound Indicator"
"B","837-Q1","C","2220","","","","","","","2","2200","644","","Required for Medicare claims when an independent laboratory renders an EKG tracing or obtains a specimen from a homebound or institutionalized patient. If not required by this implementation guide, do not send."
"C","837-Q1","C","2220","CRC","01","","","","","2","2200","","F","Code Category"
"C","837-Q1","C","2220","CRC","02","","","","","2","2200","","F","Certification Condition Indicator"
"C","837-Q1","C","2220","CRC","03","","","","","2","2200","","F","Homebound Indicator"
"B","837-Q1","C","2230","","","","","","","2","2200","645","A","EPSDT Referral"
"B","837-Q1","C","2230","","","","","","","2","2200","646","E","CRC*ZZ*Y*ST~"
"B","837-Q1","C","2230","","","","","","","2","2200","647","","Required on Early & Periodic Screening, Diagnosis, and Treatment (EPSDT) claims when the screening service is being billed in this claim. If not required by this implementation guide, do not send."
"C","837-Q1","C","2230","CRC","01","","","","","2","2200","","F","Code Qualifier"
"E","837-Q1","C","2230","CRC","01","","","1136","ZZ","2","2200","648","","EPSDT Screening referral information."
"C","837-Q1","C","2230","CRC","02","","","","","2","2200","649","","The response answers the question: Was an EPSDT referral given to the patient?"
"C","837-Q1","C","2230","CRC","02","","","","","2","2200","","F","Certification Condition Code Applies Indicator"
"E","837-Q1","C","2230","CRC","02","","","1073","N","2","2200","650","","If no, then choose ""NU"" in CRC03 indicating no referral given."
"C","837-Q1","C","2230","CRC","03","","","","","2","2200","651","","The codes for CRC03 also can be used for CRC04 through CRC05."
"C","837-Q1","C","2230","CRC","03","","","","","2","2200","","F","Condition Indicator"
"E","837-Q1","C","2230","CRC","03","","","1321","AV","2","2200","652","","Patient refused referral."
"E","837-Q1","C","2230","CRC","03","","","1321","NU","2","2200","653","","This conditioner indicator must be used when the submitter answers ""N"" in CRC02."
"E","837-Q1","C","2230","CRC","03","","","1321","S2","2","2200","654","","Patient is currently under treatment for referred diagnostic or corrective health problem."
"E","837-Q1","C","2230","CRC","03","","","1321","ST","2","2200","655","","Patient is referred to another provider for diagnostic or corrective  treatment for at least one health problem identified during an initial or periodic screening service (not including dental referrals). <R>OR <R>Patient is scheduled for another appointment with screening provider for diagnostic or corrective treatment for at least one health problem identified during an initial or periodic screening service (not including dental referrals).;"
"C","837-Q1","C","2230","CRC","04","","","","","2","2200","635","","Use the codes listed in CRC03."
"C","837-Q1","C","2230","CRC","04","","","","","2","2200","634","D","Required when a second condition code is necessary. If not required by this implementation guide, do not send."
"C","837-Q1","C","2230","CRC","04","","","","","2","2200","","F","Condition Indicator"
"C","837-Q1","C","2230","CRC","05","","","","","2","2200","635","","Use the codes listed in CRC03."
"C","837-Q1","C","2230","CRC","05","","","","","2","2200","636","D","Required when a third condition code is necessary. If not required by this implementation guide, do not send."
"C","837-Q1","C","2230","CRC","05","","","","","2","2200","","F","Condition Indicator"
"B","837-Q1","C","2310","","","","","","","2","2310","656","E","HI*BK:8901*BF:87200*BF:5559~"
"B","837-Q1","C","2310","","","","","","","2","2310","657","A","Health Care Diagnosis Code"
"B","837-Q1","C","2310","","","","","","","2","2310","210","","Do not transmit the decimal point for ICD codes. The decimal point is implied."
"C","837-Q1","C","2310","HI","01","","","","","2","2310","659","","The diagnosis listed in this element is assumed to be the principal diagnosis."
"D","837-Q1","C","2310","HI","01","C022","01","","","2","2310","","F","Diagnosis Type Code"
"E","837-Q1","C","2310","HI","01","C022","01","1270","ABK","2","2310","1541","","This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:<R>If a new rule names the ICD-10-CM as an allowable code set under HIPAA, <R>OR<R>The Secretary grants an exception to use the code set as a pilot project as allowed under the law, <R>OR<R>For claims which are not covered under HIPAA."
"D","837-Q1","C","2310","HI","01","C022","02","","","2","2310","","F","Diagnosis Code"
"C","837-Q1","C","2310","HI","02","","","","","2","2310","230","D","Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses.  If not required by this implementation guide, do not send."
"D","837-Q1","C","2310","HI","02","C022","01","","","2","2310","","F","Diagnosis Type Code"
"E","837-Q1","C","2310","HI","02","C022","01","1270","ABF","2","2310","1541","","This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:<R>If a new rule names the ICD-10-CM as an allowable code set under HIPAA, <R>OR<R>The Secretary grants an exception to use the code set as a pilot project as allowed under the law, <R>OR<R>For claims which are not covered under HIPAA."
"D","837-Q1","C","2310","HI","02","C022","02","","","2","2310","","F","Diagnosis Code"
"C","837-Q1","C","2310","HI","03","","","","","2","2310","230","D","Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses.  If not required by this implementation guide, do not send."
"D","837-Q1","C","2310","HI","03","C022","01","","","2","2310","","F","Diagnosis Type Code"
"E","837-Q1","C","2310","HI","03","C022","01","1270","ABF","2","2310","1541","","This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:<R>If a new rule names the ICD-10-CM as an allowable code set under HIPAA, <R>OR<R>The Secretary grants an exception to use the code set as a pilot project as allowed under the law, <R>OR<R>For claims which are not covered under HIPAA."
"D","837-Q1","C","2310","HI","03","C022","02","","","2","2310","","F","Diagnosis Code"
"C","837-Q1","C","2310","HI","04","","","","","2","2310","230","D","Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses.  If not required by this implementation guide, do not send."
"D","837-Q1","C","2310","HI","04","C022","01","","","2","2310","","F","Diagnosis Type Code"
"E","837-Q1","C","2310","HI","04","C022","01","1270","ABF","2","2310","1541","","This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:<R>If a new rule names the ICD-10-CM as an allowable code set under HIPAA, <R>OR<R>The Secretary grants an exception to use the code set as a pilot project as allowed under the law, <R>OR<R>For claims which are not covered under HIPAA."
"D","837-Q1","C","2310","HI","04","C022","02","","","2","2310","","F","Diagnosis Code"
"C","837-Q1","C","2310","HI","05","","","","","2","2310","230","D","Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses.  If not required by this implementation guide, do not send."
"D","837-Q1","C","2310","HI","05","C022","01","","","2","2310","","F","Diagnosis Type Code"
"E","837-Q1","C","2310","HI","05","C022","01","1270","ABF","2","2310","1541","","This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:<R>If a new rule names the ICD-10-CM as an allowable code set under HIPAA, <R>OR<R>The Secretary grants an exception to use the code set as a pilot project as allowed under the law, <R>OR<R>For claims which are not covered under HIPAA."
"D","837-Q1","C","2310","HI","05","C022","02","","","2","2310","","F","Diagnosis Code"
"C","837-Q1","C","2310","HI","06","","","","","2","2310","230","D","Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses.  If not required by this implementation guide, do not send."
"D","837-Q1","C","2310","HI","06","C022","01","","","2","2310","","F","Diagnosis Type Code"
"E","837-Q1","C","2310","HI","06","C022","01","1270","ABF","2","2310","1541","","This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:<R>If a new rule names the ICD-10-CM as an allowable code set under HIPAA, <R>OR<R>The Secretary grants an exception to use the code set as a pilot project as allowed under the law, <R>OR<R>For claims which are not covered under HIPAA."
"D","837-Q1","C","2310","HI","06","C022","02","","","2","2310","","F","Diagnosis Code"
"C","837-Q1","C","2310","HI","07","","","","","2","2310","230","D","Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses.  If not required by this implementation guide, do not send."
"D","837-Q1","C","2310","HI","07","C022","01","","","2","2310","","F","Diagnosis Type Code"
"E","837-Q1","C","2310","HI","07","C022","01","1270","ABF","2","2310","1541","","This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:<R>If a new rule names the ICD-10-CM as an allowable code set under HIPAA, <R>OR<R>The Secretary grants an exception to use the code set as a pilot project as allowed under the law, <R>OR<R>For claims which are not covered under HIPAA."
"E","837-Q1","C","2310","HI","07","C022","01","1270","BF","2","2310","660","","ICD-9 Codes"
"D","837-Q1","C","2310","HI","07","C022","02","","","2","2310","","F","Diagnosis Code"
"C","837-Q1","C","2310","HI","08","","","","","2","2310","230","D","Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses.  If not required by this implementation guide, do not send."
"D","837-Q1","C","2310","HI","08","C022","01","","","2","2310","","F","Diagnosis Type Code"
"E","837-Q1","C","2310","HI","08","C022","01","1270","ABF","2","2310","1541","","This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:<R>If a new rule names the ICD-10-CM as an allowable code set under HIPAA, <R>OR<R>The Secretary grants an exception to use the code set as a pilot project as allowed under the law, <R>OR<R>For claims which are not covered under HIPAA."
"D","837-Q1","C","2310","HI","08","C022","02","","","2","2310","","F","Diagnosis Code"
"C","837-Q1","C","2310","HI","09","","","","","2","2310","230","D","Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses.  If not required by this implementation guide, do not send."
"D","837-Q1","C","2310","HI","09","C022","01","","","2","2310","","F","Diagnosis Type Code"
"E","837-Q1","C","2310","HI","09","C022","01","1270","ABF","2","2310","1541","","This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:<R>If a new rule names the ICD-10-CM as an allowable code set under HIPAA, <R>OR<R>The Secretary grants an exception to use the code set as a pilot project as allowed under the law, <R>OR<R>For claims which are not covered under HIPAA."
"D","837-Q1","C","2310","HI","09","C022","02","","","2","2310","","F","Diagnosis Code"
"C","837-Q1","C","2310","HI","10","","","","","2","2310","230","D","Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses.  If not required by this implementation guide, do not send."
"D","837-Q1","C","2310","HI","10","C022","01","","","2","2310","","F","Diagnosis Type Code"
"E","837-Q1","C","2310","HI","10","C022","01","1270","ABF","2","2310","1541","","This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:<R>If a new rule names the ICD-10-CM as an allowable code set under HIPAA, <R>OR<R>The Secretary grants an exception to use the code set as a pilot project as allowed under the law, <R>OR<R>For claims which are not covered under HIPAA."
"D","837-Q1","C","2310","HI","10","C022","02","","","2","2310","","F","Diagnosis Code"
"C","837-Q1","C","2310","HI","11","","","","","2","2310","230","D","Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses.  If not required by this implementation guide, do not send."
"D","837-Q1","C","2310","HI","11","C022","01","","","2","2310","","F","Diagnosis Type Code"
"E","837-Q1","C","2310","HI","11","C022","01","1270","ABF","2","2310","1541","","This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:<R>If a new rule names the ICD-10-CM as an allowable code set under HIPAA, <R>OR<R>The Secretary grants an exception to use the code set as a pilot project as allowed under the law, <R>OR<R>For claims which are not covered under HIPAA."
"D","837-Q1","C","2310","HI","11","C022","02","","","2","2310","","F","Diagnosis Code"
"C","837-Q1","C","2310","HI","12","","","","","2","2310","230","D","Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses.  If not required by this implementation guide, do not send."
"D","837-Q1","C","2310","HI","12","C022","01","","","2","2310","","F","Diagnosis Type Code"
"E","837-Q1","C","2310","HI","12","C022","01","1270","ABF","2","2310","1541","","This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:<R>If a new rule names the ICD-10-CM as an allowable code set under HIPAA, <R>OR<R>The Secretary grants an exception to use the code set as a pilot project as allowed under the law, <R>OR<R>For claims which are not covered under HIPAA."
"D","837-Q1","C","2310","HI","12","C022","02","","","2","2310","","F","Diagnosis Code"
"B","837-Q1","C","2313","","","","","","","2","2310","661","A","Anesthesia Related Procedure"
"B","837-Q1","C","2313","","","","","","","2","2310","662","E","HI*BP:33414~"
"B","837-Q1","C","2313","","","","","","","2","2310","663","","Required on claims where anesthesiology services are being billed or reported when the provider knows the surgical code and knows the adjudication of the claim will depend on provision of the surgical code. If not required by this implementation guide, do not send."
"D","837-Q1","C","2313","HI","01","C022","01","","","2","2310","","F","Code List Qualifier Code"
"D","837-Q1","C","2313","HI","01","C022","02","","","2","2310","","F","Anesthesia Related Surgical Procedure"
"C","837-Q1","C","2313","HI","02","","","","","2","2310","238","D","Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send."
"D","837-Q1","C","2313","HI","02","C022","01","","","2","2310","","F","Code List Qualifier Code"
"D","837-Q1","C","2313","HI","02","C022","02","","","2","2310","","F","Industry Code"
"B","837-Q1","C","2320","","","","","","","2","2310","252","A","Condition Information"
"B","837-Q1","C","2320","","","","","","","2","2310","254","E","HI*BG:17*BG:67~"
"B","837-Q1","C","2320","","","","","","","2","2310","664","","Required when condition information applies to the claim.<R>If not required by this implementation guide, do not send."
"D","837-Q1","C","2320","HI","01","C022","01","","","2","2310","","F","Code List Qualifier Code"
"D","837-Q1","C","2320","HI","01","C022","02","","","2","2310","","F","Condition Code"
"C","837-Q1","C","2320","HI","02","","","","","2","2310","255","D","Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send."
"D","837-Q1","C","2320","HI","02","C022","01","","","2","2310","","F","Code List Qualifier Code"
"D","837-Q1","C","2320","HI","02","C022","02","","","2","2310","","F","Condition Code"
"C","837-Q1","C","2320","HI","03","","","","","2","2310","255","D","Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send."
"D","837-Q1","C","2320","HI","03","C022","01","","","2","2310","","F","Code List Qualifier Code"
"D","837-Q1","C","2320","HI","03","C022","02","","","2","2310","","F","Condition Code"
"C","837-Q1","C","2320","HI","04","","","","","2","2310","255","D","Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send."
"D","837-Q1","C","2320","HI","04","C022","01","","","2","2310","","F","Code List Qualifier Code"
"D","837-Q1","C","2320","HI","04","C022","02","","","2","2310","","F","Condition Code"
"C","837-Q1","C","2320","HI","05","","","","","2","2310","255","D","Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send."
"D","837-Q1","C","2320","HI","05","C022","01","","","2","2310","","F","Code List Qualifier Code"
"D","837-Q1","C","2320","HI","05","C022","02","","","2","2310","","F","Condition Code"
"C","837-Q1","C","2320","HI","06","","","","","2","2310","255","D","Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send."
"D","837-Q1","C","2320","HI","06","C022","01","","","2","2310","","F","Code List Qualifier Code"
"D","837-Q1","C","2320","HI","06","C022","02","","","2","2310","","F","Condition Code"
"C","837-Q1","C","2320","HI","07","","","","","2","2310","255","D","Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send."
"D","837-Q1","C","2320","HI","07","C022","01","","","2","2310","","F","Code List Qualifier Code"
"D","837-Q1","C","2320","HI","07","C022","02","","","2","2310","","F","Condition Code"
"C","837-Q1","C","2320","HI","08","","","","","2","2310","255","D","Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send."
"D","837-Q1","C","2320","HI","08","C022","01","","","2","2310","","F","Code List Qualifier Code"
"D","837-Q1","C","2320","HI","08","C022","02","","","2","2310","","F","Condition Code"
"C","837-Q1","C","2320","HI","09","","","","","2","2310","255","D","Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send."
"D","837-Q1","C","2320","HI","09","C022","01","","","2","2310","","F","Code List Qualifier Code"
"D","837-Q1","C","2320","HI","09","C022","02","","","2","2310","","F","Condition Code"
"C","837-Q1","C","2320","HI","10","","","","","2","2310","255","D","Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send."
"D","837-Q1","C","2320","HI","10","C022","01","","","2","2310","","F","Code List Qualifier Code"
"D","837-Q1","C","2320","HI","10","C022","02","","","2","2310","","F","Condition Code"
"C","837-Q1","C","2320","HI","11","","","","","2","2310","255","D","Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send."
"D","837-Q1","C","2320","HI","11","C022","01","","","2","2310","","F","Code List Qualifier Code"
"D","837-Q1","C","2320","HI","11","C022","02","","","2","2310","","F","Condition Code"
"C","837-Q1","C","2320","HI","12","","","","","2","2310","255","D","Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send."
"D","837-Q1","C","2320","HI","12","C022","01","","","2","2310","","F","Code List Qualifier Code"
"D","837-Q1","C","2320","HI","12","C022","02","","","2","2310","","F","Condition Code"
"B","837-Q1","C","2410","","","","","","","2","2410","665","E","HCP*03*100*10*RPO12345~"
"B","837-Q1","C","2410","","","","","","","2","2410","666","A","Claim Pricing/Repricing Information"
"B","837-Q1","C","2410","","","","","","","2","2410","590","","Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send."
"B","837-Q1","C","2410","","","","","","","2","2410","582","","This information is specific to the destination payer reported in Loop ID-2010BB."
"B","837-Q1","C","2410","","","","","","","2","2410","667","","For capitated encounters, pricing or repricing information usually is not applicable and is provided to qualify other information within the claim."
"C","837-Q1","C","2410","HCP","01","","","","","2","2410","668","","Specific code use is determined by Trading Partner Agreement due to the variances in contracting policies in the industry."
"C","837-Q1","C","2410","HCP","01","","","","","2","2410","","F","Pricing Methodology"
"C","837-Q1","C","2410","HCP","02","","","","","2","2410","","F","Repriced Allowed Amount"
"C","837-Q1","C","2410","HCP","03","","","","","2","2410","590","D","Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send."
"C","837-Q1","C","2410","HCP","03","","","","","2","2410","582","","This information is specific to the destination payer reported in Loop ID-2010BB."
"C","837-Q1","C","2410","HCP","03","","","","","2","2410","","F","Repriced Saving Amount"
"C","837-Q1","C","2410","HCP","04","","","","","2","2410","590","D","Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send."
"C","837-Q1","C","2410","HCP","04","","","","","2","2410","582","","This information is specific to the destination payer reported in Loop ID-2010BB."
"C","837-Q1","C","2410","HCP","04","","","","","2","2410","","F","Repricing Organization Identifier"
"C","837-Q1","C","2410","HCP","05","","","","","2","2410","590","D","Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send."
"C","837-Q1","C","2410","HCP","05","","","","","2","2410","582","","This information is specific to the destination payer reported in Loop ID-2010BB."
"C","837-Q1","C","2410","HCP","05","","","","","2","2410","","F","Repricing Per Diem or Flat Rate Amount"
"C","837-Q1","C","2410","HCP","06","","","","","2","2410","590","D","Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send."
"C","837-Q1","C","2410","HCP","06","","","","","2","2410","582","","This information is specific to the destination payer reported in Loop ID-2010BB."
"C","837-Q1","C","2410","HCP","06","","","","","2","2410","","F","Repriced Approved Ambulatory Patient Group Code"
"C","837-Q1","C","2410","HCP","07","","","","","2","2410","590","D","Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send."
"C","837-Q1","C","2410","HCP","07","","","","","2","2410","582","","This information is specific to the destination payer reported in Loop ID-2010BB."
"C","837-Q1","C","2410","HCP","07","","","","","2","2410","","F","Repriced Approved Ambulatory Patient Group Amount"
"C","837-Q1","C","2410","HCP","13","","","","","2","2410","582","","This information is specific to the destination payer reported in Loop ID-2010BB."
"C","837-Q1","C","2410","HCP","13","","","","","2","2410","590","D","Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send."
"C","837-Q1","C","2410","HCP","13","","","","","2","2410","","F","Reject Reason Code"
"C","837-Q1","C","2410","HCP","14","","","","","2","2410","582","","This information is specific to the destination payer reported in Loop ID-2010BB."
"C","837-Q1","C","2410","HCP","14","","","","","2","2410","590","D","Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send."
"C","837-Q1","C","2410","HCP","14","","","","","2","2410","","F","Policy Compliance Code"
"C","837-Q1","C","2410","HCP","15","","","","","2","2410","590","D","Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send."
"C","837-Q1","C","2410","HCP","15","","","","","2","2410","582","","This information is specific to the destination payer reported in Loop ID-2010BB."
"C","837-Q1","C","2410","HCP","15","","","","","2","2410","","F","Exception Code"
"B","837-Q1","C","2500","","","","","","","2","2500","300","E","NM1*DN*1*WELBY*MARCUS*W**JR*XX*1234567891~"
"B","837-Q1","C","2500","","","","","","","2","2500","299","A","Referring Provider Name"
"B","837-Q1","C","2500","","","","","","","2","2500","677","","Required when this claim involves a referral. If not required by this implementation guide, do not send."
"B","837-Q1","C","2500","","","","","","","2","2500","678","","When reporting the provider who ordered services such as diagnostic and lab, use Loop ID-2310A at the claim level. For ordered services such as Durable Medical Equipment, use Loop ID-2420E at the line level."
"B","837-Q1","C","2500","","","","","","","2","2500","679","","When there is only one referral on the claim, use code ""DN - Referring Provider"". When more than one referral exists and there is a requirement to report the additional referral, use code DN in the first iteration of this loop to indicate the referral received by the rendering provider on this claim. Use code ""P3 - Primary Care Provider"" in the second iteration of the loop to indicate the initial referral from the primary care provider or whatever provider wrote the initial referral for this patient's episode of care being billed/reported in this transaction."
"B","837-Q1","C","2500","","","","","","","2","2500","277","","Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101."
"C","837-Q1","C","2500","NM1","01","","","","","2","2500","","F","Entity Identifier Code"
"E","837-Q1","C","2500","NM1","01","","","98","DN","2","2500","680","","Use on the first iteration of this loop. Use if loop is used only once."
"E","837-Q1","C","2500","NM1","01","","","98","P3","2","2500","681","","Use only if loop is used twice. Use only on second iteration of this loop."
"C","837-Q1","C","2500","NM1","02","","","","","2","2500","","F","Entity Type Qualifier"
"C","837-Q1","C","2500","NM1","03","","","","","2","2500","","F","Referring Provider Last Name"
"C","837-Q1","C","2500","NM1","04","","","","","2","2500","266","D","Required when the person has a first name. If not required by this implementation guide, do not send."
"C","837-Q1","C","2500","NM1","04","","","","","2","2500","","F","Referring Provider First Name"
"C","837-Q1","C","2500","NM1","05","","","","","2","2500","1170","D","Required when the middle name or initial of the person is needed to identify the individual. If not required by this implementation guide, do not send."
"C","837-Q1","C","2500","NM1","05","","","","","2","2500","","F","Referring Provider Middle Name or Initial"
"C","837-Q1","C","2500","NM1","07","","","","","2","2500","268","D","Required when the name suffix is needed to identify the individual. If not required by this implementation guide, do not send.;"
"C","837-Q1","C","2500","NM1","07","","","","","2","2500","","F","Referring Provider Name Suffix"
"C","837-Q1","C","2500","NM1","08","","","","","2","2500","303","D","Required for providers on or after the mandated HIPAA National Provider Identifier (NPI) implementation date when the provider has received an NPI and the NPI is available to the submitter.<R>OR<R>Required for providers prior to the mandated HIPAA NPI implementation date when the provider has received an NPI and the submitter has the capability to send it.<R>If not required by this implementation guide, do not send."
"C","837-Q1","C","2500","NM1","08","","","","","2","2500","","F","Identification Code Qualifier"
"C","837-Q1","C","2500","NM1","09","","","","","2","2500","303","D","Required for providers on or after the mandated HIPAA National Provider Identifier (NPI) implementation date when the provider has received an NPI and the NPI is available to the submitter.<R>OR<R>Required for providers prior to the mandated HIPAA NPI implementation date when the provider has received an NPI and the submitter has the capability to send it.<R>If not required by this implementation guide, do not send."
"C","837-Q1","C","2500","NM1","09","","","","","2","2500","","F","Referring Provider Identifier"
"B","837-Q1","C","2710","","","","","","","2","2710","304","A","Referring Provider Secondary Identification"
"B","837-Q1","C","2710","","","","","","","2","2710","688","","The REF segment in Loop ID-2310 applies to the entire claim unless overridden on the service line level by the presence of a REF segment with the same value in REF01."
"B","837-Q1","C","2710","","","","","","","2","2710","271","","Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.<R>OR<R>Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.<R>If not required by this implementation guide, do not send."
"B","837-Q1","C","2710","","","","","","","2","2710","369","E","REF*G2*12345~"
"C","837-Q1","C","2710","REF","01","","","","","2","2710","","F","Reference Identification Qualifier"
"E","837-Q1","C","2710","REF","01","","","128","1G","2","2710","1555","","UPINs must be formatted as either X99999 or XXX999."
"E","837-Q1","C","2710","REF","01","","","128","G2","2","2710","1464","","This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc."
"C","837-Q1","C","2710","REF","02","","","","","2","2710","","F","Referring Provider Secondary Identifier"
"B","837-Q1","D","2500","","","","","","","2","2500","689","A","Rendering Provider Name"
"B","837-Q1","D","2500","","","","","","","2","2500","690","","Required when the Rendering Provider information is different than that carried in Loop ID-2010AA - Billing Provider.<R>If not required by this implementation guide, do not send."
"B","837-Q1","D","2500","","","","","","","2","2500","691","","Used for all types of rendering providers including laboratories. The Rendering Provider is the person or company (laboratory or other facility) who rendered the care. In the case where a substitute provider (locum tenens) was used, enter that provider's information here."
"B","837-Q1","D","2500","","","","","","","2","2500","277","","Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101."
"B","837-Q1","D","2500","","","","","","","2","2500","692","E","NM1*82*1*DOE*JANE*C***XX*1234567804~"
"C","837-Q1","D","2500","NM1","01","","","","","2","2500","","F","Entity Identifier Code"
"C","837-Q1","D","2500","NM1","02","","","","","2","2500","","F","Entity Type Qualifier"
"C","837-Q1","D","2500","NM1","03","","","","","2","2500","","F","Rendering Provider Last or Organization Name"
"C","837-Q1","D","2500","NM1","04","","","","","2","2500","17","D","Required when NM102 = 1 (person) and the person has a first name. If not required by this implementation guide, do not send."
