ISA- Interchange Control Header

01	I01	Authorization Information Qualifier	R
	00 03
02	I02	Authorization Information	R
03	I03	Security Information Qualifier	R
	00 01
04	I04	Security Information	R
05	I05	Interchange ID Qualifier	R
	01 14 20 27 28 29 30 33 ZZ
06	I06	Interchange Sender ID	R
07	I05	Interchange ID Qualifier	R
	01 14 20 27 28 29 30 33 ZZ
08	I07	Interchange Receiver ID	R
09	I08	Interchange Date	R
10	I09	Interchange Time	R
11	I10	Interchange Control Standards Identifier	R
	U
12	I11	Interchange Control Version Number	R
	00401
13	I12	Interchange Control Number	R
14	I13	Acknowledgment Requested	R
	0 1
15	I14	Usage Indicator	R
	P T
16	I15	Component Element Separator	R

GS- Functional Group Header

01	479	Functional Identifier Code	R
	HC
02	142	Application Sender's Code	R
03	124	Application Receiver's Code	R
04	373	Date	R
05	337	Time	R
06	28	Group Control Number	R
07	455	Responsible Agency Code	R
	X
08	480	Version / Release / Industry Identifier Code	R
	004010X096

ST- Transaction Set Header

01	143	Transaction Set Identifier Code	R
	837
02	329	Transaction Set Control Number	R

BHT- Beginning of Hierarchical Transaction

01	1005	Hierarchical Structure Code	R
	0019
02	353	Transaction Set Purpose Code	R
	00 18
03	127	Originator Application Transaction Identifier	R
04	373	Transaction Set Creation Date	R
05	337	Transaction Set Creation Time	R
06	640	Claim or Encounter Identifier	R
	CH RP

REF- Transaction Type Identification

01	128	Reference Identification Qualifier	R
	87
02	127	Transmission Type Code	R
	004010X096D 004010X096
03	352	Description	N
N		C040	Reference Identifier

NM1- Submitter Name

01	98	Entity Identifier Code	R
	41
02	1065	Entity Type Qualifier	R
	1 2
03	1035	Submitter Last or Organization Name	R
04	1036	Submitter First Name	S
05	1037	Submitter Middle Name	S
06	1038	Name Prefix	N
07	1039	Name Suffix	N
08	66	Identification Code Qualifier	R
	46
09	67	Submitter Identifier	R
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

PER- Submitter EDI Contact Information

01	366	Contact Function Code	R
	IC
02	93	Submitter Contact Name	R
03	365	Communication Number Qualifier	R
	ED EM FX TE
04	364	Communication Number	R
05	365	Communication Number Qualifier	S
	ED EM EX FX TE
06	364	Communication Number	S
07	365	Communication Number Qualifier	S
	ED EM EX FX TE
08	364	Communication Number	S
09	443	Contact Inquiry Reference	N

NM1- Receiver Name

01	98	Entity Identifier Code	R
	40
02	1065	Entity Type Qualifier	R
	2
03	1035	Receiver Name	R
04	1036	Name First	N
05	1037	Name Middle	N
06	1038	Name Prefix	N
07	1039	Name Suffix	N
08	66	Information Receiver Identification Number	R
	46
09	67	Receiver Primary Identifier	R
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

HL- Billing/Pay-To Provider Hierarchical Level

01	628	Hierarchical ID Number	R
02	734	Hierarchical Parent ID Number	N
03	735	Hierarchical Level Code	R
	20
04	736	Hierarchical Child Code	R
	1

PRV- Billing/Pay-To Provider Specialty Information

01	1221	Provider Code	R
	BI PT
02	128	Reference Identification Qualifier	R
	ZZ
03	127	Provider Taxonomy Code	R
04	156	State or Province Code	N
N		C035	Provider Specialty Information
06	1223	Provider Organization Code	N