"C","837-Q1","D","2500","NM1","04","","","","","2","2500","","F","Rendering Provider First Name"
"C","837-Q1","D","2500","NM1","05","","","","","2","2500","18","D","Required when NM102 = 1 (person) and the middle name or initial of the person is needed to identify the individual. If not required by this implementation guide, do not send."
"C","837-Q1","D","2500","NM1","05","","","","","2","2500","","F","Rendering Provider Middle Name or Initial"
"C","837-Q1","D","2500","NM1","07","","","","","2","2500","80","D","Required when NM102 = 1 (person) and the name suffix of the person is needed to identify the individual. If not required by this implementation guide, do not send."
"C","837-Q1","D","2500","NM1","07","","","","","2","2500","","F","Rendering Provider Name Suffix"
"C","837-Q1","D","2500","NM1","08","","","","","2","2500","44","D","Required for providers in the United States or its territories on or  after the mandated HIPAA National Provider Identifier (NPI)  implementation date when the provider is eligible to receive an  NPI.<R>OR<R>Required for providers not in the United States or its territories on or after the mandated HIPAA National Provider Identifier (NPI) implementation date when the provider has received an NPI.<R>OR<R>Required for providers prior to the mandated NPI implementation date when the provider has received an NPI and the submitter has the capability to send it.<R>If not required by this implementation guide, do not send."
"C","837-Q1","D","2500","NM1","08","","","","","2","2500","","F","Identification Code Qualifier"
"C","837-Q1","D","2500","NM1","09","","","","","2","2500","44","D","Required for providers in the United States or its territories on or  after the mandated HIPAA National Provider Identifier (NPI)  implementation date when the provider is eligible to receive an  NPI.<R>OR<R>Required for providers not in the United States or its territories on or after the mandated HIPAA National Provider Identifier (NPI) implementation date when the provider has received an NPI.<R>OR<R>Required for providers prior to the mandated NPI implementation date when the provider has received an NPI and the submitter has the capability to send it.<R>If not required by this implementation guide, do not send."
"C","837-Q1","D","2500","NM1","09","","","","","2","2500","","F","Rendering Provider Identifier"
"B","837-Q1","D","2550","","","","","","","2","2550","693","A","Rendering Provider Specialty Information"
"B","837-Q1","D","2550","","","","","","","2","2550","683","","Required when adjudication is known to be impacted by the provider taxonomy code. If not required by this implementation guide, do not send."
"B","837-Q1","D","2550","","","","","","","2","2550","684","","The PRV segment in Loop ID-2310 applies to the entire claim unless overridden on the service line level by the presence of a PRV segment with the same value in PRV01."
"B","837-Q1","D","2550","","","","","","","2","2550","1150","E","PRV*PE*PXC*1223G0001X~"
"C","837-Q1","D","2550","PRV","01","","","","","2","2550","","F","Provider Code"
"C","837-Q1","D","2550","PRV","02","","","","","2","2550","","F","Reference Identification Qualifier"
"C","837-Q1","D","2550","PRV","03","","","","","2","2550","","F","Provider Taxonomy Code"
"B","837-Q1","D","2710","","","","","","","2","2710","694","A","Rendering Provider Secondary Identification"
"B","837-Q1","D","2710","","","","","","","2","2710","688","","The REF segment in Loop ID-2310 applies to the entire claim unless overridden on the service line level by the presence of a REF segment with the same value in REF01."
"B","837-Q1","D","2710","","","","","","","2","2710","271","","Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.<R>OR<R>Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.<R>If not required by this implementation guide, do not send."
"B","837-Q1","D","2710","","","","","","","2","2710","369","E","REF*G2*12345~"
"C","837-Q1","D","2710","REF","01","","","","","2","2710","","F","Reference Identification Qualifier"
"E","837-Q1","D","2710","REF","01","","","128","1G","2","2710","1555","","UPINs must be formatted as either X99999 or XXX999."
"E","837-Q1","D","2710","REF","01","","","128","G2","2","2710","1464","","This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc."
"C","837-Q1","D","2710","REF","02","","","","","2","2710","","F","Rendering Provider Secondary Identifier"
"B","837-Q1","F","2500","","","","","","","2","2500","700","E","NM1*77*2*ABC CLINIC*****XX*1234567891~"
"B","837-Q1","F","2500","","","","","","","2","2500","701","A","Service Facility Location Name"
"B","837-Q1","F","2500","","","","","","","2","2500","702","","Required when the location of health care service is different than that carried in Loop ID-2010AA (Billing Provider).<R>If not required by this implementation guide, do not send."
"B","837-Q1","F","2500","","","","","","","2","2500","703","","When an organization health care provider's NPI is provided to identify the Service Location, the organization health care provider must be external to the entity identified as the Billing Provider (for example, reference lab). It is not permissible to report an organization health care provider NPI as the Service Location if the entity being identified is a component (for example, subpart) of the Billing Provider. In that case, the subpart must be the Billing Provider."
"B","837-Q1","F","2500","","","","","","","2","2500","704","","The purpose of this loop is to identify specifically where the service was rendered. When reporting ambulance services, do not use this loop. Use Loop ID-2310E - Ambulance Pick-up Location and Loop ID-2310F - Ambulance Drop-off Location."
"B","837-Q1","F","2500","","","","","","","2","2500","277","","Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101."
"C","837-Q1","F","2500","NM1","01","","","","","2","2500","","F","Entity Identifier Code"
"C","837-Q1","F","2500","NM1","02","","","","","2","2500","","F","Entity Type Qualifier"
"C","837-Q1","F","2500","NM1","03","","","","","2","2500","","F","Laboratory or Facility Name"
"C","837-Q1","F","2500","NM1","08","","","","","2","2500","705","D","Required when the service location to be identified has an NPI and is not a component or subpart of the Billing Provider entity.<R>If not required by this implementation guide, do not send."
"C","837-Q1","F","2500","NM1","08","","","","","2","2500","","F","Identification Code Qualifier"
"C","837-Q1","F","2500","NM1","09","","","","","2","2500","705","D","Required when the service location to be identified has an NPI and is not a component or subpart of the Billing Provider entity.<R>If not required by this implementation guide, do not send."
"C","837-Q1","F","2500","NM1","09","","","","","2","2500","","F","Laboratory or Facility Primary Identifier"
"B","837-Q1","F","2650","","","","","","","2","2650","84","E","N3*123 MAIN STREET~"
"B","837-Q1","F","2650","","","","","","","2","2650","706","A","Service Facility Location Address"
"B","837-Q1","F","2650","","","","","","","2","2650","707","","If service facility location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, <169>crossroad of State Road 34 and 45<170> or <169>Exit near Mile marker 265 on Interstate 80<170>.)"
"C","837-Q1","F","2650","N3","01","","","","","2","2650","","F","Laboratory or Facility Address Line"
"C","837-Q1","F","2650","N3","02","","","","","2","2650","87","D","Required when there is a second address line. If not required by this implementation guide, do not send."
"C","837-Q1","F","2650","N3","02","","","","","2","2650","","F","Laboratory or Facility Address Line"
"B","837-Q1","F","2700","","","","","","","2","2700","708","A","Service Facility Location City, State, ZIP Code"
"B","837-Q1","F","2700","","","","","","","2","2700","1548","E","N4*KANSAS CITY*MO*64108~"
"C","837-Q1","F","2700","N4","01","","","","","2","2700","","F","Laboratory or Facility City Name"
"C","837-Q1","F","2700","N4","02","","","","","2","2700","1549","D","Required when the address is in the United States of America, including its territories, or Canada. If not required by this implementation guide, do not send."
"C","837-Q1","F","2700","N4","02","","","","","2","2700","","F","Laboratory or Facility State or Province Code"
"C","837-Q1","F","2700","N4","03","","","","","2","2700","1550","D","Required when the address is in the United States of America, including its territories, or Canada, or when a postal code exists for the country in N404. If not required by this implementation guide, do not send."
"C","837-Q1","F","2700","N4","03","","","","","2","2700","1594","","When reporting the ZIP code for U.S. addresses, the full nine digit ZIP code must be provided."
"C","837-Q1","F","2700","N4","03","","","","","2","2700","","F","Laboratory or Facility Postal Zone or ZIP Code"
"C","837-Q1","F","2700","N4","04","","","","","2","2700","1551","D","Required when the address is outside the United States of America. If not required by this implementation guide, do not send."
"C","837-Q1","F","2700","N4","04","","","","","2","2700","1552","","Use the alpha-2 country codes from Part 1 of ISO 3166."
"C","837-Q1","F","2700","N4","04","","","","","2","2700","","F","Country Code"
"C","837-Q1","F","2700","N4","07","","","","","2","2700","1553","D","Required when the address is not in the United States of America, including its territories, or Canada, and the country in N404 has administrative subdivisions such as but not limited to states, provinces, cantons, etc. If not required by this implementation guide, do not send."
"C","837-Q1","F","2700","N4","07","","","","","2","2700","1554","","Use the country subdivision codes from Part 2 of ISO 3166."
"C","837-Q1","F","2700","N4","07","","","","","2","2700","","F","Country Subdivision Code"
"B","837-Q1","F","2710","","","","","","","2","2710","369","E","REF*G2*12345~"
"B","837-Q1","F","2710","","","","","","","2","2710","711","A","Service Facility Location Secondary Identification"
"B","837-Q1","F","2710","","","","","","","2","2710","271","","Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.<R>OR<R>Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.<R>If not required by this implementation guide, do not send."
"C","837-Q1","F","2710","REF","01","","","","","2","2710","","F","Reference Identification Qualifier"
"E","837-Q1","F","2710","REF","01","","","128","G2","2","2710","1464","","This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc."
"C","837-Q1","F","2710","REF","02","","","","","2","2710","","F","Laboratory or Facility Secondary Identifier"
"B","837-Q1","F","2750","","","","","","","2","2750","713","A","Service Facility Contact Information"
"B","837-Q1","F","2750","","","","","","","2","2750","450","E","PER*IC*JOHN SMITH*TE*5555551234*EX*123~"
"B","837-Q1","F","2750","","","","","","","2","2750","714","","Required for Property and Casualty claims when this information is different than the information provided in Loop ID-1000A Submitter EDI Contact Information PER Segment, and Loop ID-2010AA Billing Provider Contact Information PER segment and when deemed necessary by the submitter.<R>If not required by this implementation guide, do not send."
"B","837-Q1","F","2750","","","","","","","2","2750","24","","When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number must always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as <169>1<170>, in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as <169>ext<170> or <169>x-<170>."
"C","837-Q1","F","2750","PER","01","","","","","2","2750","","F","Contact Function Code"
"C","837-Q1","F","2750","PER","02","","","","","2","2750","715","D","Required when the name is different than the name in the Loop ID-1000A Submitter EDI Contact Information PER segment and in the Loop ID-2010AA Billing Provider Contact Information PER. If not required by this implementation guide, do not send."
"C","837-Q1","F","2750","PER","02","","","","","2","2750","","F","Name"
"C","837-Q1","F","2750","PER","03","","","","","2","2750","","F","Communication Number Qualifier"
"C","837-Q1","F","2750","PER","04","","","","","2","2750","","F","Communication Number"
"C","837-Q1","F","2750","PER","05","","","","","2","2750","29","D","Required when this information is deemed necessary by the submitter. If not required by this implementation guide, do not send."
"C","837-Q1","F","2750","PER","05","","","","","2","2750","","F","Communication Number Qualifier"
"C","837-Q1","F","2750","PER","06","","","","","2","2750","29","D","Required when this information is deemed necessary by the submitter. If not required by this implementation guide, do not send."
"C","837-Q1","F","2750","PER","06","","","","","2","2750","","F","Communication Number"
"B","837-Q1","G","2500","","","","","","","2","2500","716","A","Supervising Provider Name"
"B","837-Q1","G","2500","","","","","","","2","2500","717","","Required when the rendering provider is supervised by a physician. If not required by this implementation guide, do not send."
"B","837-Q1","G","2500","","","","","","","2","2500","277","","Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101."
"B","837-Q1","G","2500","","","","","","","2","2500","718","E","NM1*DQ*1*DOE*JOHN*B***XX*1234567891~"
"C","837-Q1","G","2500","NM1","01","","","","","2","2500","","F","Entity Identifier Code"
"C","837-Q1","G","2500","NM1","02","","","","","2","2500","","F","Entity Type Qualifier"
"C","837-Q1","G","2500","NM1","03","","","","","2","2500","","F","Supervising Provider Last Name"
"C","837-Q1","G","2500","NM1","04","","","","","2","2500","266","D","Required when the person has a first name. If not required by this implementation guide, do not send."
"C","837-Q1","G","2500","NM1","04","","","","","2","2500","","F","Supervising Provider First Name"
"C","837-Q1","G","2500","NM1","05","","","","","2","2500","1170","D","Required when the middle name or initial of the person is needed to identify the individual. If not required by this implementation guide, do not send."
"C","837-Q1","G","2500","NM1","05","","","","","2","2500","","F","Supervising Provider Middle Name or Initial"
"C","837-Q1","G","2500","NM1","07","","","","","2","2500","268","D","Required when the name suffix is needed to identify the individual. If not required by this implementation guide, do not send.;"
"C","837-Q1","G","2500","NM1","07","","","","","2","2500","","F","Supervising Provider Name Suffix"
"C","837-Q1","G","2500","NM1","08","","","","","2","2500","44","D","Required for providers in the United States or its territories on or  after the mandated HIPAA National Provider Identifier (NPI)  implementation date when the provider is eligible to receive an  NPI.<R>OR<R>Required for providers not in the United States or its territories on or after the mandated HIPAA National Provider Identifier (NPI) implementation date when the provider has received an NPI.<R>OR<R>Required for providers prior to the mandated NPI implementation date when the provider has received an NPI and the submitter has the capability to send it.<R>If not required by this implementation guide, do not send."
"C","837-Q1","G","2500","NM1","08","","","","","2","2500","","F","Identification Code Qualifier"
"C","837-Q1","G","2500","NM1","09","","","","","2","2500","44","D","Required for providers in the United States or its territories on or  after the mandated HIPAA National Provider Identifier (NPI)  implementation date when the provider is eligible to receive an  NPI.<R>OR<R>Required for providers not in the United States or its territories on or after the mandated HIPAA National Provider Identifier (NPI) implementation date when the provider has received an NPI.<R>OR<R>Required for providers prior to the mandated NPI implementation date when the provider has received an NPI and the submitter has the capability to send it.<R>If not required by this implementation guide, do not send."
"C","837-Q1","G","2500","NM1","09","","","","","2","2500","","F","Supervising Provider Identifier"
"B","837-Q1","G","2710","","","","","","","2","2710","719","A","Supervising Provider Secondary Identification"
"B","837-Q1","G","2710","","","","","","","2","2710","369","E","REF*G2*12345~"
"B","837-Q1","G","2710","","","","","","","2","2710","1579","","Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.<R>OR<R>Required on or after the mandated NPI implementation date when the entity is not a Health Care provider (a.k.a. an atypical provider), and an identifier is necessary for the claims processor to identify the entity.<R>If not required by this implementation guide, do not send."
"C","837-Q1","G","2710","REF","01","","","","","2","2710","","F","Reference Identification Qualifier"
"E","837-Q1","G","2710","REF","01","","","128","1G","2","2710","1555","","UPINs must be formatted as either X99999 or XXX999."
"E","837-Q1","G","2710","REF","01","","","128","G2","2","2710","1464","","This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc."
"C","837-Q1","G","2710","REF","02","","","","","2","2710","","F","Supervising Provider Secondary Identifier"
"B","837-Q1","H","2500","","","","","","","2","2500","720","A","Ambulance Pick-up Location"
"B","837-Q1","H","2500","","","","","","","2","2500","721","E","NM1*PW*2~"
"B","837-Q1","H","2500","","","","","","","2","2500","722","","Required when billing for ambulance or non-emergency transportation services. If not required by this implementation guide, do not send."
"B","837-Q1","H","2500","","","","","","","2","2500","277","","Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101."
"C","837-Q1","H","2500","NM1","01","","","","","2","2500","","F","Entity Identifier Code"
"C","837-Q1","H","2500","NM1","02","","","","","2","2500","","F","Entity Type Qualifier"
"B","837-Q1","H","2650","","","","","","","2","2650","724","A","Ambulance Pick-up Location Address"
"B","837-Q1","H","2650","","","","","","","2","2650","84","E","N3*123 MAIN STREET~"
"B","837-Q1","H","2650","","","","","","","2","2650","725","","If the ambulance pickup location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, <169>crossroad of State Road 34 and 45<170> or <169>Exit near Mile marker 265 on Interstate 80<170>.)"
"C","837-Q1","H","2650","N3","01","","","","","2","2650","","F","Ambulance Pick-up Address Line"
"C","837-Q1","H","2650","N3","02","","","","","2","2650","87","D","Required when there is a second address line. If not required by this implementation guide, do not send."
"C","837-Q1","H","2650","N3","02","","","","","2","2650","","F","Ambulance Pick-up Address Line"
"B","837-Q1","H","2700","","","","","","","2","2700","726","A","Ambulance Pick-up Location City, State, ZIP Code"
"B","837-Q1","H","2700","","","","","","","2","2700","1548","E","N4*KANSAS CITY*MO*64108~"
"C","837-Q1","H","2700","N4","01","","","","","2","2700","","F","Ambulance Pick-up City Name"
"C","837-Q1","H","2700","N4","02","","","","","2","2700","1549","D","Required when the address is in the United States of America, including its territories, or Canada. If not required by this implementation guide, do not send."
"C","837-Q1","H","2700","N4","02","","","","","2","2700","","F","Ambulance Pick-up State or Province Code"
"C","837-Q1","H","2700","N4","03","","","","","2","2700","1550","D","Required when the address is in the United States of America, including its territories, or Canada, or when a postal code exists for the country in N404. If not required by this implementation guide, do not send."
"C","837-Q1","H","2700","N4","03","","","","","2","2700","","F","Ambulance Pick-up Postal Zone or ZIP Code"
"C","837-Q1","H","2700","N4","04","","","","","2","2700","1551","D","Required when the address is outside the United States of America. If not required by this implementation guide, do not send."
"C","837-Q1","H","2700","N4","04","","","","","2","2700","1552","","Use the alpha-2 country codes from Part 1 of ISO 3166."
"C","837-Q1","H","2700","N4","04","","","","","2","2700","","F","Country Code"
"C","837-Q1","H","2700","N4","07","","","","","2","2700","1553","D","Required when the address is not in the United States of America, including its territories, or Canada, and the country in N404 has administrative subdivisions such as but not limited to states, provinces, cantons, etc. If not required by this implementation guide, do not send."
"C","837-Q1","H","2700","N4","07","","","","","2","2700","1554","","Use the country subdivision codes from Part 2 of ISO 3166."
"C","837-Q1","H","2700","N4","07","","","","","2","2700","","F","Country Subdivision Code"
"B","837-Q1","I","2500","","","","","","","2","2500","728","A","Ambulance Drop-off Location"
"B","837-Q1","I","2500","","","","","","","2","2500","729","E","NM1*45*2~"
"B","837-Q1","I","2500","","","","","","","2","2500","722","","Required when billing for ambulance or non-emergency transportation services. If not required by this implementation guide, do not send."
"B","837-Q1","I","2500","","","","","","","2","2500","277","","Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101."
"C","837-Q1","I","2500","NM1","01","","","","","2","2500","","F","Entity Identifier Code"
"C","837-Q1","I","2500","NM1","02","","","","","2","2500","","F","Entity Type Qualifier"
"C","837-Q1","I","2500","NM1","03","","","","","2","2500","730","D","Required when drop-off location name is known. If not required by this implementation guide, do not send."
"C","837-Q1","I","2500","NM1","03","","","","","2","2500","","F","Ambulance Drop-off Location"
"B","837-Q1","I","2650","","","","","","","2","2650","731","A","Ambulance Drop-off Location Address"
"B","837-Q1","I","2650","","","","","","","2","2650","84","E","N3*123 MAIN STREET~"
"C","837-Q1","I","2650","N3","01","","","","","2","2650","","F","Ambulance Drop-off Address Line"
"C","837-Q1","I","2650","N3","02","","","","","2","2650","87","D","Required when there is a second address line. If not required by this implementation guide, do not send."
"C","837-Q1","I","2650","N3","02","","","","","2","2650","","F","Ambulance Drop-off Address Line"
"B","837-Q1","I","2700","","","","","","","2","2700","733","A","Ambulance Drop-off Location City, State, ZIP Code"
"B","837-Q1","I","2700","","","","","","","2","2700","1548","E","N4*KANSAS CITY*MO*64108~"
"C","837-Q1","I","2700","N4","01","","","","","2","2700","","F","Ambulance Drop-off City Name"
"C","837-Q1","I","2700","N4","02","","","","","2","2700","1549","D","Required when the address is in the United States of America, including its territories, or Canada. If not required by this implementation guide, do not send."
"C","837-Q1","I","2700","N4","02","","","","","2","2700","","F","Ambulance Drop-off State or Province Code"
"C","837-Q1","I","2700","N4","03","","","","","2","2700","1550","D","Required when the address is in the United States of America, including its territories, or Canada, or when a postal code exists for the country in N404. If not required by this implementation guide, do not send."
"C","837-Q1","I","2700","N4","03","","","","","2","2700","","F","Ambulance Drop-off Postal Zone or ZIP Code"
"C","837-Q1","I","2700","N4","04","","","","","2","2700","1551","D","Required when the address is outside the United States of America. If not required by this implementation guide, do not send."
"C","837-Q1","I","2700","N4","04","","","","","2","2700","1552","","Use the alpha-2 country codes from Part 1 of ISO 3166."
"C","837-Q1","I","2700","N4","04","","","","","2","2700","","F","Country Code"
"C","837-Q1","I","2700","N4","07","","","","","2","2700","1553","D","Required when the address is not in the United States of America, including its territories, or Canada, and the country in N404 has administrative subdivisions such as but not limited to states, provinces, cantons, etc. If not required by this implementation guide, do not send."
"C","837-Q1","I","2700","N4","07","","","","","2","2700","1554","","Use the country subdivision codes from Part 2 of ISO 3166."
"C","837-Q1","I","2700","N4","07","","","","","2","2700","","F","Country Subdivision Code"
"B","837-Q1","J","2900","","","","","","","2","2900","308","","Required when other payers are known to potentially be involved in paying on this claim. If not required by this implementation guide, do not send."
"B","837-Q1","J","2900","","","","","","","2","2900","306","A","Other Subscriber Information"
"B","837-Q1","J","2900","","","","","","","2","2900","309","","All information contained in Loop ID-2320 applies only to the payer identified in Loop ID-2330B of this iteration of Loop ID-2320. It is specific only to that payer. If information for an additional payer is necessary, repeat Loop ID-2320 with its respective 2330 Loops.;"
"B","837-Q1","J","2900","","","","","","","2","2900","310","","See Crosswalking COB Data Elements section for more information on handling COB in the 837."
"B","837-Q1","J","2900","","","","","","","2","2900","307","E","SBR*S*01*GR00786******13~"
"C","837-Q1","J","2900","SBR","01","","","","","2","2900","64","","Within a given claim, the various values for the Payer Responsibility Sequence Number Code (other than value ""U"") may occur no more than once."
"C","837-Q1","J","2900","SBR","01","","","","","2","2900","","F","Payer Responsibility Sequence Number Code"
"E","837-Q1","J","2900","SBR","01","","","1138","U","2","2900","65","","This code may only be used in payer to payer COB claims when the original payer determined the presence of this coverage from eligibility files received from this payer or when the original claim did not provide the responsibility sequence for this payer."
"C","837-Q1","J","2900","SBR","02","","","","","2","2900","","F","Individual Relationship Code"
"C","837-Q1","J","2900","SBR","03","","","","","2","2900","1482","D","Required when the subscriber's identification card for the non-destination payer identified in Loop ID-2330B of this iteration of Loop ID-2320 shows a group number. If not required by this implemetation guide, do not send."
"C","837-Q1","J","2900","SBR","03","","","","","2","2900","312","","This is not the number uniquely identifying the subscriber. The unique subscriber number is submitted in Loop 2330A-NM109 for this iteration of Loop ID-2320."
"C","837-Q1","J","2900","SBR","03","","","","","2","2900","","F","Insured Group or Policy Number"
"C","837-Q1","J","2900","SBR","04","","","","","2","2900","313","D","Required when SBR03 is not used and the group name is available. If not required by this implementation guide, do not send.;"
"C","837-Q1","J","2900","SBR","04","","","","","2","2900","","F","Other Insured Group Name"
"C","837-Q1","J","2900","SBR","05","","","","","2","2900","735","D","Required when the payer identified in Loop ID-2330B for this iteration of Loop ID-2320 is Medicare and Medicare is not the primary payer (Loop ID-2320 SBR01 is not P). If not required by this implementation guide, do not send."
"C","837-Q1","J","2900","SBR","05","","","","","2","2900","","F","Insurance Type Code"
"C","837-Q1","J","2900","SBR","09","","","","","2","2900","","F","Claim Filing Indicator Code"
"E","837-Q1","J","2900","SBR","09","","","1032","OF","2","2900","1484","","Use code OF when submitting Medicare Part D claims."
"E","837-Q1","J","2900","SBR","09","","","1032","ZZ","2","2900","71","","Use Code ZZ when Type of Insurance is not known."
"B","837-Q1","J","2950","","","","","","","2","2950","736","E","CAS*PR*1*7.93~"
"B","837-Q1","J","2950","","","","","","","2","2950","737","E","CAS*OA*93*15.06~;"
"B","837-Q1","J","2950","","","","","","","2","2950","738","A","Claim Level Adjustments"
"B","837-Q1","J","2950","","","","","","","2","2950","739","","Required when the claim has been adjudicated by the payer identified in this loop, and the claim has claim level adjustment information. If not required by this implementation guide, do not send."
"B","837-Q1","J","2950","","","","","","","2","2950","740","","Submitters must use this CAS segment to report prior payers' claim level adjustments that cause the amount paid to differ from the amount originally charged."
"B","837-Q1","J","2950","","","","","","","2","2950","741","","Only one Group Code is allowed per CAS. If it is necessary to send more than one Group Code at the claim level, repeat the CAS segment."
"B","837-Q1","J","2950","","","","","","","2","2950","742","","Codes and associated amounts must come from either paper remittance  advice or 835s (Electronic Remittance Advice) received on the claim.  When the information originates from a paper remittance advice that does not use the standard Claim Adjustment Reason Codes, the paper values must be converted to standard Claim Adjustment Reason Codes.;"
"B","837-Q1","J","2950","","","","","","","2","2950","743","","A single CAS segment contains six repetitions of the ""adjustment trio"" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a particular Claim Adjustment Group Code (CAS01). The first non-zero adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19)."
"C","837-Q1","J","2950","CAS","01","","","","","2","2950","","F","Claim Adjustment Group Code"
"C","837-Q1","J","2950","CAS","02","","","","","2","2950","109","","See CODE SOURCE 139: Claim Adjustment Reason Code"
"C","837-Q1","J","2950","CAS","02","","","","","2","2950","","F","Adjustment Reason Code"
"C","837-Q1","J","2950","CAS","03","","","","","2","2950","","F","Adjustment Amount"
"C","837-Q1","J","2950","CAS","04","","","","","2","2950","744","D","Required when the number of service units has been adjusted. If not required by this implementation guide, do not send."
"C","837-Q1","J","2950","CAS","04","","","","","2","2950","","F","Adjustment Quantity"
"C","837-Q1","J","2950","CAS","05","","","","","2","2950","745","D","Required when it is necessary to report an additional non-zero adjustment, beyond what has already been supplied, to this claim for the Claim Adjustment Group Code reported in CAS01. If not required by this implementation guide, do not send."
"C","837-Q1","J","2950","CAS","05","","","","","2","2950","","F","Adjustment Reason Code"
"C","837-Q1","J","2950","CAS","06","","","","","2","2950","746","D","Required when CAS05 is present. If not required by this implementation guide, do not send."
"C","837-Q1","J","2950","CAS","06","","","","","2","2950","","F","Adjustment Amount"
"C","837-Q1","J","2950","CAS","07","","","","","2","2950","747","D","Required when CAS05 is present and is related to a units of service adjustment. If not required by this implementation guide, do not send."
"C","837-Q1","J","2950","CAS","07","","","","","2","2950","","F","Adjustment Quantity"
"C","837-Q1","J","2950","CAS","08","","","","","2","2950","745","D","Required when it is necessary to report an additional non-zero adjustment, beyond what has already been supplied, to this claim for the Claim Adjustment Group Code reported in CAS01. If not required by this implementation guide, do not send."
"C","837-Q1","J","2950","CAS","08","","","","","2","2950","","F","Adjustment Reason Code"
"C","837-Q1","J","2950","CAS","09","","","","","2","2950","748","D","Required when CAS08 is present. If not required by this implementation guide, do not send."
"C","837-Q1","J","2950","CAS","09","","","","","2","2950","","F","Adjustment Amount"
"C","837-Q1","J","2950","CAS","10","","","","","2","2950","749","D","Required when CAS08 is present and is related to a units of service adjustment. If not required by this implementation guide, do not send."
"C","837-Q1","J","2950","CAS","10","","","","","2","2950","","F","Adjustment Quantity"
"C","837-Q1","J","2950","CAS","11","","","","","2","2950","745","D","Required when it is necessary to report an additional non-zero adjustment, beyond what has already been supplied, to this claim for the Claim Adjustment Group Code reported in CAS01. If not required by this implementation guide, do not send."
"C","837-Q1","J","2950","CAS","11","","","","","2","2950","","F","Adjustment Reason Code"
"C","837-Q1","J","2950","CAS","12","","","","","2","2950","750","D","Required when CAS11 is present. If not required by this implementation guide, do not send."
"C","837-Q1","J","2950","CAS","12","","","","","2","2950","","F","Adjustment Amount"
"C","837-Q1","J","2950","CAS","13","","","","","2","2950","751","D","Required when CAS11 is present and is related to a units of service adjustment. If not required by this implementation guide, do not send."
"C","837-Q1","J","2950","CAS","13","","","","","2","2950","","F","Adjustment Quantity"
"C","837-Q1","J","2950","CAS","14","","","","","2","2950","745","D","Required when it is necessary to report an additional non-zero adjustment, beyond what has already been supplied, to this claim for the Claim Adjustment Group Code reported in CAS01. If not required by this implementation guide, do not send."
"C","837-Q1","J","2950","CAS","14","","","","","2","2950","","F","Adjustment Reason Code"
"C","837-Q1","J","2950","CAS","15","","","","","2","2950","752","D","Required when CAS14 is present. If not required by this implementation guide, do not send."
"C","837-Q1","J","2950","CAS","15","","","","","2","2950","","F","Adjustment Amount"
"C","837-Q1","J","2950","CAS","16","","","","","2","2950","753","D","Required when CAS14 is present and is related to a units of service adjustment. If not required by this implementation guide, do not send."
"C","837-Q1","J","2950","CAS","16","","","","","2","2950","","F","Adjustment Quantity"
"C","837-Q1","J","2950","CAS","17","","","","","2","2950","745","D","Required when it is necessary to report an additional non-zero adjustment, beyond what has already been supplied, to this claim for the Claim Adjustment Group Code reported in CAS01. If not required by this implementation guide, do not send."
"C","837-Q1","J","2950","CAS","17","","","","","2","2950","","F","Adjustment Reason Code"
"C","837-Q1","J","2950","CAS","18","","","","","2","2950","754","D","Required when CAS17 is present. If not required by this implementation guide, do not send."
"C","837-Q1","J","2950","CAS","18","","","","","2","2950","","F","Adjustment Amount"
"C","837-Q1","J","2950","CAS","19","","","","","2","2950","755","D","Required when CAS17 is present and is related to a units of service adjustment. If not required by this implementation guide, do not send."
"C","837-Q1","J","2950","CAS","19","","","","","2","2950","","F","Adjustment Quantity"
"B","837-Q1","J","3000","","","","","","","2","3000","317","E","AMT*D*411~"
"B","837-Q1","J","3000","","","","","","","2","3000","756","A","Coordination of Benefits (COB) Payer Paid Amount"
"B","837-Q1","J","3000","","","","","","","2","3000","757","","Required when the claim has been adjudicated by the payer identified in Loop ID-2330B of this loop.<R>OR<R>Required when Loop ID-2010AC is present. In this case, the claim is a post payment recovery claim submitted by a subrogated Medicaid agency.<R>If not required by this implementation guide, do not send.;"
"C","837-Q1","J","3000","AMT","01","","","","","2","3000","","F","Amount Qualifier Code"
"C","837-Q1","J","3000","AMT","02","","","","","2","3000","758","","It is acceptable to show <169>0<170> as the amount paid."
"C","837-Q1","J","3000","AMT","02","","","","","2","3000","759","","When Loop ID-2010AC is present, this is the amount the Medicaid agency actually paid."
"C","837-Q1","J","3000","AMT","02","","","","","2","3000","","F","Payer Paid Amount"
"B","837-Q1","J","3020","","","","","","","2","3000","760","A","Coordination of Benefits (COB) Total Non-Covered Amount"
"B","837-Q1","J","3020","","","","","","","2","3000","761","E","AMT*A8*273~"
"B","837-Q1","J","3020","","","","","","","2","3000","762","","Required when the destination payer's cost avoidance policy allows providers to bypass claim submission to the otherwise prior payer identified in Loop ID-2330B. If not required by this implementation guide, do not send."
"B","837-Q1","J","3020","","","","","","","2","3000","763","","When this segment is used, the amount reported in AMT02 must equal the total claim charge amount reported in CLM02. Neither the prior payer paid AMT, nor any CAS segments are used as this claim has not been adjudicated by this payer."
"C","837-Q1","J","3020","AMT","01","","","","","2","3000","","F","Amount Qualifier Code"
"C","837-Q1","J","3020","AMT","02","","","","","2","3000","","F","Non-Covered Charge Amount"
"B","837-Q1","J","3050","","","","","","","2","3000","765","A","Remaining Patient Liability"
"B","837-Q1","J","3050","","","","","","","2","3000","766","E","AMT*EAF*75~"
"B","837-Q1","J","3050","","","","","","","2","3000","767","","Required when the Other Payer identified in Loop ID-2330B (of this iteration of Loop ID-2320) has adjudicated this claim and provided claim level information only.<R>OR<R>Required when the Other Payer identified in Loop ID-2330B (of this iteration of Loop ID-2320) has adjudicated this claim and the provider received a paper remittance advice and the provider does not have the ability to report line item information.<R>If not required by this implementation guide, do not send."
"B","837-Q1","J","3050","","","","","","","2","3000","768","","In the judgment of the provider, this is the remaining amount to be paid after adjudication by the Other Payer identified in Loop ID-2330B of this iteration of Loop ID-2320."
"B","837-Q1","J","3050","","","","","","","2","3000","769","","This segment is only used in provider submitted claims. It is not used in Payer-to-Payer Coordination of Benefits (COB)."
"B","837-Q1","J","3050","","","","","","","2","3000","770","","This segment is not used if the line level (Loop ID-2430) Remaining Patient Liability AMT segment is used for this Other Payer."
"C","837-Q1","J","3050","AMT","01","","","","","2","3000","","F","Amount Qualifier Code"
"C","837-Q1","J","3050","AMT","02","","","","","2","3000","","F","Remaining Patient Liability"
"B","837-Q1","J","3110","","","","","","","2","3100","777","E","OI***Y*B**Y~"
"B","837-Q1","J","3110","","","","","","","2","3100","778","A","Other Insurance Coverage Information"
"B","837-Q1","J","3110","","","","","","","2","3100","779","","All information contained in the OI segment applies only to the payer identified in Loop ID-2330B in this iteration of Loop ID-2320."
"C","837-Q1","J","3110","OI","03","","","","","2","3100","780","","This is a crosswalk from CLM08 when doing COB."
"C","837-Q1","J","3110","OI","03","","","","","2","3100","486","","This element answers the question whether or not the insured has authorized the plan to remit payment directly to the provider."
"C","837-Q1","J","3110","OI","03","","","","","2","3100","","F","Benefits Assignment Certification Indicator"
"E","837-Q1","J","3110","OI","03","","","1073","W","2","3100","1563","","Use code `W' when the patient refuses to assign benefits."
"C","837-Q1","J","3110","OI","04","","","","","2","3100","490","D","Required when a signature was executed on the patient's behalf under state or federal law. If not required by this implementation guide, do not send."
"C","837-Q1","J","3110","OI","04","","","","","2","3100","782","","This is a crosswalk from CLM10 when doing COB."
"C","837-Q1","J","3110","OI","04","","","","","2","3100","","F","Patient Signature Source Code"
"E","837-Q1","J","3110","OI","04","","","1351","P","2","3100","1497","","Signature generated by an entity other than the patient according to State or Federal law."
"C","837-Q1","J","3110","OI","06","","","","","2","3100","783","","This is a crosswalk from CLM09 when doing COB."
"C","837-Q1","J","3110","OI","06","","","","","2","3100","487","","The Release of Information response is limited to the information carried in this claim."
"C","837-Q1","J","3110","OI","06","","","","","2","3100","","F","Release of Information Code"
"E","837-Q1","J","3110","OI","06","","","1363","I","2","3100","488","","Required when the provider has not collected a signature AND state or federal laws do not require a signature be collected."
"E","837-Q1","J","3110","OI","06","","","1363","Y","2","3100","489","","Required when the provider has collected a signature.<R>OR<R>Required when state or federal laws require a signature be collected."
"B","837-Q1","J","3200","","","","","","","2","3200","784","E","MOA***A4~"
"B","837-Q1","J","3200","","","","","","","2","3200","785","A","Outpatient Adjudication Information"
"B","837-Q1","J","3200","","","","","","","2","3200","786","","Required when outpatient adjudication information is reported in the remittance advice<R>OR<R>Required when it is necessary to report remark codes.<R>If not required by this implementation guide, do not send."
"C","837-Q1","J","3200","MOA","01","","","","","2","3200","787","D","Required when returned in the remittance advice. If not required by this implementation guide, do not send."
"C","837-Q1","J","3200","MOA","01","","","","","2","3200","","F","Reimbursement Rate"
"C","837-Q1","J","3200","MOA","02","","","","","2","3200","787","D","Required when returned in the remittance advice. If not required by this implementation guide, do not send."
"C","837-Q1","J","3200","MOA","02","","","","","2","3200","","F","HCPCS Payable Amount"
"C","837-Q1","J","3200","MOA","03","","","","","2","3200","787","D","Required when returned in the remittance advice. If not required by this implementation guide, do not send."
"C","837-Q1","J","3200","MOA","03","","","","","2","3200","","F","Claim Payment Remark Code"
"C","837-Q1","J","3200","MOA","04","","","","","2","3200","787","D","Required when returned in the remittance advice. If not required by this implementation guide, do not send."
"C","837-Q1","J","3200","MOA","04","","","","","2","3200","","F","Claim Payment Remark Code"
"C","837-Q1","J","3200","MOA","05","","","","","2","3200","787","D","Required when returned in the remittance advice. If not required by this implementation guide, do not send."
"C","837-Q1","J","3200","MOA","05","","","","","2","3200","","F","Claim Payment Remark Code"
"C","837-Q1","J","3200","MOA","06","","","","","2","3200","787","D","Required when returned in the remittance advice. If not required by this implementation guide, do not send."
"C","837-Q1","J","3200","MOA","06","","","","","2","3200","","F","Claim Payment Remark Code"
"C","837-Q1","J","3200","MOA","07","","","","","2","3200","787","D","Required when returned in the remittance advice. If not required by this implementation guide, do not send."
"C","837-Q1","J","3200","MOA","07","","","","","2","3200","","F","Claim Payment Remark Code"
"C","837-Q1","J","3200","MOA","08","","","","","2","3200","787","D","Required when returned in the remittance advice. If not required by this implementation guide, do not send."
"C","837-Q1","J","3200","MOA","08","","","","","2","3200","","F","End Stage Renal Disease Payment Amount"
"C","837-Q1","J","3200","MOA","09","","","","","2","3200","787","D","Required when returned in the remittance advice. If not required by this implementation guide, do not send."
"C","837-Q1","J","3200","MOA","09","","","","","2","3200","","F","Non-Payable Professional Component Billed Amount"
"B","837-Q1","J","3250","","","","","","","2","3250","78","E","NM1*IL*1*DOE*JOHN*T**JR*MI*123456~"
"B","837-Q1","J","3250","","","","","","","2","3250","322","A","Other Subscriber Name"
"B","837-Q1","J","3250","","","","","","","2","3250","323","","If the patient can be uniquely identified to the Other Payer indicated  in this iteration of Loop ID-2320 by a unique Member Identification Number, then the patient is the subscriber or is considered to be the subscriber and is identified in this Other Subscriber's Name Loop ID-2330A.;"
"B","837-Q1","J","3250","","","","","","","2","3250","324","","If the patient is a dependent of the subscriber for this other coverage and cannot be uniquely identified to the Other Payer indicated in this iteration of Loop ID-2320 by a unique Member Identification Number, then the subscriber for this other coverage is identified in this Other Subscriber's Name Loop ID-2330A."
"B","837-Q1","J","3250","","","","","","","2","3250","310","","See Crosswalking COB Data Elements section for more information on handling COB in the 837."
"C","837-Q1","J","3250","NM1","01","","","","","2","3250","","F","Entity Identifier Code"
"C","837-Q1","J","3250","NM1","02","","","","","2","3250","","F","Entity Type Qualifier"
"C","837-Q1","J","3250","NM1","03","","","","","2","3250","","F","Other Insured Last Name"
"C","837-Q1","J","3250","NM1","04","","","","","2","3250","17","D","Required when NM102 = 1 (person) and the person has a first name. If not required by this implementation guide, do not send."
"C","837-Q1","J","3250","NM1","04","","","","","2","3250","","F","Other Insured First Name"
"C","837-Q1","J","3250","NM1","05","","","","","2","3250","18","D","Required when NM102 = 1 (person) and the middle name or initial of the person is needed to identify the individual. If not required by this implementation guide, do not send."
"C","837-Q1","J","3250","NM1","05","","","","","2","3250","","F","Other Insured Middle Name"
"C","837-Q1","J","3250","NM1","07","","","","","2","3250","80","D","Required when NM102 = 1 (person) and the name suffix of the person is needed to identify the individual. If not required by this implementation guide, do not send."
"C","837-Q1","J","3250","NM1","07","","","","","2","3250","","F","Other Insured Name Suffix"
"C","837-Q1","J","3250","NM1","08","","","","","2","3250","","F","Identification Code Qualifier"
"E","837-Q1","J","3250","NM1","08","","","66","II","2","3250","1540","","Required if the HIPAA Individual Patient Identifier is mandated use.  If not required, use value `MI' instead."
"E","837-Q1","J","3250","NM1","08","","","66","MI","2","3250","82","","The code MI is intended to be the subscriber's identification number as assigned by the payer. (For example, Insured's ID, Subscriber's ID, Health Insurance Claim Number (HIC), etc.)<R><R>MI is also intended to be used in claims submitted to the Indian Health Service/Contract Health Services (IHS/CHS) Fiscal Intermediary for the purpose of reporting the Tribe Residency Code (Tribe County State). In the event that a Social Security Number (SSN) is also available on an IHS/CHS claim, put the SSN in REF02.<R><R>When sending the Social Security Number as the Member ID, it must be a string of exactly nine numbers with no separators. For example, sending <169>111002222<170> would be valid, while sending <169>111-00-2222<170> would be invalid."
"C","837-Q1","J","3250","NM1","09","","","","","2","3250","","F","Other Insured Identifier"
"B","837-Q1","J","3320","","","","","","","2","3320","84","E","N3*123 MAIN STREET~"
"B","837-Q1","J","3320","","","","","","","2","3320","788","A","Other Subscriber Address"
"B","837-Q1","J","3320","","","","","","","2","3320","789","","Required when the information is available. If not required by this implementation guide, do not send."
"C","837-Q1","J","3320","N3","01","","","","","2","3320","","F","Other Subscriber Address Line"
"C","837-Q1","J","3320","N3","02","","","","","2","3320","87","D","Required when there is a second address line. If not required by this implementation guide, do not send."
"C","837-Q1","J","3320","N3","02","","","","","2","3320","","F","Other Insured Address Line"
"B","837-Q1","J","3400","","","","","","","2","3400","790","A","Other Subscriber City, State, ZIP Code"
"B","837-Q1","J","3400","","","","","","","2","3400","1548","E","N4*KANSAS CITY*MO*64108~"
"B","837-Q1","J","3400","","","","","","","2","3400","301120","","Required when the information is available. If not required by this implementation guide, do not send."
"C","837-Q1","J","3400","N4","01","","","","","2","3400","","F","Other Subscriber City Name"
"C","837-Q1","J","3400","N4","02","","","","","2","3400","1549","D","Required when the address is in the United States of America, including its territories, or Canada. If not required by this implementation guide, do not send."
"C","837-Q1","J","3400","N4","02","","","","","2","3400","","F","Other Subscriber State or Province Code"
"C","837-Q1","J","3400","N4","03","","","","","2","3400","1550","D","Required when the address is in the United States of America, including its territories, or Canada, or when a postal code exists for the country in N404. If not required by this implementation guide, do not send."
"C","837-Q1","J","3400","N4","03","","","","","2","3400","","F","Other Subscriber Postal Zone or ZIP Code"
"C","837-Q1","J","3400","N4","04","","","","","2","3400","1551","D","Required when the address is outside the United States of America. If not required by this implementation guide, do not send."
"C","837-Q1","J","3400","N4","04","","","","","2","3400","1552","","Use the alpha-2 country codes from Part 1 of ISO 3166."
"C","837-Q1","J","3400","N4","04","","","","","2","3400","","F","Country Code"
"C","837-Q1","J","3400","N4","07","","","","","2","3400","1553","D","Required when the address is not in the United States of America, including its territories, or Canada, and the country in N404 has administrative subdivisions such as but not limited to states, provinces, cantons, etc. If not required by this implementation guide, do not send."
"C","837-Q1","J","3400","N4","07","","","","","2","3400","1554","","Use the country subdivision codes from Part 2 of ISO 3166."
"C","837-Q1","J","3400","N4","07","","","","","2","3400","","F","Country Subdivision Code"
"B","837-Q1","J","3550","","","","","","","2","3550","101","E","REF*SY*123456789~"
"B","837-Q1","J","3550","","","","","","","2","3550","325","A","Other Subscriber Secondary Identification"
"B","837-Q1","J","3550","","","","","","","2","3550","326","","Required when an additional identification number to that provided in NM109 of this loop is necessary for the claim processor to identify the entity. If not required by this implementation guide, do not send."
"C","837-Q1","J","3550","REF","01","","","","","2","3550","","F","Reference Identification Qualifier"
"E","837-Q1","J","3550","REF","01","","","128","SY","2","3550","327","","The Social Security Number must be a string of exactly nine numbers with no separators. For example, sending <169>111002222<170> would be valid, while sending <169>111-00-2222<170> would be invalid."
"C","837-Q1","J","3550","REF","02","","","","","2","3550","","F","Other Insured Additional Identifier"
"B","837-Q1","K","3250","","","","","","","2","3250","104","E","NM1*PR*2*ABC INSURANCE CO*****PI*11122333~"
"B","837-Q1","K","3250","","","","","","","2","3250","328","A","Other Payer Name"
"B","837-Q1","K","3250","","","","","","","2","3250","310","","See Crosswalking COB Data Elements section for more information on handling COB in the 837."
"C","837-Q1","K","3250","NM1","01","","","","","2","3250","","F","Entity Identifier Code"
"C","837-Q1","K","3250","NM1","02","","","","","2","3250","","F","Entity Type Qualifier"
"C","837-Q1","K","3250","NM1","03","","","","","2","3250","","F","Other Payer Organization Name"
"C","837-Q1","K","3250","NM1","08","","","","","2","3250","301710","","Use code value ""PI"" when reporting Payor Identification.<R>Use code value ""XV"" when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID).<R><R>Prior to the mandated implementation date for Health Plan Identifier, willing trading partners may agree to:<R>1. Follow a dual use approach in which both the HPID or OEID and the Payor Identification are sent. Send XV qualifier in NM108 with HPID or OEID in NM109 and the Payor Identification, that would have been sent using qualifier PI, in the corresponding REF segment using qualifier 2U (Payer Identification Number).<R>OR<R>2. Follow an early implementation approach in which the HPID or OEID is sent in NM109."
"C","837-Q1","K","3250","NM1","08","","","","","2","3250","","F","Identification Code Qualifier"
"C","837-Q1","K","3250","NM1","09","","","","","2","3250","330","","When sending Line Adjudication Information for this payer, the identifier sent in SVD01 (Payer Identifier) of Loop ID-2430 (Line  Adjudication Information) must match this value.;"
"C","837-Q1","K","3250","NM1","09","","","","","2","3250","","F","Other Payer Primary Identifier"
"B","837-Q1","K","3320","","","","","","","2","3320","791","A","Other Payer Address"
"B","837-Q1","K","3320","","","","","","","2","3320","84","E","N3*123 MAIN STREET~"
"B","837-Q1","K","3320","","","","","","","2","3320","792","","Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send."
"C","837-Q1","K","3320","N3","01","","","","","2","3320","","F","Other Payer Address Line"
"C","837-Q1","K","3320","N3","02","","","","","2","3320","87","D","Required when there is a second address line. If not required by this implementation guide, do not send."
"C","837-Q1","K","3320","N3","02","","","","","2","3320","","F","Other Payer Address Line"
"B","837-Q1","K","3400","","","","","","","2","3400","793","A","Other Payer City, State, ZIP Code"
"B","837-Q1","K","3400","","","","","","","2","3400","1548","E","N4*KANSAS CITY*MO*64108~"
"B","837-Q1","K","3400","","","","","","","2","3400","301119","","Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send."
"C","837-Q1","K","3400","N4","01","","","","","2","3400","","F","Other Payer City Name"
"C","837-Q1","K","3400","N4","02","","","","","2","3400","1549","D","Required when the address is in the United States of America, including its territories, or Canada. If not required by this implementation guide, do not send."
"C","837-Q1","K","3400","N4","02","","","","","2","3400","","F","Other Payer State or Province Code"
"C","837-Q1","K","3400","N4","03","","","","","2","3400","1550","D","Required when the address is in the United States of America, including its territories, or Canada, or when a postal code exists for the country in N404. If not required by this implementation guide, do not send."
"C","837-Q1","K","3400","N4","03","","","","","2","3400","","F","Other Payer Postal Zone or ZIP Code"
"C","837-Q1","K","3400","N4","04","","","","","2","3400","1551","D","Required when the address is outside the United States of America. If not required by this implementation guide, do not send."
"C","837-Q1","K","3400","N4","04","","","","","2","3400","1552","","Use the alpha-2 country codes from Part 1 of ISO 3166."
"C","837-Q1","K","3400","N4","04","","","","","2","3400","","F","Country Code"
"C","837-Q1","K","3400","N4","07","","","","","2","3400","1553","D","Required when the address is not in the United States of America, including its territories, or Canada, and the country in N404 has administrative subdivisions such as but not limited to states, provinces, cantons, etc. If not required by this implementation guide, do not send."
"C","837-Q1","K","3400","N4","07","","","","","2","3400","1554","","Use the country subdivision codes from Part 2 of ISO 3166."
"C","837-Q1","K","3400","N4","07","","","","","2","3400","","F","Country Subdivision Code"
"B","837-Q1","K","3470","","","","","","","2","3450","798","A","Claim Check or Remittance Date"
"B","837-Q1","K","3470","","","","","","","2","3450","799","E","DTP*573*D8*20040203~"
"B","837-Q1","K","3470","","","","","","","2","3450","800","","Required when the payer identified in this loop has previously  adjudicated the claim and Loop ID-2430, Line Check or Remittance Date,  is not used. If not required by this implementation guide, do not send.;"
"C","837-Q1","K","3470","DTP","01","","","","","2","3450","","F","Date Time Qualifier"
"C","837-Q1","K","3470","DTP","02","","","","","2","3450","","F","Date Time Period Format Qualifier"
"C","837-Q1","K","3470","DTP","03","","","","","2","3450","","F","Adjudication or Payment Date"
"B","837-Q1","K","3550","","","","","","","2","3550","435","E","REF*2U*98765~"
"B","837-Q1","K","3550","","","","","","","2","3550","332","A","Other Payer Secondary Identifier"
"B","837-Q1","K","3550","","","","","","","2","3550","301711","","Required when an additional identification number to that provided in the NM109 of this loop is necessary to identify the entity.<R>If not required by this implementation guide, do not send."