CUR- Foreign Currency Information

01	98	Entity Identifier Code	R
	85
02	100	Currency Code	R
	External Source: currency
03	280	Exchange Rate	N
04	98	Entity Identifier Code	N
05	100	Currency Code	N
	External Source: currency
06	669	Currency Market/Exchange Code	N
07	374	Date/Time Qualifier	N
08	373	Date	N
09	337	Time	N
10	374	Date/Time Qualifier	N
11	373	Date	N
12	337	Time	N
13	374	Date/Time Qualifier	N
14	373	Date	N
15	337	Time	N
16	374	Date/Time Qualifier	N
17	373	Date	N
18	337	Time	N
19	374	Date/Time Qualifier	N
20	373	Date	N
21	337	Time	N

NM1- Billing Provider Name

01	98	Entity Identifier Code	R
	85
02	1065	Entity Type Qualifier	R
	2
03	1035	Billing Provider Last or Organizational Name	R
04	1036	Name First	N
05	1037	Name Middle	N
06	1038	Name Prefix	N
07	1039	Name Suffix	N
08	66	Identification Code Qualifier	R
	24 34 XX
09	67	Billing Provider Identifier	R
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

N3- Billing Provider Address

01	166	Billing Provider Address Line	R
02	166	Billing Provider Address Line	S

N4- Billing Provider City/State/ZIP Code

01	19	Billing Provider City Name	R
02	156	Billing Provider State or Province Code	R
	AA AB AE AK AL AP AR AS AZ BC CA CO CT DC DE FL FM GA GU HI IA ID IL IN KS KY LA MA MB MD ME MH MI MN MO MP MS MT NB NC ND NE NF NH NJ NM NS NT NV NY OH OK ON OR PA PE PQ PR RI SC SD SK TN TX UT VA VI VT WA WI WV WY YT
03	116	Billing Provider Postal Zone or ZIP Code	R
04	26	Country Code	S
	External Source: country
05	309	Location Qualifier	N
06	310	Location Identifier	N

REF- Billing Provider Secondary Identification

01	128	Reference Identification Qualifier	R
	0B 1A 1B 1C 1D 1G 1H 1J B3 BQ EI FH G2 G5 LU SY X5
02	127	Billing Provider Additional Identifier	R
03	352	Description	N
N		C040	Reference Identifier

REF- Credit/Debit Card Billing Information

01	128	Reference Identification Qualifier	R
	06 8U EM IJ LU RB ST TT
02	127	Billing Provider Credit Card Identifier	R
03	352	Description	N
N		C040	Reference Identifier

PER- Billing Provider Contact Information

01	366	Contact Function Code	R
	IC
02	93	Billing Provider Contact Name	R
03	365	Communication Number Qualifier	R
	EM FX TE
04	364	Communication Number	R
05	365	Communication Number Qualifier	S
	EM EX FX TE
06	364	Communication Number	S
07	365	Communication Number Qualifier	S
	EM EX FX TE
08	364	Communication Number	S
09	443	Contact Inquiry Reference	N

NM1- Pay-To Provider Name

01	98	Entity Identifier Code	R
	87
02	1065	Entity Type Qualifier	R
	2
03	1035	Pay-to Provider Last or Organizational Name	R
04	1036	Name First	N
05	1037	Name Middle	N
06	1038	Name Prefix	N
07	1039	Name Suffix	N
08	66	Identification Code Qualifier	R
	24 34 XX
09	67	Pay-To Provider Identifier	R
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

N3- Pay-To Provider Address

01	166	Pay-to Provider Address Line	R
02	166	Pay-to Provider Address Line	S

N4- Pay-To Provider City/State/ZIP Code

01	19	Pay-to Provider City Name	R
02	156	Pay-to Provider State Code	R
	AA AB AE AK AL AP AR AS AZ BC CA CO CT DC DE FL FM GA GU HI IA ID IL IN KS KY LA MA MB MD ME MH MI MN MO MP MS MT NB NC ND NE NF NH NJ NM NS NT NV NY OH OK ON OR PA PE PQ PR RI SC SD SK TN TX UT VA VI VT WA WI WV WY YT
03	116	Pay-to Provider Postal Zone or ZIP Code	R
04	26	Pay-to Provider Country Code	S
	External Source: country
05	309	Location Qualifier	N
06	310	Location Identifier	N