"C","837-Q1","K","3550","REF","01","","","","","2","3550","","F","Reference Identification Qualifier"
"E","837-Q1","K","3550","REF","01","","","128","2U","2","3550","301712","","This code is only allowed when the qualifier XV is reported in NM108 of this loop."
"E","837-Q1","K","3550","REF","01","","","128","EI","2","3550","112","","The Employer's Identification Number must be a string of exactly nine numbers with no separators.<R><R>For example, <169>001122333<170> would be valid, while sending <169>001-12-2333<170> or <169>00-1122333<170> would be invalid."
"C","837-Q1","K","3550","REF","02","","","","","2","3550","","F","Other Payer Secondary Identifier"
"B","837-Q1","K","3560","","","","","","","2","3550","803","E","REF*G1*AB333-Y5~"
"B","837-Q1","K","3560","","","","","","","2","3550","1538","A","Other Payer Prior Authorization Number"
"B","837-Q1","K","3560","","","","","","","2","3550","1564","","Required when the payer identified in this loop has assigned a prior authorization number to this claim.<R>If not required by this implementation guide, do not send."
"C","837-Q1","K","3560","REF","01","","","","","2","3550","","F","Reference Identification Qualifier"
"C","837-Q1","K","3560","REF","02","","","","","2","3550","","F","Other Payer Prior Authorization Number"
"B","837-Q1","K","3563","","","","","","","2","3550","1539","A","Other Payer Referral Number"
"B","837-Q1","K","3563","","","","","","","2","3550","804","","Required when the payer identified in this loop has assigned a referral number to this claim.<R>If not required by this implementation guide, do not send."
"B","837-Q1","K","3563","","","","","","","2","3550","948","E","REF*9F*12345~"
"C","837-Q1","K","3563","REF","01","","","","","2","3550","","F","Reference Identification Qualifier"
"C","837-Q1","K","3563","REF","02","","","","","2","3550","","F","Other Payer Prior Authorization or Referral Number"
"B","837-Q1","K","3570","","","","","","","2","3550","805","A","Other Payer Claim Adjustment Indicator"
"B","837-Q1","K","3570","","","","","","","2","3550","806","E","REF*T4*Y~"
"B","837-Q1","K","3570","","","","","","","2","3550","807","","Required when the claim is being sent in the payer-to-payer COB model, <R>AND<R>the destination payer is secondary to the payer identified in this Loop ID-2330B, <R>AND<R>the payer identified in this Loop ID-2330B has re-adjudicated the claim.<R>If not required by this implementation guide, do not send."
"C","837-Q1","K","3570","REF","01","","","","","2","3550","","F","Reference Identification Qualifier"
"C","837-Q1","K","3570","REF","02","","","","","2","3550","808","","The only valid value for this element is `Y'."
"C","837-Q1","K","3570","REF","02","","","","","2","3550","","F","Other Payer Claim Adjustment Indicator"
"B","837-Q1","K","3575","","","","","","","2","3550","1580","A","Other Payer Claim Control Number"
"B","837-Q1","K","3575","","","","","","","2","3550","1581","","Required when it is necessary to identify the Other Payer's Claim Control Number in a payer-to-payer COB situation.<R>OR<R>Required when the Other Payer's Claim Control Number is available.<R>If not required by this implementation guide, do not send."
"B","837-Q1","K","3575","","","","","","","2","3550","579","E","REF*F8*R555588~"
"C","837-Q1","K","3575","REF","01","","","","","2","3550","","F","Reference Identification Qualifier"
"C","837-Q1","K","3575","REF","02","","","","","2","3550","","F","Other Payer's Claim Control Number"
"B","837-Q1","M","3250","","","","","","","2","3250","813","A","Other Payer Referring Provider"
"B","837-Q1","M","3250","","","","","","","2","3250","814","E","NM1*DN*1~"
"B","837-Q1","M","3250","","","","","","","2","3250","310","","See Crosswalking COB Data Elements section for more information on handling COB in the 837."
"B","837-Q1","M","3250","","","","","","","2","3250","815","","Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.<R>OR<R>Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.<R>If not required by this implementation guide, do not send."
"C","837-Q1","M","3250","NM1","01","","","","","2","3250","","F","Entity Identifier Code"
"E","837-Q1","M","3250","NM1","01","","","98","DN","2","3250","680","","Use on the first iteration of this loop. Use if loop is used only once."
"E","837-Q1","M","3250","NM1","01","","","98","P3","2","3250","681","","Use only if loop is used twice. Use only on second iteration of this loop."
"C","837-Q1","M","3250","NM1","02","","","","","2","3250","","F","Entity Type Qualifier"
"B","837-Q1","M","3550","","","","","","","2","3550","1432","A","Other Payer Referring Provider Secondary Identification"
"B","837-Q1","M","3550","","","","","","","2","3550","817","","Non-destination (COB) payer's provider identification number(s)."
"B","837-Q1","M","3550","","","","","","","2","3550","310","","See Crosswalking COB Data Elements section for more information on handling COB in the 837."
"B","837-Q1","M","3550","","","","","","","2","3550","369","E","REF*G2*12345~"
"C","837-Q1","M","3550","REF","01","","","","","2","3550","","F","Reference Identification Qualifier"
"E","837-Q1","M","3550","REF","01","","","128","1G","2","3550","1555","","UPINs must be formatted as either X99999 or XXX999."
"E","837-Q1","M","3550","REF","01","","","128","G2","2","3550","818","","This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan."
"C","837-Q1","M","3550","REF","02","","","","","2","3550","","F","Other Payer Referring Provider Identifier"
"B","837-Q1","M","3650","","","","","","","2","3250","819","A","Other Payer Rendering Provider"
"B","837-Q1","M","3650","","","","","","","2","3250","820","E","NM1*82*1~"
"B","837-Q1","M","3650","","","","","","","2","3250","310","","See Crosswalking COB Data Elements section for more information on handling COB in the 837."
"B","837-Q1","M","3650","","","","","","","2","3250","815","","Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.<R>OR<R>Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.<R>If not required by this implementation guide, do not send."
"C","837-Q1","M","3650","NM1","01","","","","","2","3250","","F","Entity Identifier Code"
"C","837-Q1","M","3650","NM1","02","","","","","2","3250","","F","Entity Type Qualifier"
"B","837-Q1","M","4150","","","","","","","2","3550","821","A","Other Payer Rendering Provider Secondary Identification"
"B","837-Q1","M","4150","","","","","","","2","3550","326","","Required when an additional identification number to that provided in NM109 of this loop is necessary for the claim processor to identify the entity. If not required by this implementation guide, do not send."
"B","837-Q1","M","4150","","","","","","","2","3550","310","","See Crosswalking COB Data Elements section for more information on handling COB in the 837."
"B","837-Q1","M","4150","","","","","","","2","3550","369","E","REF*G2*12345~"
"C","837-Q1","M","4150","REF","01","","","","","2","3550","","F","Reference Identification Qualifier"
"E","837-Q1","M","4150","REF","01","","","128","1G","2","3550","1555","","UPINs must be formatted as either X99999 or XXX999."
"E","837-Q1","M","4150","REF","01","","","128","G2","2","3550","818","","This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan."
"C","837-Q1","M","4150","REF","02","","","","","2","3550","","F","Other Payer Rendering Provider Secondary Identifier"
"B","837-Q1","M","4650","","","","","","","2","3250","825","A","Other Payer Service Facility Location"
"B","837-Q1","M","4650","","","","","","","2","3250","826","E","NM1*77*2~"
"B","837-Q1","M","4650","","","","","","","2","3250","310","","See Crosswalking COB Data Elements section for more information on handling COB in the 837."
"B","837-Q1","M","4650","","","","","","","2","3250","815","","Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.<R>OR<R>Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.<R>If not required by this implementation guide, do not send."
"C","837-Q1","M","4650","NM1","01","","","","","2","3250","","F","Entity Identifier Code"
"C","837-Q1","M","4650","NM1","02","","","","","2","3250","","F","Entity Type Qualifier"
"B","837-Q1","M","5550","","","","","","","2","3550","827","A","Other Payer Service Facility Location Secondary Identification"
"B","837-Q1","M","5550","","","","","","","2","3550","369","E","REF*G2*12345~"
"C","837-Q1","M","5550","REF","01","","","","","2","3550","","F","Reference Identification Qualifier"
"E","837-Q1","M","5550","REF","01","","","128","G2","2","3550","818","","This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan."
"C","837-Q1","M","5550","REF","02","","","","","2","3550","","F","Other Payer Service Facility Location Secondary Identifier"
"B","837-Q1","M","5650","","","","","","","2","3250","828","A","Other Payer Supervising Provider"
"B","837-Q1","M","5650","","","","","","","2","3250","829","E","NM1*DQ*1~"
"B","837-Q1","M","5650","","","","","","","2","3250","310","","See Crosswalking COB Data Elements section for more information on handling COB in the 837."
"B","837-Q1","M","5650","","","","","","","2","3250","815","","Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.<R>OR<R>Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.<R>If not required by this implementation guide, do not send."
"C","837-Q1","M","5650","NM1","01","","","","","2","3250","","F","Entity Identifier Code"
"C","837-Q1","M","5650","NM1","02","","","","","2","3250","","F","Entity Type Qualifier"
"B","837-Q1","M","6050","","","","","","","2","3550","830","A","Other Payer Supervising Provider Secondary Identification"
"B","837-Q1","M","6050","","","","","","","2","3550","369","E","REF*G2*12345~"
"C","837-Q1","M","6050","REF","01","","","","","2","3550","","F","Reference Identification Qualifier"
"E","837-Q1","M","6050","REF","01","","","128","1G","2","3550","1555","","UPINs must be formatted as either X99999 or XXX999."
"E","837-Q1","M","6050","REF","01","","","128","G2","2","3550","818","","This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan."
"C","837-Q1","M","6050","REF","02","","","","","2","3550","","F","Other Payer Supervising Provider Identifier"
"B","837-Q1","M","6350","","","","","","","2","3250","831","A","Other Payer Billing Provider"
"B","837-Q1","M","6350","","","","","","","2","3250","832","E","NM1*85*2~"
"B","837-Q1","M","6350","","","","","","","2","3250","815","","Required prior to the mandated implementation of the HIPAA National Provider Identifier (NPI) rule when the provider in the corresponding Loop ID-2310 is sent and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.<R>OR<R>Required after the mandated implementation of the NPI rule for providers who are not Health Care Providers when the provider is sent in the corresponding Loop ID-2310 and one or more additional payer-specific provider identification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.<R>If not required by this implementation guide, do not send."
"B","837-Q1","M","6350","","","","","","","2","3250","310","","See Crosswalking COB Data Elements section for more information on handling COB in the 837."
"C","837-Q1","M","6350","NM1","01","","","","","2","3250","","F","Entity Identifier Code"
"C","837-Q1","M","6350","NM1","02","","","","","2","3250","","F","Entity Type Qualifier"
"B","837-Q1","M","6600","","","","","","","2","3550","834","A","Other Payer Billing Provider Secondary Identification"
"B","837-Q1","M","6600","","","","","","","2","3550","369","E","REF*G2*12345~"
"B","837-Q1","M","6600","","","","","","","2","3550","310","","See Crosswalking COB Data Elements section for more information on handling COB in the 837."
"C","837-Q1","M","6600","REF","01","","","","","2","3550","","F","Reference Identification Qualifier"
"E","837-Q1","M","6600","REF","01","","","128","G2","2","3550","818","","This code designates a proprietary provider number for the non-destination payer identified in the Other Payer Name Loop ID-2330B for this iteration of Loop ID-2320. This is true regardless of whether that payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a commercial plan, or any other health plan."
"C","837-Q1","M","6600","REF","02","","","","","2","3550","","F","Other Payer Billing Provider Identifier"
"B","837-Q1","P","3650","","","","","","","2","3650","340","E","LX*1~"
"B","837-Q1","P","3650","","","","","","","2","3650","342","","The LX functions as a line counter."
"B","837-Q1","P","3650","","","","","","","2","3650","341","A","Service Line Number"
"B","837-Q1","P","3650","","","","","","","2","3650","343","","The Service Line LX segment must begin with one and is incremented by one for each additional service line of a claim."
"B","837-Q1","P","3650","","","","","","","2","3650","344","","LX01 is used to indicate bundling in SVD06 in the Line Item Adjudication loop. See Section 1.4.1.2 for more information on bundling and unbundling."
"C","837-Q1","P","3650","LX","01","","","","","2","3650","","F","Assigned Number"
"B","837-Q1","P","3700","","","","","","","2","3700","839","E","SV1*HC:99211:25*12.25*UN*1*11**1:2:3**Y~"
"B","837-Q1","P","3700","","","","","","","2","3700","840","A","Professional Service"
"D","837-Q1","P","3700","SV1","01","C003","01","","","2","3700","841","","The NDC number is used for reporting prescribed drugs and biologics when required by government regulation, or as deemed by the provider to enhance claim reporting or adjudication processes. The NDC number is reported in the LIN segment of Loop ID-2410 only."
"D","837-Q1","P","3700","SV1","01","C003","01","","","2","3700","","F","Product or Service ID Qualifier"
"E","837-Q1","P","3700","SV1","01","C003","01","235","ER","2","3700","1529","","This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:<R>If a new rule names the Jurisdiction Specific Procedure and Supply Codes as an allowable code set under HIPAA, <R>OR<R>The Secretary grants an exception to use the code set as a pilot project as allowed under the law, <R>OR<R>For claims which are not covered under HIPAA."
"E","837-Q1","P","3700","SV1","01","C003","01","235","HC","2","3700","351","","Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC."
"E","837-Q1","P","3700","SV1","01","C003","01","235","IV","2","3700","352","","This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:<R> If a new rule names the Home Infusion EDI Coalition (HIEC) Product/Service Codes as an allowable code set under HIPAA, <R> OR<R> The Secretary grants an exception to use the code set as a pilot project as allowed under the law, <R> OR<R> For claims which are not covered under HIPAA.;"
"E","837-Q1","P","3700","SV1","01","C003","01","235","WK","2","3700","353","","At the time of this writing, this code set has been approved by the Secretary of HHS as a pilot project allowed under HIPAA law. <R>The qualifier may only be used in transactions covered under HIPAA; <R>By parties registered in the pilot project and their trading partners, <R>OR<R>If a new rule names the Complementary, Alternative, or Holistic Procedure Codes as an allowable code set under HIPAA, <R>OR<R>For claims which are not covered under HIPAA."
"D","837-Q1","P","3700","SV1","01","C003","02","","","2","3700","","F","Procedure Code"
"D","837-Q1","P","3700","SV1","01","C003","03","","","2","3700","355","D","Required when a modifier clarifies or improves the reporting accuracy of the associated procedure code. This is the first procedure code modifier. If not required by this implementation guide, do not send."
"D","837-Q1","P","3700","SV1","01","C003","03","","","2","3700","","F","Procedure Modifier"
"D","837-Q1","P","3700","SV1","01","C003","04","","","2","3700","356","D","Required when a second modifier clarifies or improves the reporting accuracy of the associated procedure code. If not required by this implementation guide, do not send."
"D","837-Q1","P","3700","SV1","01","C003","04","","","2","3700","","F","Procedure Modifier"
"D","837-Q1","P","3700","SV1","01","C003","05","","","2","3700","357","D","Required when a third modifier clarifies or improves the reporting accuracy of the associated procedure code. If not required by this implementation guide, do not send."
"D","837-Q1","P","3700","SV1","01","C003","05","","","2","3700","","F","Procedure Modifier"
"D","837-Q1","P","3700","SV1","01","C003","06","","","2","3700","358","D","Required when a fourth modifier clarifies or improves the reporting accuracy of the associated procedure code. If not required by this implementation guide, do not send.;"
"D","837-Q1","P","3700","SV1","01","C003","06","","","2","3700","","F","Procedure Modifier"
"D","837-Q1","P","3700","SV1","01","C003","07","","","2","3700","842","D","Required when, in the judgment of the submitter, the Procedure Code does not definitively describe the service/product/supply and loop 2410 is not used.<R>OR<R>Required when SV101-2 is a non-specific Procedure Code. Non-specific codes may include in their descriptors terms such as: Not Otherwise Classified (NOC); Unlisted; Unspecified; Unclassified; Other; Miscellaneous; Prescription Drug, Generic; or Prescription Drug, Brand Name.<R>If not required by this implementation guide, do not send."
"D","837-Q1","P","3700","SV1","01","C003","07","","","2","3700","","F","Description"
"C","837-Q1","P","3700","SV1","02","","","","","2","3700","844","","This is the total charge amount for this service line. The amount is inclusive of the provider's base charge and any applicable tax and/or postage claimed amounts reported within this line's AMT segments."
"C","837-Q1","P","3700","SV1","02","","","","","2","3700","843","","Zero ""0"" is an acceptable value for this element."
"C","837-Q1","P","3700","SV1","02","","","","","2","3700","","F","Line Item Charge Amount"
"C","837-Q1","P","3700","SV1","03","","","","","2","3700","","F","Unit or Basis for Measurement Code"
"E","837-Q1","P","3700","SV1","03","","","355","MJ","2","3700","845","","Required for Anesthesia claims.<R>
Anesthesia time is counted from the moment that the practitioner, having completed the preoperative evaluation, starts an intravenous line, places monitors, administers pre-anesthesia sedation, or otherwise physically begins to prepare the patient for anesthesia. Time continues throughout the case and while the practitioner accompanies the patient to the post-anesthesia recovery unit (PACU). Time stops when the practitioner releases the patient to the care of PACU personnel."
"C","837-Q1","P","3700","SV1","04","","","","","2","3700","846","","Note: When a decimal is needed to report units, include it in this element, for example, ""15.6""."
"C","837-Q1","P","3700","SV1","04","","","","","2","3700","847","","The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three."
"C","837-Q1","P","3700","SV1","04","","","","","2","3700","","F","Service Unit Count"
"C","837-Q1","P","3700","SV1","05","","","","","2","3700","848","D","Required when value is different than value carried in CLM05-1 in Loop ID-2300. If not required by this implementation guide, do not send."
"C","837-Q1","P","3700","SV1","05","","","","","2","3700","1574","","See CODE SOURCE 237: Place of Service Codes for Professional Claims"
"C","837-Q1","P","3700","SV1","05","","","","","2","3700","","F","Place of Service Code"
"D","837-Q1","P","3700","SV1","07","C004","01","","","2","3700","851","","This first pointer designates the primary diagnosis for this service line. Remaining diagnosis pointers indicate declining level of importance to service line. Acceptable values are 1 through 12, and correspond to Composite Data Elements 01 through 12 in the Health Care Diagnosis Code HI segment in the Claim Loop ID-2300."
"D","837-Q1","P","3700","SV1","07","C004","01","","","2","3700","","F","Diagnosis Code Pointer"
"D","837-Q1","P","3700","SV1","07","C004","02","","","2","3700","852","D","Required when it is necessary to point to a second diagnosis related to this service line. Acceptable values are the same as SV107-1. If not required by this implementation guide, do not send."
"D","837-Q1","P","3700","SV1","07","C004","02","","","2","3700","","F","Diagnosis Code Pointer"
"D","837-Q1","P","3700","SV1","07","C004","03","","","2","3700","853","D","Required when it is necessary to point to a third diagnosis related to this service line. Acceptable values are the same as SV107-1. If not required by this implementation guide, do not send."
"D","837-Q1","P","3700","SV1","07","C004","03","","","2","3700","","F","Diagnosis Code Pointer"
"D","837-Q1","P","3700","SV1","07","C004","04","","","2","3700","854","D","Required when it is necessary to point to a fourth diagnosis related to this service line. Acceptable values are the same as SV107-1. If not required by this implementation guide, do not send."
"D","837-Q1","P","3700","SV1","07","C004","04","","","2","3700","","F","Diagnosis Code Pointer"
"C","837-Q1","P","3700","SV1","09","","","","","2","3700","855","","For this implementation, the listed value takes precedence over the semantic note.<R>
Emergency definition: The patient requires immediate medical intervention as a result of severe, life threatening, or potentially disabling conditions."
"C","837-Q1","P","3700","SV1","09","","","","","2","3700","856","D","Required when the service is known to be an emergency by the provider. If not required by this implementation guide, do not send."
"C","837-Q1","P","3700","SV1","09","","","","","2","3700","","F","Emergency Indicator"
"C","837-Q1","P","3700","SV1","11","","","","","2","3700","857","D","Required when Medicaid services are the result of a screening referral.<R>If not required by this implementation guide, do not send."
"C","837-Q1","P","3700","SV1","11","","","","","2","3700","858","","For this implementation, the listed value takes precedence over the semantic note."
"C","837-Q1","P","3700","SV1","11","","","","","2","3700","1530","","When this element is used, this service is not the screening service."
"C","837-Q1","P","3700","SV1","11","","","","","2","3700","","F","EPSDT Indicator"
"C","837-Q1","P","3700","SV1","12","","","","","2","3700","859","D","Required when applicable for Medicaid claims. If not required by this implementation guide, do not send."
"C","837-Q1","P","3700","SV1","12","","","","","2","3700","858","","For this implementation, the listed value takes precedence over the semantic note."
"C","837-Q1","P","3700","SV1","12","","","","","2","3700","","F","Family Planning Indicator"
"C","837-Q1","P","3700","SV1","15","","","","","2","3700","860","D","Required when patient is exempt from co-pay. If not required by this implementation guide, do not send."
"C","837-Q1","P","3700","SV1","15","","","","","2","3700","","F","Co-Pay Status Code"
"B","837-Q1","P","4000","","","","","","","2","4000","861","E","SV5*HC:A4631*DA*30*50*5000*4~"
"B","837-Q1","P","4000","","","","","","","2","4000","862","","Required when necessary to report both the rental and purchase price information for durable medical equipment. This is not used for claims where the provider is reporting only the rental price or only the purchase price. If not required by this implementation guide, do not send."
"B","837-Q1","P","4000","","","","","","","2","4000","","A","Durable Medical Equipment Service"
"D","837-Q1","P","4000","SV5","01","C003","01","","","2","4000","","F","Procedure Identifier"
"E","837-Q1","P","4000","SV5","01","C003","01","235","HC","2","4000","351","","Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC."
"D","837-Q1","P","4000","SV5","01","C003","02","","","2","4000","863","","This value must be the same as that reported in SV101-2."
"D","837-Q1","P","4000","SV5","01","C003","02","","","2","4000","","F","Procedure Code"
"C","837-Q1","P","4000","SV5","02","","","","","2","4000","","F","Unit or Basis for Measurement Code"
"C","837-Q1","P","4000","SV5","03","","","","","2","4000","","F","Length of Medical Necessity"
"C","837-Q1","P","4000","SV5","04","","","","","2","4000","","F","DME Rental Price"
"C","837-Q1","P","4000","SV5","05","","","","","2","4000","","F","DME Purchase Price"
"C","837-Q1","P","4000","SV5","06","","","","","2","4000","","F","Rental Unit Price Indicator"
"B","837-Q1","P","4200","","","","","","","2","4200","176","","Required when there is a paper attachment following this claim.<R>OR<R>Required when attachments are sent electronically (PWK02 = EL) but are transmitted in another functional group (for example, 275) rather than by paper. PWK06 is then used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment.<R>OR<R>Required when the provider deems it necessary to identify additional information that is being held at the provider's office and is available upon request by the payer (or appropriate entity), but the information is not being submitted with the claim. Use the value of ""AA"" in PWK02 to convey this specific use of the PWK segment.<R>If not required by this implementation guide, do not send."
"B","837-Q1","P","4200","","","","","","","2","4200","177","E","PWK*OZ*BM***AC*DMN0012~"
"B","837-Q1","P","4200","","","","","","","2","4200","1587","A","Line Supplemental Information"
"C","837-Q1","P","4200","PWK","01","","","","","2","4200","","F","Attachment Report Type Code"
"C","837-Q1","P","4200","PWK","02","","","","","2","4200","1523","","Required when the actual attachment is maintained by an attachment warehouse or similar vendor."
"C","837-Q1","P","4200","PWK","02","","","","","2","4200","","F","Attachment Transmission Code"
"E","837-Q1","P","4200","PWK","02","","","756","AA","2","4200","179","","This means that the additional information is not being sent with the claim at this time. Instead, it is available to the payer (or appropriate entity) at their request."
"E","837-Q1","P","4200","PWK","02","","","756","EL","2","4200","180","","Indicates that the attachment is being transmitted in a separate X12 functional group."
"C","837-Q1","P","4200","PWK","05","","","","","2","4200","181","D","Required when PWK02 = ""BM"", ""EL"", ""EM"", ""FX"" or ""FT"". If not required by this implementation guide, do not send."
"C","837-Q1","P","4200","PWK","05","","","","","2","4200","","F","Identification Code Qualifier"
"C","837-Q1","P","4200","PWK","06","","","","","2","4200","181","D","Required when PWK02 = ""BM"", ""EL"", ""EM"", ""FX"" or ""FT"". If not required by this implementation guide, do not send."
"C","837-Q1","P","4200","PWK","06","","","","","2","4200","1494","","PWK06 is used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment."
"C","837-Q1","P","4200","PWK","06","","","","","2","4200","1495","","For the purpose of this implementation, the maximum field length is 50."
"C","837-Q1","P","4200","PWK","06","","","","","2","4200","","F","Attachment Control Number"
"B","837-Q1","P","4220","","","","","","","2","4200","864","E","PWK*CT*AB~"
"B","837-Q1","P","4220","","","","","","","2","4200","865","","Required on claims that include a Durable Medical Equipment Regional Carrier (DMERC) Certificate of Medical Necessity (CMN). If not required by this implementation guide, do not send.;"
"B","837-Q1","P","4220","","","","","","","2","4200","866","A","Durable Medical Equipment Certificate of Medical Necessity Indicator"
"C","837-Q1","P","4220","PWK","01","","","","","2","4200","","F","Attachment Report Type Code"
"C","837-Q1","P","4220","PWK","02","","","","","2","4200","867","B","Attachment Transmission Code"
"C","837-Q1","P","4220","PWK","02","","","","","2","4200","1523","","Required when the actual attachment is maintained by an attachment warehouse or similar vendor."
"C","837-Q1","P","4220","PWK","02","","","","","2","4200","","F","Attachment Transmission Code"
"E","837-Q1","P","4220","PWK","02","","","756","NS","2","4200","868","","NS = Paperwork is available on request at the provider's site. This means that the paperwork is not being sent with the claim at this time. Instead, it is available to the payer (or appropriate entity) at their request."
"B","837-Q1","P","4250","","","","","","","2","4250","613","E","CR1*LB*140**A*DH*12****UNCONSCIOUS~"
"B","837-Q1","P","4250","","","","","","","2","4250","615","A","Ambulance Transport Information"
"B","837-Q1","P","4250","","","","","","","2","4250","869","","Required on ambulance transport services when the information applicable to any one of the segment's elements is different than the information reported in the CR1 at the claim level (Loop ID-2300). If not required by this implementation guide, do not send."
"C","837-Q1","P","4250","CR1","01","","","","","2","4250","870","D","Required when CR102 is used. If not required by this implementation guide, do not send."
"C","837-Q1","P","4250","CR1","01","","","","","2","4250","","F","Unit or Basis for Measurement Code"
"C","837-Q1","P","4250","CR1","02","","","","","2","4250","617","D","Required when it is necessary to justify the medical necessity of the level of ambulance services. If not required by this implementation guide, do not send."
"C","837-Q1","P","4250","CR1","02","","","","","2","4250","","F","Patient Weight"
"C","837-Q1","P","4250","CR1","04","","","","","2","4250","","F","Ambulance Transport Reason Code"
"C","837-Q1","P","4250","CR1","05","","","","","2","4250","","F","Unit or Basis for Measurement Code"
"C","837-Q1","P","4250","CR1","06","","","","","2","4250","619","","0 (zero) is a valid value when ambulance services do not include a charge for mileage."
"C","837-Q1","P","4250","CR1","06","","","","","2","4250","","F","Transport Distance"
"C","837-Q1","P","4250","CR1","09","","","","","2","4250","871","D","Required when the ambulance service is for a round trip. If not required by this implementation guide, do not send."
"C","837-Q1","P","4250","CR1","09","","","","","2","4250","","F","Round Trip Purpose Description"
"C","837-Q1","P","4250","CR1","10","","","","","2","4250","621","D","Required when needed to justify usage of stretcher. If not required by this implementation guide, do not send."
"C","837-Q1","P","4250","CR1","10","","","","","2","4250","","F","Stretcher Purpose Description"
"B","837-Q1","P","4350","","","","","","","2","4350","873","A","Durable Medical Equipment Certification"
"B","837-Q1","P","4350","","","","","","","2","4350","874","E","CR3*I*MO*6~"
"B","837-Q1","P","4350","","","","","","","2","4350","875","","Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN) or a DMERC Information Form (DIF) or Oxygen Therapy Certification is included on this service line.<R>If not required by this implementation guide, do not send."
"C","837-Q1","P","4350","CR3","01","","","","","2","4350","","F","Certification Type Code"
"C","837-Q1","P","4350","CR3","02","","","","","2","4350","","F","Unit or Basis for Measurement Code"
"C","837-Q1","P","4350","CR3","03","","","","","2","4350","876","","Length of time DME equipment is needed."
"C","837-Q1","P","4350","CR3","03","","","","","2","4350","","F","Durable Medical Equipment Duration"
"B","837-Q1","P","4500","","","","","","","2","4500","629","A","Ambulance Certification"
"B","837-Q1","P","4500","","","","","","","2","4500","627","E","CRC*07*Y*01~"
"B","837-Q1","P","4500","","","","","","","2","4500","886","","The maximum number of CRC segments which can occur per Loop ID-2400 is 3. Submitters are free to mix and match the three types of service line level CRC segments shown in this implementation guide to meet their billing or reporting needs but no more than a total of 3 CRC segments per Loop ID-2400 are allowed."
"B","837-Q1","P","4500","","","","","","","2","4500","887","","Required on ambulance transport services when the information applicable to any one of the segment's elements is different than the information reported in the Ambulance Certification CRC at the claim level (Loop ID-2300). If not required by this implementation guide, do not send."
"C","837-Q1","P","4500","CRC","01","","","","","2","4500","","F","Code Category"
"C","837-Q1","P","4500","CRC","02","","","","","2","4500","","F","Certification Condition Indicator"
"C","837-Q1","P","4500","CRC","03","","","","","2","4500","632","","The codes for CRC03 also can be used for CRC04 through CRC07."
"C","837-Q1","P","4500","CRC","03","","","","","2","4500","","F","Condition Code"
"E","837-Q1","P","4500","CRC","03","","","1321","12","2","4500","633","","Use code 12 to indicate patient was bedridden during transport."
"C","837-Q1","P","4500","CRC","04","","","","","2","4500","634","D","Required when a second condition code is necessary. If not required by this implementation guide, do not send."
"C","837-Q1","P","4500","CRC","04","","","","","2","4500","635","","Use the codes listed in CRC03."
"C","837-Q1","P","4500","CRC","04","","","","","2","4500","","F","Condition Code"
"C","837-Q1","P","4500","CRC","05","","","","","2","4500","636","D","Required when a third condition code is necessary. If not required by this implementation guide, do not send."
"C","837-Q1","P","4500","CRC","05","","","","","2","4500","635","","Use the codes listed in CRC03."
"C","837-Q1","P","4500","CRC","05","","","","","2","4500","","F","Condition Code"
"C","837-Q1","P","4500","CRC","06","","","","","2","4500","637","D","Required when a fourth condition code is necessary. If not required by this implementation guide, do not send."
"C","837-Q1","P","4500","CRC","06","","","","","2","4500","635","","Use the codes listed in CRC03."
"C","837-Q1","P","4500","CRC","06","","","","","2","4500","","F","Condition Code"
"C","837-Q1","P","4500","CRC","07","","","","","2","4500","638","D","Required when a fifth condition code is necessary. If not required by this implementation guide, do not send."
"C","837-Q1","P","4500","CRC","07","","","","","2","4500","635","","Use the codes listed in CRC03."
"C","837-Q1","P","4500","CRC","07","","","","","2","4500","","F","Condition Code"
"B","837-Q1","P","4520","","","","","","","2","4500","889","E","CRC*70*Y*65~"
"B","837-Q1","P","4520","","","","","","","2","4500","890","A","Hospice Employee Indicator"
"B","837-Q1","P","4520","","","","","","","2","4500","891","","Required on all Medicare claims involving physician services to hospice patients. If not required by this implementation guide, do not send."
"B","837-Q1","P","4520","","","","","","","2","4500","886","","The maximum number of CRC segments which can occur per Loop ID-2400 is 3. Submitters are free to mix and match the three types of service line level CRC segments shown in this implementation guide to meet their billing or reporting needs but no more than a total of 3 CRC segments per Loop ID-2400 are allowed."
"B","837-Q1","P","4520","","","","","","","2","4500","892","","The example shows the method used to indicate whether the rendering provider is an employee of the hospice."
"C","837-Q1","P","4520","CRC","01","","","","","2","4500","","F","Code Category"
"C","837-Q1","P","4520","CRC","02","","","","","2","4500","893","","A ""Y"" value indicates the provider is employed by the hospice. A ""N"" value indicates the provider is not employed by the hospice."
"C","837-Q1","P","4520","CRC","02","","","","","2","4500","","F","Hospice Employed Provider Indicator"
"C","837-Q1","P","4520","CRC","03","","","","","2","4500","","F","Condition Indicator"
"E","837-Q1","P","4520","CRC","03","","","1321","65","2","4500","894","","This code value is a placeholder to satisfy the Mandatory Data Element syntax requirement."
"B","837-Q1","P","4530","","","","","","","2","4500","895","E","CRC*09*N*ZV~"
"B","837-Q1","P","4530","","","","","","","2","4500","896","E","CRC*09*Y*38~"
"B","837-Q1","P","4530","","","","","","","2","4500","897","A","Condition Indicator/Durable Medical Equipment"
"B","837-Q1","P","4530","","","","","","","2","4500","898","","Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN) or a DMERC Information Form (DIF), or Oxygen Therapy Certification is included on this service line and the information is necessary for adjudication.<R>If not required by this implementation guide, do not send."
"B","837-Q1","P","4530","","","","","","","2","4500","886","","The maximum number of CRC segments which can occur per Loop ID-2400 is 3. Submitters are free to mix and match the three types of service line level CRC segments shown in this implementation guide to meet their billing or reporting needs but no more than a total of 3 CRC segments per Loop ID-2400 are allowed."
"B","837-Q1","P","4530","","","","","","","2","4500","899","","The first example shows a case where an item billed was not a replacement item."
"C","837-Q1","P","4530","CRC","01","","","","","2","4500","","F","Code Category"
"C","837-Q1","P","4530","CRC","02","","","","","2","4500","","F","Certification Condition Indicator"
"C","837-Q1","P","4530","CRC","03","","","","","2","4500","","F","Condition Indicator"
"C","837-Q1","P","4530","CRC","04","","","","","2","4500","634","D","Required when a second condition code is necessary. If not required by this implementation guide, do not send."
"C","837-Q1","P","4530","CRC","04","","","","","2","4500","635","","Use the codes listed in CRC03."
"C","837-Q1","P","4530","CRC","04","","","","","2","4500","","F","Condition Indicator"
"B","837-Q1","P","4550","","","","","","","2","4550","904","E","DTP*472*RD8*20050314-20050325~"
"B","837-Q1","P","4550","","","","","","","2","4550","905","A","Date - Service Date"
"B","837-Q1","P","4550","","","","","","","2","4550","365","","In cases where a drug is being billed on a service line, date range may be used to indicate drug duration for which the drug supply will be used by the patient. The difference in dates, including both the begin and end dates, are the days supply of the drug. Example: 20000101 - 20000107 (1/1/00 to 1/7/00) is used for a 7 day supply where the first day of the drug used by the patient is 1/1/00. In the event a drug is administered on less than a daily basis (for example, every other day) the date range would include the entire period during which the drug was supplied, including the last day the drug was used. Example: 20000101 - 20000108 (1/1/00 to 1/8/00) is used for an 8 days supply where the prescription is written for Q48 (every 48 hours), four doses of the drug are dispensed and the first dose is used on 1/1/00."
"C","837-Q1","P","4550","DTP","01","","","","","2","4550","","F","Date Time Qualifier"
"C","837-Q1","P","4550","DTP","02","","","","","2","4550","367","","RD8 is required only when the ""To and From"" dates are different. However, at the discretion of the submitter, RD8 can also be used when the ""To and From"" dates are the same."
"C","837-Q1","P","4550","DTP","02","","","","","2","4550","","F","Date Time Period Format Qualifier"
"C","837-Q1","P","4550","DTP","03","","","","","2","4550","","F","Service Date"
"B","837-Q1","P","4555","","","","","","","2","4550","518","E","DTP*471*D8*20050108~"
"B","837-Q1","P","4555","","","","","","","2","4550","907","","Required when a drug is billed for this line and a prescription was written (or otherwise communicated by the prescriber if not written). If not required by this implementation guide, do not send."
"B","837-Q1","P","4555","","","","","","","2","4550","908","A","Date - Prescription Date"
"C","837-Q1","P","4555","DTP","01","","","","","2","4550","","F","Date Time Qualifier"
"C","837-Q1","P","4555","DTP","02","","","","","2","4550","","F","Date Time Period Format Qualifier"
"C","837-Q1","P","4555","DTP","03","","","","","2","4550","","F","Prescription Date"
"B","837-Q1","P","4560","","","","","","","2","4550","909","E","DTP*607*D8*20050112~"
"B","837-Q1","P","4560","","","","","","","2","4550","910","A","DATE - Certification Revision/Recertification Date"
"B","837-Q1","P","4560","","","","","","","2","4550","911","","Required when CR301 (DMERC Certification) = ""R"" or ""S"". If not required by this implementation guide, do not send."
"C","837-Q1","P","4560","DTP","01","","","","","2","4550","","F","Date Time Qualifier"
"C","837-Q1","P","4560","DTP","02","","","","","2","4550","","F","Date Time Period Format Qualifier"
"C","837-Q1","P","4560","DTP","03","","","","","2","4550","","F","Certification Revision or Recertification Date"
"B","837-Q1","P","4580","","","","","","","2","4550","912","A","Date - Begin Therapy Date"
"B","837-Q1","P","4580","","","","","","","2","4550","913","E","DTP*463*D8*20050112~"
"B","837-Q1","P","4580","","","","","","","2","4550","914","","Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN) or DMERC Information Form (DIF), or Oxygen Therapy Certification is included on this service line. If not required by this implementation guide, do not send."
"C","837-Q1","P","4580","DTP","01","","","","","2","4550","","F","Date Time Qualifier"
"C","837-Q1","P","4580","DTP","02","","","","","2","4550","","F","Date Time Period Format Qualifier"
"C","837-Q1","P","4580","DTP","03","","","","","2","4550","","F","Begin Therapy Date"
"B","837-Q1","P","4590","","","","","","","2","4550","915","A","Date - Last Certification Date"
"B","837-Q1","P","4590","","","","","","","2","4550","916","E","DTP*461*D8*20050112~"
"B","837-Q1","P","4590","","","","","","","2","4550","917","","Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN), DMERC Information Form (DIF), or Oxygen Therapy Certification is included on this service line. If not required by this implementation guide, do not send."
"B","837-Q1","P","4590","","","","","","","2","4550","918","","This is the date the ordering physician signed the CMN or Oxygen Therapy Certification, or the date the supplier signed the DMERC Information Form (DIF)."
"C","837-Q1","P","4590","DTP","01","","","","","2","4550","","F","Date Time Qualifier"
"C","837-Q1","P","4590","DTP","02","","","","","2","4550","","F","Date Time Period Format Qualifier"
"C","837-Q1","P","4590","DTP","03","","","","","2","4550","","F","Last Certification Date"
"B","837-Q1","P","45B0","","","","","","","2","4550","502","E","DTP*304*D8*20050108~"
"B","837-Q1","P","45B0","","","","","","","2","4550","503","A","Date - Last Seen Date"
"B","837-Q1","P","45B0","","","","","","","2","4550","919","","Required when a claim involves physician services for routine foot care; and is different than the date listed at the claim  level and is known to impact the payer's adjudication process. If not required by this implementation guide, do not send.;"
"C","837-Q1","P","45B0","DTP","01","","","","","2","4550","","F","Date Time Qualifier"
"C","837-Q1","P","45B0","DTP","02","","","","","2","4550","","F","Date Time Period Format Qualifier"
"C","837-Q1","P","45B0","DTP","03","","","","","2","4550","","F","Treatment or Therapy Date"
"B","837-Q1","P","45C0","","","","","","","2","4550","920","A","Date - Test Date"
"B","837-Q1","P","45C0","","","","","","","2","4550","921","E","DTP*738*D8*20050112~"
"B","837-Q1","P","45C0","","","","","","","2","4550","922","","Required on initial EPO claims service lines for dialysis patients when test results are being billed or reported. If not required by this implementation guide, do not send."
"C","837-Q1","P","45C0","DTP","01","","","","","2","4550","","F","Date Time Qualifier"
"C","837-Q1","P","45C0","DTP","02","","","","","2","4550","","F","Date Time Period Format Qualifier"
"C","837-Q1","P","45C0","DTP","03","","","","","2","4550","","F","Test Performed Date"
"B","837-Q1","P","45E0","","","","","","","2","4550","928","E","DTP*011*D8*20050112~"
"B","837-Q1","P","45E0","","","","","","","2","4550","929","A","Date - Shipped Date"
"B","837-Q1","P","45E0","","","","","","","2","4550","930","","Required when billing or reporting shipped products. If not required by this implementation guide, do not send."
"C","837-Q1","P","45E0","DTP","01","","","","","2","4550","","F","Date Time Qualifier"
"C","837-Q1","P","45E0","DTP","02","","","","","2","4550","","F","Date Time Period Format Qualifier"
"C","837-Q1","P","45E0","DTP","03","","","","","2","4550","","F","Shipped Date"
"B","837-Q1","P","45G0","","","","","","","2","4550","515","E","DTP*455*D8*20050108~"
"B","837-Q1","P","45G0","","","","","","","2","4550","517","A","Date - Last X-ray Date"
"B","837-Q1","P","45G0","","","","","","","2","4550","931","","Required when claim involves spinal manipulation and an x-ray was taken and is different than information at the claim level (Loop ID-2300). If not required by this implementation guide, do not send."
"C","837-Q1","P","45G0","DTP","01","","","","","2","4550","","F","Date Time Qualifier"
"C","837-Q1","P","45G0","DTP","02","","","","","2","4550","","F","Date Time Period Format Qualifier"
"C","837-Q1","P","45G0","DTP","03","","","","","2","4550","","F","Last X-Ray Date"
"B","837-Q1","P","45J0","","","","","","","2","4550","498","E","DTP*454*D8*20050108~"
"B","837-Q1","P","45J0","","","","","","","2","4550","499","A","Date - Initial Treatment Date"
"B","837-Q1","P","45J0","","","","","","","2","4550","1483","","Required when the Initial Treatment Date is known to impact adjudication for claims involving spinal manipulation, physcial therapy, occupational therapy, or speech language pathology and when different from what is reported at the claim level. If not required by this implementation guide, do not send."
"C","837-Q1","P","45J0","DTP","01","","","","","2","4550","","F","Date Time Qualifier"
"C","837-Q1","P","45J0","DTP","02","","","","","2","4550","","F","Date Time Period Format Qualifier"
"C","837-Q1","P","45J0","DTP","03","","","","","2","4550","","F","Initial Treatment Date"
"B","837-Q1","P","4600","","","","","","","2","4600","932","A","Ambulance Patient Count"
"B","837-Q1","P","4600","","","","","","","2","4600","933","E","QTY*PT*2~"
"B","837-Q1","P","4600","","","","","","","2","4600","934","","Required when more than one patient is transported in the same vehicle for Ambulance or non-emergency transportation services. If not required by this implementation guide, do not send."
"B","837-Q1","P","4600","","","","","","","2","4600","935","","The QTY02 is the only place to report the number of patients when there are multiple patients transported."
"C","837-Q1","P","4600","QTY","01","","","","","2","4600","","F","Quantity Qualifier"
"C","837-Q1","P","4600","QTY","02","","","","","2","4600","","F","Ambulance Patient Count"
"B","837-Q1","P","4610","","","","","","","2","4600","1582","A","Obstetric Anesthesia Additional Units"
"B","837-Q1","P","4610","","","","","","","2","4600","1583","E","QTY*FL*3~"
"B","837-Q1","P","4610","","","","","","","2","4600","1584","","Required in conjunction with anesthesia for obstetric services when the anesthesia provider chooses to report additional complexity beyond the normal services reflected by the procedure base units and anesthesia time.<R>If not required by this implementation guide, do not send."
"C","837-Q1","P","4610","QTY","01","","","","","2","4600","","F","Quantity Qualifier"
"C","837-Q1","P","4610","QTY","02","","","","","2","4600","1585","","The number of additional units reported by an anesthesia provider to reflect additional complexity of services."
"C","837-Q1","P","4610","QTY","02","","","","","2","4600","","F","Obstetric Additional Units"
"B","837-Q1","P","4620","","","","","","","2","4620","936","E","MEA*TR*R1*113.4~"
"B","837-Q1","P","4620","","","","","","","2","4620","937","A","Test Result"
"B","837-Q1","P","4620","","","","","","","2","4620","938","","Required on Dialysis related service lines for ESRD. Use R1, R2, R3, or R4 to qualify the Hemoglobin, Hematocrit, Epoetin Starting Dosage, and Creatinine test results. <R>OR<R> Required on DMERC service lines to report the Patient's Height from the Certificate of Medical Necessity (CMN). Use HT qualifier.<R>If not required by this implementation guide, do not send."
"C","837-Q1","P","4620","MEA","01","","","","","2","4620","","F","Measurement Reference Identification Code"
"E","837-Q1","P","4620","MEA","01","","","737","OG","2","4620","939","","Use OG to report Starting Dosage."
"C","837-Q1","P","4620","MEA","02","","","","","2","4620","","F","Measurement Qualifier"
"C","837-Q1","P","4620","MEA","03","","","","","2","4620","940","B","Test Results"
"C","837-Q1","P","4620","MEA","03","","","","","2","4620","","F","Test Results"
"B","837-Q1","P","4650","","","","","","","2","4650","549","E","CN1*02*550~"
"B","837-Q1","P","4650","","","","","","","2","4650","550","A","Contract Information"
"B","837-Q1","P","4650","","","","","","","2","4650","551","","The developers of this implementation guide note that the CN1 segment is for use only for post-adjudicated claims, which do not meet the definition of a health care claim under HIPAA. Consequently, at the time of this writing, the CN1 segment is for non-HIPAA use only."
"B","837-Q1","P","4650","","","","","","","2","4650","552","","Required when the submitter is contractually obligated to supply this information on post-adjudicated claims. If not required by this implementation guide, do not send."
"C","837-Q1","P","4650","CN1","01","","","","","2","4650","","F","Contract Type Code"
"C","837-Q1","P","4650","CN1","02","","","","","2","4650","941","D","Required when information is different than that given at claim level (Loop ID-2300). If not required by this implementation guide, do not send."
"C","837-Q1","P","4650","CN1","02","","","","","2","4650","","F","Contract Amount"
"C","837-Q1","P","4650","CN1","03","","","","","2","4650","941","D","Required when information is different than that given at claim level (Loop ID-2300). If not required by this implementation guide, do not send."
"C","837-Q1","P","4650","CN1","03","","","","","2","4650","","F","Contract Percentage"
"C","837-Q1","P","4650","CN1","04","","","","","2","4650","941","D","Required when information is different than that given at claim level (Loop ID-2300). If not required by this implementation guide, do not send."
"C","837-Q1","P","4650","CN1","04","","","","","2","4650","","F","Contract Code"
"C","837-Q1","P","4650","CN1","05","","","","","2","4650","941","D","Required when information is different than that given at claim level (Loop ID-2300). If not required by this implementation guide, do not send."
"C","837-Q1","P","4650","CN1","05","","","","","2","4650","","F","Terms Discount Percentage"
"C","837-Q1","P","4650","CN1","06","","","","","2","4650","941","D","Required when information is different than that given at claim level (Loop ID-2300). If not required by this implementation guide, do not send."
"C","837-Q1","P","4650","CN1","06","","","","","2","4650","","F","Contract Version Identifier"
"B","837-Q1","P","4700","","","","","","","2","4700","942","E","REF*9B*444444~"
"B","837-Q1","P","4700","","","","","","","2","4700","943","A","Repriced Line Item Reference Number"
"B","837-Q1","P","4700","","","","","","","2","4700","944","","Required when a repricing (pricing) organization needs to have an identifying number on the service line in their submission to their payer organization. This segment is not completed by providers. If not required by this implementation guide, do not send."
"C","837-Q1","P","4700","REF","01","","","","","2","4700","","F","Reference Identification Qualifier"
"C","837-Q1","P","4700","REF","02","","","","","2","4700","","F","Repriced Line Item Reference Number"
"B","837-Q1","P","4710","","","","","","","2","4700","945","E","REF*9D*444444~"
"B","837-Q1","P","4710","","","","","","","2","4700","946","A","Adjusted Repriced Line Item Reference Number"
"B","837-Q1","P","4710","","","","","","","2","4700","947","","Required when a repricing (pricing) organization needs to have an identifying number on an adjusted service line in their submission to their payer organization. This segment is not completed by providers. If not required by this implementation guide, do not send."
"C","837-Q1","P","4710","REF","01","","","","","2","4700","","F","Reference Identification Qualifier"
"C","837-Q1","P","4710","REF","02","","","","","2","4700","","F","Adjusted Repriced Line Item Reference Number"
"B","837-Q1","P","4730","","","","","","","2","4700","575","A","Prior Authorization"
"B","837-Q1","P","4730","","","","","","","2","4700","949","","Required when service line involved a prior authorization number that is different than the number reported at the claim level (Loop ID-2300).<R>If not required by this implementation guide, do not send."
"B","837-Q1","P","4730","","","","","","","2","4700","574","E","REF*G1*13579~"
"B","837-Q1","P","4730","","","","","","","2","4700","1567","","When it is necessary to report one or more non-destination payer Prior Authorization Numbers, the composite data element in REF04 is used to identify the payer which assigned this number."
"C","837-Q1","P","4730","REF","01","","","","","2","4700","","F","Reference Identification Qualifier"
"C","837-Q1","P","4730","REF","02","","","","","2","4700","","F","Prior Authorization or Referral Number"
"C","837-Q1","P","4730","REF","04","","","","","2","4700","1568","D","Required when the Prior Authorization Number reported in REF02 of this segment is for a non-destination payer."
"D","837-Q1","P","4730","REF","04","C040","01","","","2","4700","","F","Reference Identification Qualifier"
"D","837-Q1","P","4730","REF","04","C040","02","","","2","4700","1569","","The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109."
"D","837-Q1","P","4730","REF","04","C040","02","","","2","4700","","F","Other Payer Primary Identifier"
"B","837-Q1","P","47A0","","","","","","","2","4700","950","E","REF*6R*54321~"
"B","837-Q1","P","47A0","","","","","","","2","4700","951","A","Line Item Control Number"
"B","837-Q1","P","47A0","","","","","","","2","4700","952","","Required when the submitter needs a line item control number for subsequent communications to or from the payer. If not required by this implementation guide, do not send."
"B","837-Q1","P","47A0","","","","","","","2","4700","953","","The line item control number must be unique within a patient control number (CLM01). Payers are required to return this number in the remittance advice transaction (835) if the provider sends it to them in the 837 and adjudication is based upon line item detail regardless of whether bundling or unbundling has occurred."