REF- Pay-To Provider Secondary Identification

01	128	Reference Identification Qualifier	R
	0B 1A 1B 1C 1D 1G 1H 1J B3 BQ EI FH G2 G5 LU SY X5
02	127	Pay-to Provider Additional Identifier	R
03	352	Description	N
N		C040	Reference Identifier

HL- Subscriber Hierarchical Level

01	628	Hierarchical ID Number	R
02	734	Hierarchical Parent ID Number	R
03	735	Hierarchical Level Code	R
	22
04	736	Hierarchical Child Code	R
	0 1

SBR- Subscriber Information

01	1138	Payer Responsibility Sequence Number Code	R
	P S T
02	1069	Patients Relationship to Insured	S
	18
03	127	Insured Group or Policy Number	S
04	93	Insured Group Name	S
05	1336	Insurance Type Code	N
06	1143	Coordination of Benefits Code	N
07	1073	Yes/No Condition or Response Code	N
08	584	Employment Status Code	N
09	1032	Claim Filing Indicator Code	S
	09 10 11 12 13 14 15 16 AM BL CH CI DS HM LI LM MA MB MC OF TV VA WC ZZ

PAT- Patient Information

01	1069	Individual Relationship Code	N
02	1384	Patient Location Code	N
03	584	Employment Status Code	N
04	1220	Student Status Code	N
05	1250	Date Time Period Format Qualifier	N
06	1251	Date Time Period	N
07	355	Unit or Basis for Measurement Code	S
	GR
08	81	Patient Weight	S
09	1073	Pregnancy Indicator	S
	Y

NM1- Subscriber Name

01	98	Entity Identifier Code	R
	IL
02	1065	Entity Type Qualifier	R
	1 2
03	1035	Subscriber Last Name	R
04	1036	Subscriber First Name	S
05	1037	Subscriber Middle Name	S
06	1038	Name Prefix	N
07	1039	Subscriber Name Suffix	S
08	66	Identification Code Qualifier	S
	MI ZZ
09	67	Subscriber Primary Identifier	S
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

N3- Subscriber Address

01	166	Subscriber Address Line	R
02	166	Subscriber Address Line	S

N4- Subscriber City/State/ZIP Code

01	19	Subscriber City Name	R
02	156	Subscriber State Code	R
	AA AB AE AK AL AP AR AS AZ BC CA CO CT DC DE FL FM GA GU HI IA ID IL IN KS KY LA MA MB MD ME MH MI MN MO MP MS MT NB NC ND NE NF NH NJ NM NS NT NV NY OH OK ON OR PA PE PQ PR RI SC SD SK TN TX UT VA VI VT WA WI WV WY YT
03	116	Subscriber Postal Zone or ZIP Code	R
04	26	Country Code	S
	External Source: country
05	309	Location Qualifier	N
06	310	Location Identifier	N

DMG- Subscriber Demographic Information

01	1250	Date Time Period Format Qualifier	R
	D8
02	1251	Subscriber Birth Date	R
03	1068	Subscriber Gender Code	R
	F M U
04	1067	Marital Status Code	N
05	1109	Race or Ethnicity Code	N
06	1066	Citizenship Status Code	N
07	26	Country Code	N
	External Source: country
08	659	Basis of Verification Code	N
09	380	Quantity	N

REF- Subscriber Secondary Identification

01	128	Reference Identification Qualifier	R
	1W 23 IG SY
02	127	Subscriber Supplemental Identifier	R
03	352	Description	N
N		C040	Reference Identifier

REF- Property and Casualty Claim Number

01	128	Reference Identification Qualifier	R
	Y4
02	127	Property Casualty Claim Number	R
03	352	Description	N
N		C040	Reference