"B","837-Q1","P","47A0","","","","","","","2","4700","954","","Submitters are STRONGLY encouraged to routinely send a unique line item control number on all service lines, particularly if the submitter automatically posts their remittance advice. Submitting a unique line item control number allows the capability to automatically post by service line."
"C","837-Q1","P","47A0","REF","01","","","","","2","4700","","F","Reference Identification Qualifier"
"C","837-Q1","P","47A0","REF","02","","","","","2","4700","955","","The maximum number of characters to be supported for this field is `30'. A submitter may submit fewer characters depending upon their needs. However, the HIPAA maximum requirement to be supported by any receiving system is `30'. Characters beyond 30 are not required to be stored nor returned by any 837-receiving system."
"C","837-Q1","P","47A0","REF","02","","","","","2","4700","","F","Line Item Control Number"
"B","837-Q1","P","47B0","","","","","","","2","4700","571","E","REF*EW*T554~"
"B","837-Q1","P","47B0","","","","","","","2","4700","572","A","Mammography Certification Number"
"B","837-Q1","P","47B0","","","","","","","2","4700","956","","Required when mammography services are rendered by a certified mammography provider and the mammography certification number is different than that sent in Loop ID-2300. If not required by this implementation guide, do not send."
"C","837-Q1","P","47B0","REF","01","","","","","2","4700","","F","Reference Identification Qualifier"
"C","837-Q1","P","47B0","REF","02","","","","","2","4700","","F","Mammography Certification Number"
"B","837-Q1","P","47C0","","","","","","","2","4700","583","E","REF*X4*12D4567890~"
"B","837-Q1","P","47C0","","","","","","","2","4700","586","A","Clinical Laboratory Improvement Amendment (CLIA) Number"
"B","837-Q1","P","47C0","","","","","","","2","4700","957","","Required for all CLIA certified facilities performing CLIA covered laboratory services and the number is different than the CLIA number reported at the claim level (Loop ID-2300). If not required by this implementation guide, do not send.;"
"C","837-Q1","P","47C0","REF","01","","","","","2","4700","","F","Reference Identification Qualifier"
"C","837-Q1","P","47C0","REF","02","","","","","2","4700","","F","Clinical Laboratory Improvement Amendment Number"
"B","837-Q1","P","47D0","","","","","","","2","4700","958","A","Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification"
"B","837-Q1","P","47D0","","","","","","","2","4700","959","E","REF*F4*34D1234567~"
"B","837-Q1","P","47D0","","","","","","","2","4700","960","","Required for claims for any laboratory that referred tests to another laboratory covered by the CLIA Act that is billed on this line. If not required by this implementation guide, do not send."
"C","837-Q1","P","47D0","REF","01","","","","","2","4700","","F","Reference Identification Qualifier"
"C","837-Q1","P","47D0","REF","02","","","","","2","4700","","F","Referring CLIA Number"
"B","837-Q1","P","47F0","","","","","","","2","4700","961","A","Immunization Batch Number"
"B","837-Q1","P","47F0","","","","","","","2","4700","962","E","REF*BT*DTP22333444~"
"B","837-Q1","P","47F0","","","","","","","2","4700","963","","Required when mandated by state or federal law or regulations to report an Immunization Batch Number. If not required by this implementation guide, do not send."
"C","837-Q1","P","47F0","REF","01","","","","","2","4700","","F","Reference Identification Qualifier"
"C","837-Q1","P","47F0","REF","02","","","","","2","4700","","F","Immunization Batch Number"
"B","837-Q1","P","47G0","","","","","","","2","4700","1496","A","Referral Number"
"B","837-Q1","P","47G0","","","","","","","2","4700","1571","","Required when this service line involved a referral number that is different than the number reported at the claim level (Loop-ID 2300).<R>If not required by this implementation guide, do not send."
"B","837-Q1","P","47G0","","","","","","","2","4700","1572","","When it is necessary to report one or more non-destination payer Referral Numbers, the composite data element in REF04 is used to identify the payer which assigned this referral number."
"B","837-Q1","P","47G0","","","","","","","2","4700","948","E","REF*9F*12345~"
"C","837-Q1","P","47G0","REF","01","","","","","2","4700","","F","Reference Identification Qualifier"
"C","837-Q1","P","47G0","REF","02","","","","","2","4700","","F","Referral Number"
"C","837-Q1","P","47G0","REF","04","","","","","2","4700","1573","D","Required when the Referral Number reported in REF02 of this segment is for a non-destination payer."
"D","837-Q1","P","47G0","REF","04","C040","01","","","2","4700","","F","Reference Identification Qualifier"
"D","837-Q1","P","47G0","REF","04","C040","02","","","2","4700","1569","","The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109."
"D","837-Q1","P","47G0","REF","04","C040","02","","","2","4700","","F","Other Payer Primary Identifier"
"B","837-Q1","P","4810","","","","","","","2","4750","969","E","AMT*T*45~"
"B","837-Q1","P","4810","","","","","","","2","4750","970","A","Sales Tax Amount"
"B","837-Q1","P","4810","","","","","","","2","4750","971","","Required when sales tax applies to the service line and the submitter is required to report that information to the receiver. If not required by this implementation guide, do not send."
"B","837-Q1","P","4810","","","","","","","2","4750","972","","When reporting the Sales Tax Amount (AMT02), the amount reported in the Line Item Charge Amount (SV102) for this service line must include the amount reported in the Sales Tax Amount."
"C","837-Q1","P","4810","AMT","01","","","","","2","4750","","F","Amount Qualifier Code"
"C","837-Q1","P","4810","AMT","02","","","","","2","4750","","F","Sales Tax Amount"
"B","837-Q1","P","4830","","","","","","","2","4750","977","E","AMT*F4*56.78~"
"B","837-Q1","P","4830","","","","","","","2","4750","978","A","Postage Claimed Amount"
"B","837-Q1","P","4830","","","","","","","2","4750","979","","Required when service line charge (SV102) includes postage amount claimed in this service line. If not required by this implementation guide, do not send."
"B","837-Q1","P","4830","","","","","","","2","4750","980","","When reporting the Postage Claimed Amount (AMT02), the amount reported in the Line Item Charge Amount (SV102) for this service line must include the amount reported in the Postage Claimed Amount."
"C","837-Q1","P","4830","AMT","01","","","","","2","4750","","F","Amount Qualifier Code"
"C","837-Q1","P","4830","AMT","02","","","","","2","4750","","F","Postage Claimed Amount"
"B","837-Q1","P","4850","","","","","","","2","4800","609","A","File Information"
"B","837-Q1","P","4850","","","","","","","2","4800","199","E","K3*STATE DATA REQUIREMENT~"
"B","837-Q1","P","4850","","","","","","","2","4800","200","","Required when ALL of the following conditions are met:<R><195> A regulatory agency concludes it must use the K3 to meet an emergency<R><_>legislative requirement;<R><195> The administering regulatory agency or other state organization has<R><_>completed each one of the following steps:<R><_><_>contacted the X12N workgroup, <R><_><_>requested a review of the K3 data requirement to ensure there is not<R><_><_><_>an existing method within the implementation guide to meet this<R><_><_><_>requirement<R><195> X12N determines that there is no method to meet the requirement.<R>If not required by this implementation guide, do not send."
"B","837-Q1","P","4850","","","","","","","2","4800","201","","At the time of publication of this implementation, K3 segments have no specific use. The K3 segment is expected to be used only when necessary to meet the unexpected data requirement of a legislative authority. Before this segment can be used : <R>- The X12N Health Care Claim workgroup must conclude there is no other available option in the implementation guide to meet the emergency legislative requirement.<R>- The requestor must submit a proposal for approval accompanied by the relevant business documentation to the X12N Health Care Claim workgroup chairs and receive approval for the request.<R>Upon review of the request, X12N will issue an approval or denial decision to the requesting entity. Approved usage(s) of the K3 segment will be reviewed by the X12N Health Care Claim workgroup to develop a permanent change to include the business case in future transaction implementations."
"B","837-Q1","P","4850","","","","","","","2","4800","202","","Only when all of the requirements above have been met, may the regulatory agency require the temporary use of the K3 segment."
"B","837-Q1","P","4850","","","","","","","2","4800","203","","X12N will submit the necessary data maintenance and refer the request to the appropriate data content committee(s)."
"C","837-Q1","P","4850","K3","01","","","","","2","4800","","F","Fixed Format Information"
"B","837-Q1","P","4860","","","","","","","2","4850","981","E","NTE*DCP*PATIENT GOAL TO BE OFF OXYGEN BY END OF MONTH~"
"B","837-Q1","P","4860","","","","","","","2","4850","982","A","Line Note"
"B","837-Q1","P","4860","","","","","","","2","4850","611","","Required when in the judgment of the provider, the information is needed to substantiate the medical treatment and is not supported elsewhere within the claim data set.<R>If not required by this implementation guide, do not send."
"B","837-Q1","P","4860","","","","","","","2","4850","1180","","Use SV101-7 to describe non-specific procedure codes. Do not use this NTE Segment to describe a non-specific procedure code. If an NDC code is reported in Loop 2410, do not use this segment for a description of the procedure code. The NDC in loop 2410 will provide the description."
"C","837-Q1","P","4860","NTE","01","","","","","2","4850","","F","Note Reference Code"
"C","837-Q1","P","4860","NTE","02","","","","","2","4850","","F","Line Note Text"
"B","837-Q1","P","4865","","","","","","","2","4850","983","A","Third Party Organization Notes"
"B","837-Q1","P","4865","","","","","","","2","4850","984","","Required when the TPO/repricer needs to forward additional information to the payer. This segment is not completed by providers. If not required by this implementation guide, do not send."
"B","837-Q1","P","4865","","","","","","","2","4850","985","E","NTE*TPO*STATE REGULATION 123 WAS APPLIED DURING THE PRICING OF THIS CLAIM~"
"C","837-Q1","P","4865","NTE","01","","","","","2","4850","","F","Note Reference Code"
"C","837-Q1","P","4865","NTE","02","","","","","2","4850","","F","Line Note Text"
"B","837-Q1","P","4880","","","","","","","2","4880","986","E","PS1*PN222222*110~"
"B","837-Q1","P","4880","","","","","","","2","4880","987","A","Purchased Service Information"
"B","837-Q1","P","4880","","","","","","","2","4880","988","","Required on non-vision service lines when adjudication is known to be impacted by the charge amount for services purchased from another source.<R>OR<R>Required on vision service lines when adjudication is known to be impacted by the acquisition cost of lenses.<R>If not required by this implementation guide, do not send."
"C","837-Q1","P","4880","PS1","01","","","","","2","4880","989","","This must be the identifier from the Purchased Service Provider Loop (Loop ID-2420B). When the Secondary Identifier REF is used, that is the identifier to be reported. If not present, use the identifier in NM109."
"C","837-Q1","P","4880","PS1","01","","","","","2","4880","","F","Purchased Service Provider Identifier"
"C","837-Q1","P","4880","PS1","02","","","","","2","4880","","F","Purchased Service Charge Amount"
"B","837-Q1","P","4920","","","","","","","2","4920","665","E","HCP*03*100*10*RPO12345~"
"B","837-Q1","P","4920","","","","","","","2","4920","990","A","Line Pricing/Repricing Information"
"B","837-Q1","P","4920","","","","","","","2","4920","582","","This information is specific to the destination payer reported in Loop ID-2010BB."
"B","837-Q1","P","4920","","","","","","","2","4920","667","","For capitated encounters, pricing or repricing information usually is not applicable and is provided to qualify other information within the claim."
"B","837-Q1","P","4920","","","","","","","2","4920","590","","Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send."
"C","837-Q1","P","4920","HCP","01","","","","","2","4920","668","","Specific code use is determined by Trading Partner Agreement due to the variances in contracting policies in the industry."
"C","837-Q1","P","4920","HCP","01","","","","","2","4920","","F","Pricing Methodology"
"C","837-Q1","P","4920","HCP","02","","","","","2","4920","","F","Repriced Allowed Amount"
"C","837-Q1","P","4920","HCP","03","","","","","2","4920","590","D","Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send."
"C","837-Q1","P","4920","HCP","03","","","","","2","4920","","F","Repriced Saving Amount"
"C","837-Q1","P","4920","HCP","04","","","","","2","4920","590","D","Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send."
"C","837-Q1","P","4920","HCP","04","","","","","2","4920","","F","Repricing Organization Identifier"
"C","837-Q1","P","4920","HCP","05","","","","","2","4920","590","D","Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send."
"C","837-Q1","P","4920","HCP","05","","","","","2","4920","","F","Repricing Per Diem or Flat Rate Amount"
"C","837-Q1","P","4920","HCP","06","","","","","2","4920","590","D","Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send."
"C","837-Q1","P","4920","HCP","06","","","","","2","4920","","F","Repriced Approved Ambulatory Patient Group Code"
"C","837-Q1","P","4920","HCP","07","","","","","2","4920","590","D","Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send."
"C","837-Q1","P","4920","HCP","07","","","","","2","4920","","F","Repriced Approved Ambulatory Patient Group Amount"
"C","837-Q1","P","4920","HCP","09","","","","","2","4920","590","D","Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send."
"C","837-Q1","P","4920","HCP","09","","","","","2","4920","","F","Product or Service ID Qualifier"
"E","837-Q1","P","4920","HCP","09","","","235","ER","2","4920","1529","","This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:<R>If a new rule names the Jurisdiction Specific Procedure and Supply Codes as an allowable code set under HIPAA, <R>OR<R>The Secretary grants an exception to use the code set as a pilot project as allowed under the law, <R>OR<R>For claims which are not covered under HIPAA."
"E","837-Q1","P","4920","HCP","09","","","235","HC","2","4920","351","","Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC."
"E","837-Q1","P","4920","HCP","09","","","235","IV","2","4920","352","","This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:<R> If a new rule names the Home Infusion EDI Coalition (HIEC) Product/Service Codes as an allowable code set under HIPAA, <R> OR<R> The Secretary grants an exception to use the code set as a pilot project as allowed under the law, <R> OR<R> For claims which are not covered under HIPAA.;"
"E","837-Q1","P","4920","HCP","09","","","235","WK","2","4920","353","","At the time of this writing, this code set has been approved by the Secretary of HHS as a pilot project allowed under HIPAA law. <R>The qualifier may only be used in transactions covered under HIPAA; <R>By parties registered in the pilot project and their trading partners, <R>OR<R>If a new rule names the Complementary, Alternative, or Holistic Procedure Codes as an allowable code set under HIPAA, <R>OR<R>For claims which are not covered under HIPAA."
"C","837-Q1","P","4920","HCP","10","","","","","2","4920","590","D","Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send."
"C","837-Q1","P","4920","HCP","10","","","","","2","4920","","F","Repriced Approved HCPCS Code"
"C","837-Q1","P","4920","HCP","11","","","","","2","4920","590","D","Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send."
"C","837-Q1","P","4920","HCP","11","","","","","2","4920","","F","Unit or Basis for Measurement Code"
"C","837-Q1","P","4920","HCP","12","","","","","2","4920","590","D","Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send."
"C","837-Q1","P","4920","HCP","12","","","","","2","4920","846","","Note: When a decimal is needed to report units, include it in this element, for example, ""15.6""."
"C","837-Q1","P","4920","HCP","12","","","","","2","4920","847","","The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three."
"C","837-Q1","P","4920","HCP","12","","","","","2","4920","","F","Repriced Approved Service Unit Count"
"C","837-Q1","P","4920","HCP","13","","","","","2","4920","590","D","Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send."
"C","837-Q1","P","4920","HCP","13","","","","","2","4920","","F","Reject Reason Code"
"C","837-Q1","P","4920","HCP","14","","","","","2","4920","590","D","Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send."
"C","837-Q1","P","4920","HCP","14","","","","","2","4920","","F","Policy Compliance Code"
"C","837-Q1","P","4920","HCP","15","","","","","2","4920","590","D","Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send."
"C","837-Q1","P","4920","HCP","15","","","","","2","4920","","F","Exception Code"
"B","837-Q1","P","4940","","","","","","","2","4930","992","A","Drug Identification"
"B","837-Q1","P","4940","","","","","","","2","4930","993","E","LIN**N4*01234567891~"
"B","837-Q1","P","4940","","","","","","","2","4930","994","","Required when government regulation mandates that prescribed drugs and biologics are reported with NDC numbers.<R>OR<R>Required when the provider or submitter chooses to report NDC numbers to enhance the claim reporting or adjudication processes.<R>OR<R>Required when an HHS approved pilot project specifies reporting of Universal Product Number (UPN) by parties registered in the pilot and their trading partners.<R>OR<R>Required when government regulation mandates that medical and surgical supplies are reported with UPN's.<R><R>If not required by this implementation guide, do not send."
"B","837-Q1","P","4940","","","","","","","2","4930","995","","Drugs and biologics reported in this segment are a further specification of service(s) described in the SV1 segment of this Service Line Loop ID-2400."
"C","837-Q1","P","4940","LIN","02","","","","","2","4930","301145","","At the time of this writing, UPN code sets designated by values EN, EO, HI, ON, UK, and UP have been approved by the Secretary of HHS as a pilot project allowed under HIPAA law. During the pilot, these code values may only be used by parties registered in the pilot project and their trading partners. Beyond the pilot, these codes may only be used if mandated by government regulation."
"C","837-Q1","P","4940","LIN","02","","","","","2","4930","","F","Product or Service ID Qualifier"
"C","837-Q1","P","4940","LIN","03","","","","","2","4930","","F","National Drug Code or Universal Product Number"
"B","837-Q1","P","4950","","","","","","","2","4940","996","A","Drug Quantity"
"B","837-Q1","P","4950","","","","","","","2","4940","997","E","CTP****2*UN~"
"C","837-Q1","P","4950","CTP","04","","","","","2","4940","","F","National Drug Unit Count"
"D","837-Q1","P","4950","CTP","05","C001","01","","","2","4940","998","B","Code qualifier"
"D","837-Q1","P","4950","CTP","05","C001","01","","","2","4940","","F","Code Qualifier"
"B","837-Q1","P","4960","","","","","","","2","4950","999","E","REF*XZ*123456~"
"B","837-Q1","P","4960","","","","","","","2","4950","1000","A","Prescription or Compound Drug Association Number"
"B","837-Q1","P","4960","","","","","","","2","4950","1001","","Required when dispensing of the drug has been done with an assigned prescription number.<R>OR<R>Required when the provided medication involves the compounding of two or more drugs being reported and there is no prescription number.<R>If not required by this implementation guide, do not send."
"B","837-Q1","P","4960","","","","","","","2","4950","1002","","In cases where a compound drug is being billed, the components of the compound will all have the same prescription number. Payers receiving the claim can relate all the components by matching the prescription number."
"B","837-Q1","P","4960","","","","","","","2","4950","1003","","For cases where the drug is provided without a prescription (for example, from a physician's office), the value provided in this segment is a ""link sequence number"". The link sequence number is a provider assigned number that is unique to this claim. Its purpose is to enable the receiver to piece together the components of the compound."
"C","837-Q1","P","4960","REF","01","","","","","2","4950","","F","Reference Identification Qualifier"
"C","837-Q1","P","4960","REF","02","","","","","2","4950","","F","Prescription Number"
"B","837-Q1","P","5000","","","","","","","2","5000","689","A","Rendering Provider Name"
"B","837-Q1","P","5000","","","","","","","2","5000","691","","Used for all types of rendering providers including laboratories. The Rendering Provider is the person or company (laboratory or other facility) who rendered the care. In the case where a substitute provider (locum tenens) was used, enter that provider's information here."
"B","837-Q1","P","5000","","","","","","","2","5000","692","E","NM1*82*1*DOE*JANE*C***XX*1234567804~"
"B","837-Q1","P","5000","","","","","","","2","5000","1005","","Required when the Rendering Provider NM1 information is different than that carried in the Loop ID-2310B Rendering Provider.<R>OR<R>Required  when Loop ID-2310B Rendering Provider is not used AND this particular line item has different Rendering Provider information than that which is carried in Loop ID-2010AA Billing Provider.<R>If not required by this implementation guide, do not send.;"
"C","837-Q1","P","5000","NM1","01","","","","","2","5000","","F","Entity Identifier Code"
"C","837-Q1","P","5000","NM1","02","","","","","2","5000","","F","Entity Type Qualifier"
"C","837-Q1","P","5000","NM1","03","","","","","2","5000","","F","Rendering Provider Last or Organization Name"
"C","837-Q1","P","5000","NM1","04","","","","","2","5000","17","D","Required when NM102 = 1 (person) and the person has a first name. If not required by this implementation guide, do not send."
"C","837-Q1","P","5000","NM1","04","","","","","2","5000","","F","Rendering Provider First Name"
"C","837-Q1","P","5000","NM1","05","","","","","2","5000","18","D","Required when NM102 = 1 (person) and the middle name or initial of the person is needed to identify the individual. If not required by this implementation guide, do not send."
"C","837-Q1","P","5000","NM1","05","","","","","2","5000","","F","Rendering Provider Middle Name or Initial"
"C","837-Q1","P","5000","NM1","07","","","","","2","5000","80","D","Required when NM102 = 1 (person) and the name suffix of the person is needed to identify the individual. If not required by this implementation guide, do not send."
"C","837-Q1","P","5000","NM1","07","","","","","2","5000","","F","Rendering Provider Name Suffix"
"C","837-Q1","P","5000","NM1","08","","","","","2","5000","44","D","Required for providers in the United States or its territories on or  after the mandated HIPAA National Provider Identifier (NPI)  implementation date when the provider is eligible to receive an  NPI.<R>OR<R>Required for providers not in the United States or its territories on or after the mandated HIPAA National Provider Identifier (NPI) implementation date when the provider has received an NPI.<R>OR<R>Required for providers prior to the mandated NPI implementation date when the provider has received an NPI and the submitter has the capability to send it.<R>If not required by this implementation guide, do not send."
"C","837-Q1","P","5000","NM1","08","","","","","2","5000","","F","Identification Code Qualifier"
"C","837-Q1","P","5000","NM1","09","","","","","2","5000","44","D","Required for providers in the United States or its territories on or  after the mandated HIPAA National Provider Identifier (NPI)  implementation date when the provider is eligible to receive an  NPI.<R>OR<R>Required for providers not in the United States or its territories on or after the mandated HIPAA National Provider Identifier (NPI) implementation date when the provider has received an NPI.<R>OR<R>Required for providers prior to the mandated NPI implementation date when the provider has received an NPI and the submitter has the capability to send it.<R>If not required by this implementation guide, do not send."
"C","837-Q1","P","5000","NM1","09","","","","","2","5000","","F","Rendering Provider Identifier"
"B","837-Q1","P","5050","","","","","","","2","5050","693","A","Rendering Provider Specialty Information"
"B","837-Q1","P","5050","","","","","","","2","5050","683","","Required when adjudication is known to be impacted by the provider taxonomy code. If not required by this implementation guide, do not send."
"B","837-Q1","P","5050","","","","","","","2","5050","1006","E","PRV*PE*PXC*208D00000X~"
"C","837-Q1","P","5050","PRV","01","","","","","2","5050","","F","Provider Code"
"C","837-Q1","P","5050","PRV","02","","","","","2","5050","","F","Reference Identification Qualifier"
"C","837-Q1","P","5050","PRV","03","","","","","2","5050","","F","Provider Taxonomy Code"
"B","837-Q1","P","5250","","","","","","","2","5250","694","A","Rendering Provider Secondary Identification"
"B","837-Q1","P","5250","","","","","","","2","5250","369","E","REF*G2*12345~"
"B","837-Q1","P","5250","","","","","","","2","5250","271","","Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.<R>OR<R>Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.<R>If not required by this implementation guide, do not send."
"B","837-Q1","P","5250","","","","","","","2","5250","1575","","When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier."
"C","837-Q1","P","5250","REF","01","","","","","2","5250","","F","Reference Identification Qualifier"
"E","837-Q1","P","5250","REF","01","","","128","1G","2","5250","1555","","UPINs must be formatted as either X99999 or XXX999."
"E","837-Q1","P","5250","REF","01","","","128","G2","2","5250","1464","","This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc."
"C","837-Q1","P","5250","REF","02","","","","","2","5250","","F","Rendering Provider Secondary Identifier"
"C","837-Q1","P","5250","REF","04","","","","","2","5250","1576","D","Required when the identifier reported in REF02 of this segment is for a non-destination payer."
"C","837-Q1","P","5250","REF","04","","","","","2","5250","1577","","Do not use this composite when the value reported in REF01 is either 0B or 1G."
"D","837-Q1","P","5250","REF","04","C040","01","","","2","5250","","F","Reference Identification Qualifier"
"D","837-Q1","P","5250","REF","04","C040","02","","","2","5250","1569","","The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109."
"D","837-Q1","P","5250","REF","04","C040","02","","","2","5250","","F","Other Payer Primary Identifier"
"B","837-Q1","Q","5000","","","","","","","2","5000","696","A","Purchased Service Provider Name"
"B","837-Q1","Q","5000","","","","","","","2","5000","695","E","NM1*QB*2******XX*1234567891~"
"B","837-Q1","Q","5000","","","","","","","2","5000","1007","","Required when the service reported in this line item is a purchased service. If not required by this implementation guide, do not send."
"B","837-Q1","Q","5000","","","","","","","2","5000","698","","Purchased services are situations where, for example, a physician purchases a diagnostic exam from an outside entity. Purchased services do not include substitute (locum tenens) provider situations."
"C","837-Q1","Q","5000","NM1","01","","","","","2","5000","1008","","The entity identifier in NM101 applies to all segments in this iteration of Loop ID-2420."
"C","837-Q1","Q","5000","NM1","01","","","","","2","5000","","F","Entity Identifier Code"
"C","837-Q1","Q","5000","NM1","02","","","","","2","5000","","F","Entity Type Qualifier"
"C","837-Q1","Q","5000","NM1","08","","","","","2","5000","303","D","Required for providers on or after the mandated HIPAA National Provider Identifier (NPI) implementation date when the provider has received an NPI and the NPI is available to the submitter.<R>OR<R>Required for providers prior to the mandated HIPAA NPI implementation date when the provider has received an NPI and the submitter has the capability to send it.<R>If not required by this implementation guide, do not send."
"C","837-Q1","Q","5000","NM1","08","","","","","2","5000","","F","Identification Code Qualifier"
"C","837-Q1","Q","5000","NM1","09","","","","","2","5000","303","D","Required for providers on or after the mandated HIPAA National Provider Identifier (NPI) implementation date when the provider has received an NPI and the NPI is available to the submitter.<R>OR<R>Required for providers prior to the mandated HIPAA NPI implementation date when the provider has received an NPI and the submitter has the capability to send it.<R>If not required by this implementation guide, do not send."
"C","837-Q1","Q","5000","NM1","09","","","","","2","5000","","F","Purchased Service Provider Identifier"
"B","837-Q1","Q","5250","","","","","","","2","5250","699","A","Purchased Service Provider Secondary Identification"
"B","837-Q1","Q","5250","","","","","","","2","5250","369","E","REF*G2*12345~"
"B","837-Q1","Q","5250","","","","","","","2","5250","271","","Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.<R>OR<R>Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.<R>If not required by this implementation guide, do not send."
"B","837-Q1","Q","5250","","","","","","","2","5250","1575","","When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier."
"C","837-Q1","Q","5250","REF","01","","","","","2","5250","","F","Reference Identification Qualifier"
"E","837-Q1","Q","5250","REF","01","","","128","1G","2","5250","1555","","UPINs must be formatted as either X99999 or XXX999."
"E","837-Q1","Q","5250","REF","01","","","128","G2","2","5250","1464","","This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc."
"C","837-Q1","Q","5250","REF","02","","","","","2","5250","","F","Purchased Service Provider Secondary Identifier"
"C","837-Q1","Q","5250","REF","04","","","","","2","5250","1576","D","Required when the identifier reported in REF02 of this segment is for a non-destination payer."
"C","837-Q1","Q","5250","REF","04","","","","","2","5250","1577","","Do not use this composite when the value reported in REF01 is either 0B or 1G."
"D","837-Q1","Q","5250","REF","04","C040","01","","","2","5250","","F","Reference Identification Qualifier"
"D","837-Q1","Q","5250","REF","04","C040","02","","","2","5250","1569","","The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109."
"D","837-Q1","Q","5250","REF","04","C040","02","","","2","5250","","F","Other Payer Primary Identifier"
"B","837-Q1","R","5000","","","","","","","2","5000","703","","When an organization health care provider's NPI is provided to identify the Service Location, the organization health care provider must be external to the entity identified as the Billing Provider (for example, reference lab). It is not permissible to report an organization health care provider NPI as the Service Location if the entity being identified is a component (for example, subpart) of the Billing Provider. In that case, the subpart must be the Billing Provider."
"B","837-Q1","R","5000","","","","","","","2","5000","701","A","Service Facility Location Name"
"B","837-Q1","R","5000","","","","","","","2","5000","700","E","NM1*77*2*ABC CLINIC*****XX*1234567891~"
"B","837-Q1","R","5000","","","","","","","2","5000","1009","","Required when the location of health care service for this service line is different than that carried in Loop ID-2010AA Billing Provider or Loop ID-2310C Service Facility Location. If not required by this implementation guide, do not send."
"B","837-Q1","R","5000","","","","","","","2","5000","1010","","The purpose of this loop is to identify specifically where the service was rendered. When reporting ambulance services, do not use this loop. Use the pick-up (2420G) and drop-off location (2420H) loops elsewhere in this transaction.;"
"C","837-Q1","R","5000","NM1","01","","","","","2","5000","","F","Entity Identifier Code"
"C","837-Q1","R","5000","NM1","02","","","","","2","5000","","F","Entity Type Qualifier"
"C","837-Q1","R","5000","NM1","03","","","","","2","5000","","F","Laboratory or Facility Name"
"C","837-Q1","R","5000","NM1","08","","","","","2","5000","705","D","Required when the service location to be identified has an NPI and is not a component or subpart of the Billing Provider entity.<R>If not required by this implementation guide, do not send."
"C","837-Q1","R","5000","NM1","08","","","","","2","5000","","F","Identification Code Qualifier"
"C","837-Q1","R","5000","NM1","09","","","","","2","5000","705","D","Required when the service location to be identified has an NPI and is not a component or subpart of the Billing Provider entity.<R>If not required by this implementation guide, do not send."
"C","837-Q1","R","5000","NM1","09","","","","","2","5000","","F","Laboratory or Facility Primary Identifier"
"B","837-Q1","R","5140","","","","","","","2","5140","84","E","N3*123 MAIN STREET~"
"B","837-Q1","R","5140","","","","","","","2","5140","706","A","Service Facility Location Address"
"B","837-Q1","R","5140","","","","","","","2","5140","707","","If service facility location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, <169>crossroad of State Road 34 and 45<170> or <169>Exit near Mile marker 265 on Interstate 80<170>.)"
"C","837-Q1","R","5140","N3","01","","","","","2","5140","","F","Laboratory or Facility Address Line"
"C","837-Q1","R","5140","N3","02","","","","","2","5140","87","D","Required when there is a second address line. If not required by this implementation guide, do not send."
"C","837-Q1","R","5140","N3","02","","","","","2","5140","","F","Laboratory or Facility Address Line"
"B","837-Q1","R","5200","","","","","","","2","5200","708","A","Service Facility Location City, State, ZIP Code"
"B","837-Q1","R","5200","","","","","","","2","5200","1548","E","N4*KANSAS CITY*MO*64108~"
"C","837-Q1","R","5200","N4","01","","","","","2","5200","","F","Laboratory or Facility City Name"
"C","837-Q1","R","5200","N4","02","","","","","2","5200","1549","D","Required when the address is in the United States of America, including its territories, or Canada. If not required by this implementation guide, do not send."
"C","837-Q1","R","5200","N4","02","","","","","2","5200","","F","Laboratory or Facility State or Province Code"
"C","837-Q1","R","5200","N4","03","","","","","2","5200","1550","D","Required when the address is in the United States of America, including its territories, or Canada, or when a postal code exists for the country in N404. If not required by this implementation guide, do not send."
"C","837-Q1","R","5200","N4","03","","","","","2","5200","1594","","When reporting the ZIP code for U.S. addresses, the full nine digit ZIP code must be provided."
"C","837-Q1","R","5200","N4","03","","","","","2","5200","","F","Laboratory or Facility Postal Zone or ZIP Code"
"C","837-Q1","R","5200","N4","04","","","","","2","5200","1551","D","Required when the address is outside the United States of America. If not required by this implementation guide, do not send."
"C","837-Q1","R","5200","N4","04","","","","","2","5200","1552","","Use the alpha-2 country codes from Part 1 of ISO 3166."
"C","837-Q1","R","5200","N4","04","","","","","2","5200","","F","Country Code"
"C","837-Q1","R","5200","N4","07","","","","","2","5200","1553","D","Required when the address is not in the United States of America, including its territories, or Canada, and the country in N404 has administrative subdivisions such as but not limited to states, provinces, cantons, etc. If not required by this implementation guide, do not send."
"C","837-Q1","R","5200","N4","07","","","","","2","5200","1554","","Use the country subdivision codes from Part 2 of ISO 3166."
"C","837-Q1","R","5200","N4","07","","","","","2","5200","","F","Country Subdivision Code"
"B","837-Q1","R","5250","","","","","","","2","5250","711","A","Service Facility Location Secondary Identification"
"B","837-Q1","R","5250","","","","","","","2","5250","369","E","REF*G2*12345~"
"B","837-Q1","R","5250","","","","","","","2","5250","1575","","When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier."
"B","837-Q1","R","5250","","","","","","","2","5250","1579","","Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.<R>OR<R>Required on or after the mandated NPI implementation date when the entity is not a Health Care provider (a.k.a. an atypical provider), and an identifier is necessary for the claims processor to identify the entity.<R>If not required by this implementation guide, do not send."
"C","837-Q1","R","5250","REF","01","","","","","2","5250","","F","Reference Identification Qualifier"
"E","837-Q1","R","5250","REF","01","","","128","G2","2","5250","1464","","This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc."
"C","837-Q1","R","5250","REF","02","","","","","2","5250","","F","Service Facility Location Secondary Identifier"
"C","837-Q1","R","5250","REF","04","","","","","2","5250","1576","D","Required when the identifier reported in REF02 of this segment is for a non-destination payer."
"D","837-Q1","R","5250","REF","04","C040","01","","","2","5250","","F","Reference Identification Qualifier"
"D","837-Q1","R","5250","REF","04","C040","02","","","2","5250","1569","","The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109."
"D","837-Q1","R","5250","REF","04","C040","02","","","2","5250","","F","Other Payer Primary Identifier"
"B","837-Q1","S","5000","","","","","","","2","5000","718","E","NM1*DQ*1*DOE*JOHN*B***XX*1234567891~"
"B","837-Q1","S","5000","","","","","","","2","5000","716","A","Supervising Provider Name"
"B","837-Q1","S","5000","","","","","","","2","5000","1011","","Required when the rendering provider is supervised by a physician and the supervising physician is different than that listed at the claim level for this service line. If not required by this implementation guide, do not send."
"C","837-Q1","S","5000","NM1","01","","","","","2","5000","","F","Entity Identifier Code"
"C","837-Q1","S","5000","NM1","02","","","","","2","5000","","F","Entity Type Qualifier"
"C","837-Q1","S","5000","NM1","03","","","","","2","5000","","F","Supervising Provider Last Name"
"C","837-Q1","S","5000","NM1","04","","","","","2","5000","266","D","Required when the person has a first name. If not required by this implementation guide, do not send."
"C","837-Q1","S","5000","NM1","04","","","","","2","5000","","F","Supervising Provider First Name"
"C","837-Q1","S","5000","NM1","05","","","","","2","5000","1170","D","Required when the middle name or initial of the person is needed to identify the individual. If not required by this implementation guide, do not send."
"C","837-Q1","S","5000","NM1","05","","","","","2","5000","","F","Supervising Provider Middle Name or Initial"
"C","837-Q1","S","5000","NM1","07","","","","","2","5000","268","D","Required when the name suffix is needed to identify the individual. If not required by this implementation guide, do not send.;"
"C","837-Q1","S","5000","NM1","07","","","","","2","5000","","F","Supervising Provider Name Suffix"
"C","837-Q1","S","5000","NM1","08","","","","","2","5000","44","D","Required for providers in the United States or its territories on or  after the mandated HIPAA National Provider Identifier (NPI)  implementation date when the provider is eligible to receive an  NPI.<R>OR<R>Required for providers not in the United States or its territories on or after the mandated HIPAA National Provider Identifier (NPI) implementation date when the provider has received an NPI.<R>OR<R>Required for providers prior to the mandated NPI implementation date when the provider has received an NPI and the submitter has the capability to send it.<R>If not required by this implementation guide, do not send."
"C","837-Q1","S","5000","NM1","08","","","","","2","5000","","F","Identification Code Qualifier"
"C","837-Q1","S","5000","NM1","09","","","","","2","5000","44","D","Required for providers in the United States or its territories on or  after the mandated HIPAA National Provider Identifier (NPI)  implementation date when the provider is eligible to receive an  NPI.<R>OR<R>Required for providers not in the United States or its territories on or after the mandated HIPAA National Provider Identifier (NPI) implementation date when the provider has received an NPI.<R>OR<R>Required for providers prior to the mandated NPI implementation date when the provider has received an NPI and the submitter has the capability to send it.<R>If not required by this implementation guide, do not send."
"C","837-Q1","S","5000","NM1","09","","","","","2","5000","","F","Supervising Provider Identifier"
"B","837-Q1","S","5250","","","","","","","2","5250","719","A","Supervising Provider Secondary Identification"
"B","837-Q1","S","5250","","","","","","","2","5250","369","E","REF*G2*12345~"
"B","837-Q1","S","5250","","","","","","","2","5250","271","","Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.<R>OR<R>Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.<R>If not required by this implementation guide, do not send."
"B","837-Q1","S","5250","","","","","","","2","5250","1575","","When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier."
"C","837-Q1","S","5250","REF","01","","","","","2","5250","","F","Reference Identification Qualifier"
"E","837-Q1","S","5250","REF","01","","","128","1G","2","5250","1555","","UPINs must be formatted as either X99999 or XXX999."
"E","837-Q1","S","5250","REF","01","","","128","G2","2","5250","1464","","This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc."
"C","837-Q1","S","5250","REF","02","","","","","2","5250","","F","Supervising Provider Secondary Identifier"
"C","837-Q1","S","5250","REF","04","","","","","2","5250","1576","D","Required when the identifier reported in REF02 of this segment is for a non-destination payer."
"C","837-Q1","S","5250","REF","04","","","","","2","5250","1577","","Do not use this composite when the value reported in REF01 is either 0B or 1G."
"D","837-Q1","S","5250","REF","04","C040","01","","","2","5250","","F","Reference Identification Qualifier"
"D","837-Q1","S","5250","REF","04","C040","02","","","2","5250","1569","","The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109."
"D","837-Q1","S","5250","REF","04","C040","02","","","2","5250","","F","Other Payer Primary Identifier"
"B","837-Q1","T","5000","","","","","","","2","5000","1012","E","NM1*DK*1*RICHARDSON*TRENT****XX*1234567891~"
"B","837-Q1","T","5000","","","","","","","2","5000","1013","A","Ordering Provider Name"
"B","837-Q1","T","5000","","","","","","","2","5000","1015","","Required when the service or supply was ordered by a provider who is different than the rendering provider for this service line.<R>If not required by this implementation guide, do not send."
"C","837-Q1","T","5000","NM1","01","","","","","2","5000","1008","","The entity identifier in NM101 applies to all segments in this iteration of Loop ID-2420."
"C","837-Q1","T","5000","NM1","01","","","","","2","5000","","F","Entity Identifier Code"
"C","837-Q1","T","5000","NM1","02","","","","","2","5000","","F","Entity Type Qualifier"
"C","837-Q1","T","5000","NM1","03","","","","","2","5000","","F","Ordering Provider Last Name"
"C","837-Q1","T","5000","NM1","04","","","","","2","5000","266","D","Required when the person has a first name. If not required by this implementation guide, do not send."
"C","837-Q1","T","5000","NM1","04","","","","","2","5000","","F","Ordering Provider First Name"
"C","837-Q1","T","5000","NM1","05","","","","","2","5000","1170","D","Required when the middle name or initial of the person is needed to identify the individual. If not required by this implementation guide, do not send."
"C","837-Q1","T","5000","NM1","05","","","","","2","5000","","F","Ordering Provider Middle Name or Initial"
"C","837-Q1","T","5000","NM1","07","","","","","2","5000","268","D","Required when the name suffix is needed to identify the individual. If not required by this implementation guide, do not send.;"
"C","837-Q1","T","5000","NM1","07","","","","","2","5000","","F","Ordering Provider Name Suffix"
"C","837-Q1","T","5000","NM1","08","","","","","2","5000","303","D","Required for providers on or after the mandated HIPAA National Provider Identifier (NPI) implementation date when the provider has received an NPI and the NPI is available to the submitter.<R>OR<R>Required for providers prior to the mandated HIPAA NPI implementation date when the provider has received an NPI and the submitter has the capability to send it.<R>If not required by this implementation guide, do not send."
"C","837-Q1","T","5000","NM1","08","","","","","2","5000","","F","Identification Code Qualifier"
"C","837-Q1","T","5000","NM1","09","","","","","2","5000","303","D","Required for providers on or after the mandated HIPAA National Provider Identifier (NPI) implementation date when the provider has received an NPI and the NPI is available to the submitter.<R>OR<R>Required for providers prior to the mandated HIPAA NPI implementation date when the provider has received an NPI and the submitter has the capability to send it.<R>If not required by this implementation guide, do not send."
"C","837-Q1","T","5000","NM1","09","","","","","2","5000","","F","Ordering Provider Identifier"
"B","837-Q1","T","5140","","","","","","","2","5140","84","E","N3*123 MAIN STREET~"
"B","837-Q1","T","5140","","","","","","","2","5140","1016","A","Ordering Provider Address"
"B","837-Q1","T","5140","","","","","","","2","5140","914","","Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN) or DMERC Information Form (DIF), or Oxygen Therapy Certification is included on this service line. If not required by this implementation guide, do not send."
"C","837-Q1","T","5140","N3","01","","","","","2","5140","","F","Ordering Provider Address Line"
"C","837-Q1","T","5140","N3","02","","","","","2","5140","87","D","Required when there is a second address line. If not required by this implementation guide, do not send."
"C","837-Q1","T","5140","N3","02","","","","","2","5140","","F","Ordering Provider Address Line"
"B","837-Q1","T","5200","","","","","","","2","5200","1017","A","Ordering Provider City, State, ZIP Code"
"B","837-Q1","T","5200","","","","","","","2","5200","1548","E","N4*KANSAS CITY*MO*64108~"
"B","837-Q1","T","5200","","","","","","","2","5200","301121","","Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN) or DMERC Information Form (DIF), or Oxygen Therapy Certification is included on this service line. If not required by this implementation guide, do not send."
"C","837-Q1","T","5200","N4","01","","","","","2","5200","","F","Ordering Provider City Name"
"C","837-Q1","T","5200","N4","02","","","","","2","5200","1549","D","Required when the address is in the United States of America, including its territories, or Canada. If not required by this implementation guide, do not send."
"C","837-Q1","T","5200","N4","02","","","","","2","5200","","F","Ordering Provider State or Province Code"
"C","837-Q1","T","5200","N4","03","","","","","2","5200","1550","D","Required when the address is in the United States of America, including its territories, or Canada, or when a postal code exists for the country in N404. If not required by this implementation guide, do not send."
"C","837-Q1","T","5200","N4","03","","","","","2","5200","","F","Ordering Provider Postal Zone or ZIP Code"
"C","837-Q1","T","5200","N4","04","","","","","2","5200","1551","D","Required when the address is outside the United States of America. If not required by this implementation guide, do not send."
"C","837-Q1","T","5200","N4","04","","","","","2","5200","1552","","Use the alpha-2 country codes from Part 1 of ISO 3166."
"C","837-Q1","T","5200","N4","04","","","","","2","5200","","F","Country Code"
"C","837-Q1","T","5200","N4","07","","","","","2","5200","1553","D","Required when the address is not in the United States of America, including its territories, or Canada, and the country in N404 has administrative subdivisions such as but not limited to states, provinces, cantons, etc. If not required by this implementation guide, do not send."
"C","837-Q1","T","5200","N4","07","","","","","2","5200","1554","","Use the country subdivision codes from Part 2 of ISO 3166."
"C","837-Q1","T","5200","N4","07","","","","","2","5200","","F","Country Subdivision Code"
"B","837-Q1","T","5250","","","","","","","2","5250","1018","A","Ordering Provider Secondary Identification"
"B","837-Q1","T","5250","","","","","","","2","5250","369","E","REF*G2*12345~"
"B","837-Q1","T","5250","","","","","","","2","5250","271","","Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.<R>OR<R>Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.<R>If not required by this implementation guide, do not send."
"B","837-Q1","T","5250","","","","","","","2","5250","1575","","When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier."
"C","837-Q1","T","5250","REF","01","","","","","2","5250","","F","Reference Identification Qualifier"
"E","837-Q1","T","5250","REF","01","","","128","1G","2","5250","1555","","UPINs must be formatted as either X99999 or XXX999."
"E","837-Q1","T","5250","REF","01","","","128","G2","2","5250","1464","","This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc."
"C","837-Q1","T","5250","REF","02","","","","","2","5250","","F","Ordering Provider Secondary Identifier"
"C","837-Q1","T","5250","REF","04","","","","","2","5250","1576","D","Required when the identifier reported in REF02 of this segment is for a non-destination payer."
"C","837-Q1","T","5250","REF","04","","","","","2","5250","1577","","Do not use this composite when the value reported in REF01 is either 0B or 1G."
"D","837-Q1","T","5250","REF","04","C040","01","","","2","5250","","F","Reference Identification Qualifier"
"D","837-Q1","T","5250","REF","04","C040","02","","","2","5250","1569","","The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109."
"D","837-Q1","T","5250","REF","04","C040","02","","","2","5250","","F","Other Payer Primary Identifier"
"B","837-Q1","T","5300","","","","","","","2","5300","450","E","PER*IC*JOHN SMITH*TE*5555551234*EX*123~"
"B","837-Q1","T","5300","","","","","","","2","5300","1019","A","Ordering Provider Contact Information"
"B","837-Q1","T","5300","","","","","","","2","5300","914","","Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN) or DMERC Information Form (DIF), or Oxygen Therapy Certification is included on this service line. If not required by this implementation guide, do not send."
"B","837-Q1","T","5300","","","","","","","2","5300","24","","When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number must always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as <169>1<170>, in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as <169>ext<170> or <169>x-<170>."
"C","837-Q1","T","5300","PER","01","","","","","2","5300","","F","Contact Function Code"
"C","837-Q1","T","5300","PER","02","","","","","2","5300","1020","D","Required in the first iteration of the Ordering Provider Contact Information segment. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver."
"C","837-Q1","T","5300","PER","02","","","","","2","5300","","F","Ordering Provider Contact Name"
"C","837-Q1","T","5300","PER","03","","","","","2","5300","","F","Communication Number Qualifier"
"C","837-Q1","T","5300","PER","04","","","","","2","5300","","F","Communication Number"
"C","837-Q1","T","5300","PER","05","","","","","2","5300","29","D","Required when this information is deemed necessary by the submitter. If not required by this implementation guide, do not send."
"C","837-Q1","T","5300","PER","05","","","","","2","5300","","F","Communication Number Qualifier"
"C","837-Q1","T","5300","PER","06","","","","","2","5300","29","D","Required when this information is deemed necessary by the submitter. If not required by this implementation guide, do not send."
"C","837-Q1","T","5300","PER","06","","","","","2","5300","","F","Communication Number"
"C","837-Q1","T","5300","PER","07","","","","","2","5300","29","D","Required when this information is deemed necessary by the submitter. If not required by this implementation guide, do not send."
"C","837-Q1","T","5300","PER","07","","","","","2","5300","","F","Communication Number Qualifier"
"C","837-Q1","T","5300","PER","08","","","","","2","5300","29","D","Required when this information is deemed necessary by the submitter. If not required by this implementation guide, do not send."
"C","837-Q1","T","5300","PER","08","","","","","2","5300","","F","Communication Number"
"B","837-Q1","U","5000","","","","","","","2","5000","299","A","Referring Provider Name"
"B","837-Q1","U","5000","","","","","","","2","5000","300","E","NM1*DN*1*WELBY*MARCUS*W**JR*XX*1234567891~"
"B","837-Q1","U","5000","","","","","","","2","5000","678","","When reporting the provider who ordered services such as diagnostic and lab, use Loop ID-2310A at the claim level. For ordered services such as Durable Medical Equipment, use Loop ID-2420E at the line level."
"B","837-Q1","U","5000","","","","","","","2","5000","679","","When there is only one referral on the claim, use code ""DN - Referring Provider"". When more than one referral exists and there is a requirement to report the additional referral, use code DN in the first iteration of this loop to indicate the referral received by the rendering provider on this claim. Use code ""P3 - Primary Care Provider"" in the second iteration of the loop to indicate the initial referral from the primary care provider or whatever provider wrote the initial referral for this patient's episode of care being billed/reported in this transaction."
"B","837-Q1","U","5000","","","","","","","2","5000","1022","","Required when this service line involves a referral and the referring provider differs from that reported at the claim level (loop 2310A). If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver."
"C","837-Q1","U","5000","NM1","01","","","","","2","5000","","F","Entity Identifier Code"
"E","837-Q1","U","5000","NM1","01","","","98","DN","2","5000","680","","Use on the first iteration of this loop. Use if loop is used only once."
"E","837-Q1","U","5000","NM1","01","","","98","P3","2","5000","681","","Use only if loop is used twice. Use only on second iteration of this loop."
"C","837-Q1","U","5000","NM1","02","","","","","2","5000","","F","Entity Type Qualifier"
"C","837-Q1","U","5000","NM1","03","","","","","2","5000","","F","Referring Provider Last Name"
"C","837-Q1","U","5000","NM1","04","","","","","2","5000","266","D","Required when the person has a first name. If not required by this implementation guide, do not send."
"C","837-Q1","U","5000","NM1","04","","","","","2","5000","","F","Referring Provider First Name"
"C","837-Q1","U","5000","NM1","05","","","","","2","5000","1170","D","Required when the middle name or initial of the person is needed to identify the individual. If not required by this implementation guide, do not send."
"C","837-Q1","U","5000","NM1","05","","","","","2","5000","","F","Referring Provider Middle Name or Initial"
"C","837-Q1","U","5000","NM1","07","","","","","2","5000","268","D","Required when the name suffix is needed to identify the individual. If not required by this implementation guide, do not send.;"
"C","837-Q1","U","5000","NM1","07","","","","","2","5000","","F","Referring Provider Name Suffix"
"C","837-Q1","U","5000","NM1","08","","","","","2","5000","303","D","Required for providers on or after the mandated HIPAA National Provider Identifier (NPI) implementation date when the provider has received an NPI and the NPI is available to the submitter.<R>OR<R>Required for providers prior to the mandated HIPAA NPI implementation date when the provider has received an NPI and the submitter has the capability to send it.<R>If not required by this implementation guide, do not send."
"C","837-Q1","U","5000","NM1","08","","","","","2","5000","","F","Identification Code Qualifier"
"C","837-Q1","U","5000","NM1","09","","","","","2","5000","303","D","Required for providers on or after the mandated HIPAA National Provider Identifier (NPI) implementation date when the provider has received an NPI and the NPI is available to the submitter.<R>OR<R>Required for providers prior to the mandated HIPAA NPI implementation date when the provider has received an NPI and the submitter has the capability to send it.<R>If not required by this implementation guide, do not send."
"C","837-Q1","U","5000","NM1","09","","","","","2","5000","","F","Referring Provider Identifier"
"B","837-Q1","U","5250","","","","","","","2","5250","304","A","Referring Provider Secondary Identification"
"B","837-Q1","U","5250","","","","","","","2","5250","369","E","REF*G2*12345~"
"B","837-Q1","U","5250","","","","","","","2","5250","271","","Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider.<R>OR<R>Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider.<R>If not required by this implementation guide, do not send."
"B","837-Q1","U","5250","","","","","","","2","5250","1575","","When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier."
"C","837-Q1","U","5250","REF","01","","","","","2","5250","","F","Reference Identification Qualifier"
"E","837-Q1","U","5250","REF","01","","","128","1G","2","5250","1555","","UPINs must be formatted as either X99999 or XXX999."
"E","837-Q1","U","5250","REF","01","","","128","G2","2","5250","1464","","This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc."
"C","837-Q1","U","5250","REF","02","","","","","2","5250","","F","Referring Provider Secondary Identifier"
"C","837-Q1","U","5250","REF","04","","","","","2","5250","1576","D","Required when the identifier reported in REF02 of this segment is for a non-destination payer."
"C","837-Q1","U","5250","REF","04","","","","","2","5250","1577","","Do not use this composite when the value reported in REF01 is either 0B or 1G."
"D","837-Q1","U","5250","REF","04","C040","01","","","2","5250","","F","Reference Identification Qualifier"
"D","837-Q1","U","5250","REF","04","C040","02","","","2","5250","1569","","The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109."
"D","837-Q1","U","5250","REF","04","C040","02","","","2","5250","","F","Other Payer Primary Identifier"
"B","837-Q1","V","5310","","","","","","","2","5000","720","A","Ambulance Pick-up Location"
"B","837-Q1","V","5310","","","","","","","2","5000","721","E","NM1*PW*2~"
"B","837-Q1","V","5310","","","","","","","2","5000","1029","","Required when the ambulance pick-up location for this service line is different than the ambulance pick-up location provided in Loop ID-2310E. If not required by this implementation guide, do not send.;"
"C","837-Q1","V","5310","NM1","01","","","","","2","5000","","F","Entity Identifier Code"
"C","837-Q1","V","5310","NM1","02","","","","","2","5000","","F","Entity Type Qualifier"
"B","837-Q1","V","5340","","","","","","","2","5140","724","A","Ambulance Pick-up Location Address"
"B","837-Q1","V","5340","","","","","","","2","5140","725","","If the ambulance pickup location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, <169>crossroad of State Road 34 and 45<170> or <169>Exit near Mile marker 265 on Interstate 80<170>.)"
"B","837-Q1","V","5340","","","","","","","2","5140","84","E","N3*123 MAIN STREET~"
"C","837-Q1","V","5340","N3","01","","","","","2","5140","","F","Ambulance Pick-up Address Line"
"C","837-Q1","V","5340","N3","02","","","","","2","5140","87","D","Required when there is a second address line. If not required by this implementation guide, do not send."
"C","837-Q1","V","5340","N3","02","","","","","2","5140","","F","Ambulance Pick-up Address Line"
"B","837-Q1","V","5350","","","","","","","2","5200","726","A","Ambulance Pick-up Location City, State, ZIP Code"
"B","837-Q1","V","5350","","","","","","","2","5200","1548","E","N4*KANSAS CITY*MO*64108~"
"C","837-Q1","V","5350","N4","01","","","","","2","5200","","F","Ambulance Pick-up City Name"
"C","837-Q1","V","5350","N4","02","","","","","2","5200","1549","D","Required when the address is in the United States of America, including its territories, or Canada. If not required by this implementation guide, do not send."
"C","837-Q1","V","5350","N4","02","","","","","2","5200","","F","Ambulance Pick-up State or Province Code"
"C","837-Q1","V","5350","N4","03","","","","","2","5200","1550","D","Required when the address is in the United States of America, including its territories, or Canada, or when a postal code exists for the country in N404. If not required by this implementation guide, do not send."
"C","837-Q1","V","5350","N4","03","","","","","2","5200","","F","Ambulance Pick-up Postal Zone or ZIP Code"
"C","837-Q1","V","5350","N4","04","","","","","2","5200","1551","D","Required when the address is outside the United States of America. If not required by this implementation guide, do not send."
"C","837-Q1","V","5350","N4","04","","","","","2","5200","1552","","Use the alpha-2 country codes from Part 1 of ISO 3166."
"C","837-Q1","V","5350","N4","04","","","","","2","5200","","F","Country Code"
"C","837-Q1","V","5350","N4","07","","","","","2","5200","1553","D","Required when the address is not in the United States of America, including its territories, or Canada, and the country in N404 has administrative subdivisions such as but not limited to states, provinces, cantons, etc. If not required by this implementation guide, do not send."
"C","837-Q1","V","5350","N4","07","","","","","2","5200","1554","","Use the country subdivision codes from Part 2 of ISO 3166."
"C","837-Q1","V","5350","N4","07","","","","","2","5200","","F","Country Subdivision Code"
"B","837-Q1","V","5380","","","","","","","2","5000","728","A","Ambulance Drop-off Location"
"B","837-Q1","V","5380","","","","","","","2","5000","729","E","NM1*45*2~"
"B","837-Q1","V","5380","","","","","","","2","5000","1030","","Required when the ambulance drop-off location for this service line is different than the ambulance drop-off location provided in Loop ID-2310F. If not required by this implementation guide, do not send."
"C","837-Q1","V","5380","NM1","01","","","","","2","5000","","F","Entity Identifier Code"
"C","837-Q1","V","5380","NM1","02","","","","","2","5000","","F","Entity Type Qualifier"
"C","837-Q1","V","5380","NM1","03","","","","","2","5000","730","D","Required when drop-off location name is known. If not required by this implementation guide, do not send."
"C","837-Q1","V","5380","NM1","03","","","","","2","5000","","F","Ambulance Drop-off Location"
"B","837-Q1","V","5410","","","","","","","2","5140","731","A","Ambulance Drop-off Location Address"
"B","837-Q1","V","5410","","","","","","","2","5140","84","E","N3*123 MAIN STREET~"
"B","837-Q1","V","5410","","","","","","","2","5140","732","","If the ambulance drop-off location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, <169>crossroad of State Road 34 and 45<170> or <169>Exit near Mile marker 265 on Interstate 80<170>.)"
"C","837-Q1","V","5410","N3","01","","","","","2","5140","","F","Ambulance Drop-off Address Line"
"C","837-Q1","V","5410","N3","02","","","","","2","5140","87","D","Required when there is a second address line. If not required by this implementation guide, do not send."
"C","837-Q1","V","5410","N3","02","","","","","2","5140","","F","Ambulance Drop-off Address Line"
"B","837-Q1","V","5420","","","","","","","2","5200","733","A","Ambulance Drop-off Location City, State, ZIP Code"
"B","837-Q1","V","5420","","","","","","","2","5200","1548","E","N4*KANSAS CITY*MO*64108~"
"C","837-Q1","V","5420","N4","01","","","","","2","5200","","F","Ambulance Drop-off City Name"
"C","837-Q1","V","5420","N4","02","","","","","2","5200","1549","D","Required when the address is in the United States of America, including its territories, or Canada. If not required by this implementation guide, do not send."
"C","837-Q1","V","5420","N4","02","","","","","2","5200","","F","Ambulance Drop-off State or Province Code"
"C","837-Q1","V","5420","N4","03","","","","","2","5200","1550","D","Required when the address is in the United States of America, including its territories, or Canada, or when a postal code exists for the country in N404. If not required by this implementation guide, do not send."
"C","837-Q1","V","5420","N4","03","","","","","2","5200","","F","Ambulance Drop-off Postal Zone or ZIP Code"
"C","837-Q1","V","5420","N4","04","","","","","2","5200","1551","D","Required when the address is outside the United States of America. If not required by this implementation guide, do not send."
"C","837-Q1","V","5420","N4","04","","","","","2","5200","1552","","Use the alpha-2 country codes from Part 1 of ISO 3166."
"C","837-Q1","V","5420","N4","04","","","","","2","5200","","F","Country Code"
"C","837-Q1","V","5420","N4","07","","","","","2","5200","1553","D","Required when the address is not in the United States of America, including its territories, or Canada, and the country in N404 has administrative subdivisions such as but not limited to states, provinces, cantons, etc. If not required by this implementation guide, do not send."
"C","837-Q1","V","5420","N4","07","","","","","2","5200","1554","","Use the country subdivision codes from Part 2 of ISO 3166."
"C","837-Q1","V","5420","N4","07","","","","","2","5200","","F","Country Subdivision Code"
"B","837-Q1","W","5400","","","","","","","2","5400","1031","E","SVD*43*55*HC:84550**3~"
"B","837-Q1","W","5400","","","","","","","2","5400","1032","A","Line Adjudication Information"
"B","837-Q1","W","5400","","","","","","","2","5400","1033","","Required when the claim has been previously adjudicated by payer identified in Loop ID-2330B and this service line has payments and/or adjustments applied to it. If not required by this implementation guide, do not send."
"B","837-Q1","W","5400","","","","","","","2","5400","1034","","To show unbundled lines: If, in the original claim, line 3 is unbundled into (for example) 2 additional lines, then the SVD for line 3 is used 3 times: once for the original adjustment to line 3 and then two more  times for the additional unbundled lines."
"C","837-Q1","W","5400","SVD","01","","","","","2","5400","1035","","This identifier indicates the payer responsible for the reimbursement described in this iteration of the 2430 loop. The identifier indicates the Other Payer by matching the appropriate Other Payer Primary Identifier (Loop ID-2330B, element NM109)."
"C","837-Q1","W","5400","SVD","01","","","","","2","5400","","F","Other Payer Primary Identifier"
"C","837-Q1","W","5400","SVD","02","","","","","2","5400","843","","Zero ""0"" is an acceptable value for this element."
"C","837-Q1","W","5400","SVD","02","","","","","2","5400","","F","Service Line Paid Amount"
"C","837-Q1","W","5400","SVD","03","","","","","2","5400","1036","","This element contains the procedure code that was used to pay this service line."
"D","837-Q1","W","5400","SVD","03","C003","01","","","2","5400","","F","Product or Service ID Qualifier"
"E","837-Q1","W","5400","SVD","03","C003","01","235","ER","2","5400","1529","","This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:<R>If a new rule names the Jurisdiction Specific Procedure and Supply Codes as an allowable code set under HIPAA, <R>OR<R>The Secretary grants an exception to use the code set as a pilot project as allowed under the law, <R>OR<R>For claims which are not covered under HIPAA."
"E","837-Q1","W","5400","SVD","03","C003","01","235","HC","2","5400","351","","Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC."
"E","837-Q1","W","5400","SVD","03","C003","01","235","IV","2","5400","352","","This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:<R> If a new rule names the Home Infusion EDI Coalition (HIEC) Product/Service Codes as an allowable code set under HIPAA, <R> OR<R> The Secretary grants an exception to use the code set as a pilot project as allowed under the law, <R> OR<R> For claims which are not covered under HIPAA.;"
"E","837-Q1","W","5400","SVD","03","C003","01","235","WK","2","5400","353","","At the time of this writing, this code set has been approved by the Secretary of HHS as a pilot project allowed under HIPAA law. <R>The qualifier may only be used in transactions covered under HIPAA; <R>By parties registered in the pilot project and their trading partners, <R>OR<R>If a new rule names the Complementary, Alternative, or Holistic Procedure Codes as an allowable code set under HIPAA, <R>OR<R>For claims which are not covered under HIPAA."
"D","837-Q1","W","5400","SVD","03","C003","02","","","2","5400","","F","Procedure Code"
"D","837-Q1","W","5400","SVD","03","C003","03","","","2","5400","355","D","Required when a modifier clarifies or improves the reporting accuracy of the associated procedure code. This is the first procedure code modifier. If not required by this implementation guide, do not send."
"D","837-Q1","W","5400","SVD","03","C003","03","","","2","5400","","F","Procedure Modifier"
"D","837-Q1","W","5400","SVD","03","C003","04","","","2","5400","356","D","Required when a second modifier clarifies or improves the reporting accuracy of the associated procedure code. If not required by this implementation guide, do not send."
"D","837-Q1","W","5400","SVD","03","C003","04","","","2","5400","","F","Procedure Modifier"
"D","837-Q1","W","5400","SVD","03","C003","05","","","2","5400","357","D","Required when a third modifier clarifies or improves the reporting accuracy of the associated procedure code. If not required by this implementation guide, do not send."
"D","837-Q1","W","5400","SVD","03","C003","05","","","2","5400","","F","Procedure Modifier"
"D","837-Q1","W","5400","SVD","03","C003","06","","","2","5400","358","D","Required when a fourth modifier clarifies or improves the reporting accuracy of the associated procedure code. If not required by this implementation guide, do not send.;"
"D","837-Q1","W","5400","SVD","03","C003","06","","","2","5400","","F","Procedure Modifier"
"D","837-Q1","W","5400","SVD","03","C003","07","","","2","5400","1037","D","Required when SVC01-7 was returned in the 835 transaction. If not required by this implementation guide, do not send."
"D","837-Q1","W","5400","SVD","03","C003","07","","","2","5400","","F","Procedure Code Description"
"C","837-Q1","W","5400","SVD","05","","","","","2","5400","1038","","This is the number of paid units from the remittance advice. When paid units are not present on the remittance advice, use the original billed units."
"C","837-Q1","W","5400","SVD","05","","","","","2","5400","847","","The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three."
"C","837-Q1","W","5400","SVD","05","","","","","2","5400","","F","Paid Service Unit Count"
"C","837-Q1","W","5400","SVD","06","","","","","2","5400","1040","D","Required when payer bundled this service line. If not required by this implementation guide, do not send."
"C","837-Q1","W","5400","SVD","06","","","","","2","5400","","F","Bundled or Unbundled Line Number"
"B","837-Q1","W","5450","","","","","","","2","5450","736","E","CAS*PR*1*7.93~"
"B","837-Q1","W","5450","","","","","","","2","5450","737","E","CAS*OA*93*15.06~;"
"B","837-Q1","W","5450","","","","","","","2","5450","1041","","Required when the payer identified in Loop 2330B made line level adjustments which caused the amount paid to differ from the amount originally charged. If not required by this implementation guide, do not send."
"B","837-Q1","W","5450","","","","","","","2","5450","1042","A","Line Adjustment"
"B","837-Q1","W","5450","","","","","","","2","5450","743","","A single CAS segment contains six repetitions of the ""adjustment trio"" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a particular Claim Adjustment Group Code (CAS01). The first non-zero adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19)."
"C","837-Q1","W","5450","CAS","01","","","","","2","5450","","F","Claim Adjustment Group Code"
"C","837-Q1","W","5450","CAS","02","","","","","2","5450","","F","Adjustment Reason Code"
"C","837-Q1","W","5450","CAS","03","","","","","2","5450","","F","Adjustment Amount"
"C","837-Q1","W","5450","CAS","04","","","","","2","5450","744","D","Required when the number of service units has been adjusted. If not required by this implementation guide, do not send."
"C","837-Q1","W","5450","CAS","04","","","","","2","5450","","F","Adjustment Quantity"
"C","837-Q1","W","5450","CAS","05","","","","","2","5450","1045","D","Required when it is necessary to report an additional non-zero adjustment, beyond what has already been supplied, to this service line for the Claim Adjustment Group Code reported in CAS01. If not required by this implementation guide, do not send.;"
"C","837-Q1","W","5450","CAS","05","","","","","2","5450","109","","See CODE SOURCE 139: Claim Adjustment Reason Code"
"C","837-Q1","W","5450","CAS","05","","","","","2","5450","","F","Adjustment Reason Code"
"C","837-Q1","W","5450","CAS","06","","","","","2","5450","746","D","Required when CAS05 is present. If not required by this implementation guide, do not send."
"C","837-Q1","W","5450","CAS","06","","","","","2","5450","","F","Adjustment Amount"
"C","837-Q1","W","5450","CAS","07","","","","","2","5450","747","D","Required when CAS05 is present and is related to a units of service adjustment. If not required by this implementation guide, do not send."
"C","837-Q1","W","5450","CAS","07","","","","","2","5450","","F","Adjustment Quantity"
"C","837-Q1","W","5450","CAS","08","","","","","2","5450","1045","D","Required when it is necessary to report an additional non-zero adjustment, beyond what has already been supplied, to this service line for the Claim Adjustment Group Code reported in CAS01. If not required by this implementation guide, do not send.;"
"C","837-Q1","W","5450","CAS","08","","","","","2","5450","109","","See CODE SOURCE 139: Claim Adjustment Reason Code"
"C","837-Q1","W","5450","CAS","08","","","","","2","5450","","F","Adjustment Reason Code"
"C","837-Q1","W","5450","CAS","09","","","","","2","5450","748","D","Required when CAS08 is present. If not required by this implementation guide, do not send."
"C","837-Q1","W","5450","CAS","09","","","","","2","5450","","F","Adjustment Amount"
"C","837-Q1","W","5450","CAS","10","","","","","2","5450","749","D","Required when CAS08 is present and is related to a units of service adjustment. If not required by this implementation guide, do not send."
"C","837-Q1","W","5450","CAS","10","","","","","2","5450","","F","Adjustment Quantity"
"C","837-Q1","W","5450","CAS","11","","","","","2","5450","1045","D","Required when it is necessary to report an additional non-zero adjustment, beyond what has already been supplied, to this service line for the Claim Adjustment Group Code reported in CAS01. If not required by this implementation guide, do not send.;"
"C","837-Q1","W","5450","CAS","11","","","","","2","5450","109","","See CODE SOURCE 139: Claim Adjustment Reason Code"
"C","837-Q1","W","5450","CAS","11","","","","","2","5450","","F","Adjustment Reason Code"
"C","837-Q1","W","5450","CAS","12","","","","","2","5450","750","D","Required when CAS11 is present. If not required by this implementation guide, do not send."
"C","837-Q1","W","5450","CAS","12","","","","","2","5450","","F","Adjustment Amount"
"C","837-Q1","W","5450","CAS","13","","","","","2","5450","751","D","Required when CAS11 is present and is related to a units of service adjustment. If not required by this implementation guide, do not send."
"C","837-Q1","W","5450","CAS","13","","","","","2","5450","","F","Adjustment Quantity"
"C","837-Q1","W","5450","CAS","14","","","","","2","5450","1045","D","Required when it is necessary to report an additional non-zero adjustment, beyond what has already been supplied, to this service line for the Claim Adjustment Group Code reported in CAS01. If not required by this implementation guide, do not send.;"
"C","837-Q1","W","5450","CAS","14","","","","","2","5450","109","","See CODE SOURCE 139: Claim Adjustment Reason Code"
"C","837-Q1","W","5450","CAS","14","","","","","2","5450","","F","Adjustment Reason Code"
"C","837-Q1","W","5450","CAS","15","","","","","2","5450","752","D","Required when CAS14 is present. If not required by this implementation guide, do not send."
"C","837-Q1","W","5450","CAS","15","","","","","2","5450","","F","Adjustment Amount"
"C","837-Q1","W","5450","CAS","16","","","","","2","5450","753","D","Required when CAS14 is present and is related to a units of service adjustment. If not required by this implementation guide, do not send."
"C","837-Q1","W","5450","CAS","16","","","","","2","5450","","F","Adjustment Quantity"
"C","837-Q1","W","5450","CAS","17","","","","","2","5450","1045","D","Required when it is necessary to report an additional non-zero adjustment, beyond what has already been supplied, to this service line for the Claim Adjustment Group Code reported in CAS01. If not required by this implementation guide, do not send.;"
"C","837-Q1","W","5450","CAS","17","","","","","2","5450","109","","See CODE SOURCE 139: Claim Adjustment Reason Code"
"C","837-Q1","W","5450","CAS","17","","","","","2","5450","","F","Adjustment Reason Code"
"C","837-Q1","W","5450","CAS","18","","","","","2","5450","754","D","Required when CAS17 is present. If not required by this implementation guide, do not send."
"C","837-Q1","W","5450","CAS","18","","","","","2","5450","","F","Adjustment Amount"
"C","837-Q1","W","5450","CAS","19","","","","","2","5450","755","D","Required when CAS17 is present and is related to a units of service adjustment. If not required by this implementation guide, do not send."
"C","837-Q1","W","5450","CAS","19","","","","","2","5450","","F","Adjustment Quantity"
"B","837-Q1","W","5500","","","","","","","2","5500","799","E","DTP*573*D8*20040203~"
"B","837-Q1","W","5500","","","","","","","2","5500","1046","A","Line Check or Remittance Date"
"C","837-Q1","W","5500","DTP","01","","","","","2","5500","","F","Date Time Qualifier"
"C","837-Q1","W","5500","DTP","02","","","","","2","5500","","F","Date Time Period Format Qualifier"
"C","837-Q1","W","5500","DTP","03","","","","","2","5500","","F","Adjudication or Payment Date"
"B","837-Q1","W","5505","","","","","","","2","5505","1050","","In the judgment of the provider, this is the remaining amount to be paid after adjudication by the Other Payer referenced in SVD01 of this iteration of Loop ID-2430."
"B","837-Q1","W","5505","","","","","","","2","5505","765","A","Remaining Patient Liability"
"B","837-Q1","W","5505","","","","","","","2","5505","766","E","AMT*EAF*75~"
"B","837-Q1","W","5505","","","","","","","2","5505","769","","This segment is only used in provider submitted claims. It is not used in Payer-to-Payer Coordination of Benefits (COB)."
"B","837-Q1","W","5505","","","","","","","2","5505","1267","","Required when the Other Payer referenced in SVD01 of this iteration of Loop ID-2430 has adjudicated this claim, provided line level information, and the provider has the ability to report line item information. If not required by this implementation guide, do not send."
"B","837-Q1","W","5505","","","","","","","2","5505","1270","","This segment is not used if the claim level (Loop ID-2320) Remaining Patient Liability AMT segment is used for this Other Payer."
"C","837-Q1","W","5505","AMT","01","","","","","2","5505","","F","Amount Qualifier Code"
"C","837-Q1","W","5505","AMT","02","","","","","2","5505","","F","Remaining Patient Liability"
"B","837-Q1","Y","5510","","","","","","","2","5510","1053","A","Form Identification Code"
"B","837-Q1","Y","5510","","","","","","","2","5510","1054","E","LQ*UT*01.02~"
"B","837-Q1","Y","5510","","","","","","","2","5510","1055","","Required when adjudication is known to be impacted by one of the types of supporting documentation (standardized paper forms) listed in LQ01. If not required by this implementation guide, do not send."
"B","837-Q1","Y","5510","","","","","","","2","5510","1057","","Loop ID-2440 is designed to allow providers to attach standardized supplemental information to the claim when required to do so by the payer. The LQ segment contains information to identify the form (LQ01) and the specific form number (LQ02). In the example given below, LQ01=UT which identifies the form as a Medicare DMERC CMN form. LQ02=01.02 identifies which DMERC CMN form is being used."
"B","837-Q1","Y","5510","","","","","","","2","5510","1056","","An example application of this Form Identification Code Loop is for Medicare DMERC claims for which the DME provider is required to obtain a Certificate of Medical Necessity (DMERC CMN) or DMERC Information Form (DIF), or Oxygen Therapy Certification from the referring physician. Another example is payer documentation requirements for Home Health services."
"C","837-Q1","Y","5510","LQ","01","","","","","2","5510","","F","Code List Qualifier Code"
"E","837-Q1","Y","5510","LQ","01","","","1270","AS","2","5510","1059","","Code value AS indicates that a Home Health form from External Code Source 656 is being identified in LQ02."
"C","837-Q1","Y","5510","LQ","02","","","","","2","5510","","F","Form Identifier"
"B","837-Q1","Y","5520","","","","","","","2","5520","1060","E","FRM*1A**J0234~
FRM*1B**500~
FRM*1C**4~
FRM*4*Y~
FRM*5A**5~
FRM*5B**3~
FRM*8**Methodist Hospital~
FRM*9**Indianapolis~
FRM*10**IN~
FRM*11***19971101~
FRM*12*N~"
"B","837-Q1","Y","5520","","","","","","","2","5520","1061","A","Supporting Documentation"
"B","837-Q1","Y","5520","","","","","","","2","5520","1062","","The LQ segment is used to identify the general (LQ01) and specific type (LQ02) for the form being reported in Loop ID-2440. The FRM segment is used to answer specific questions on the form identified in the LQ segment. FRM01 is used to indicate the question being answered. Answers can take one of 4 forms: FRM02 for Yes/No questions, FRM03 for text/uncodified answers, FRM04 for answers which use dates, and FRM05 for answers which are percents. For each FRM01 (question) use a remaining FRM element, choosing the element which has the most appropriate format. One FRM segment is used for each question/answer pair.<R><R>The example below shows how the FRM can be used to answer all the pertinent questions on DMERC form 0802 (LQ*UT*08.02~)."
"C","837-Q1","Y","5520","FRM","01","","","","","2","5520","","F","Question Number/Letter"
"C","837-Q1","Y","5520","FRM","02","","","","","2","5520","1063","D","Required when the question identified in FRM01 uses a Yes or No response format. If not required by this implementation guide, do not send."
"C","837-Q1","Y","5520","FRM","02","","","","","2","5520","","F","Question Response"
"C","837-Q1","Y","5520","FRM","03","","","","","2","5520","1064","D","Required when question identified in FRM01 uses a text or uncodified response format. If not required by this implementation guide, do not send."
"C","837-Q1","Y","5520","FRM","03","","","","","2","5520","","F","Question Response"
"C","837-Q1","Y","5520","FRM","04","","","","","2","5520","1065","D","Required when question identified in FRM01 uses a date response format. If not required by this implementation guide, do not send."
"C","837-Q1","Y","5520","FRM","04","","","","","2","5520","","F","Question Response"
"C","837-Q1","Y","5520","FRM","05","","","","","2","5520","1066","D","Required when question identified in FRM01 uses a percent response format. If not required by this implementation guide, do not send."
"C","837-Q1","Y","5520","FRM","05","","","","","2","5520","","F","Question Response"
"B","837-Q1","Z","5550","","","","","","","2","5550","385","E","SE*1230*987654~"
"B","837-Q1","Z","5550","","","","","","","2","5550","384","A","Transaction Set Trailer"
"C","837-Q1","Z","5550","SE","01","","","","","2","5550","","F","Transaction Segment Count"
"C","837-Q1","Z","5550","SE","02","","","","","2","5550","3","","The Transaction Set Control Number in ST02 and SE02 must be identical. The number must be unique within a specific interchange (ISA-IEA), but can repeat in other interchanges."
"C","837-Q1","Z","5550","SE","02","","","","","2","5550","","F","Transaction Set Control Number"
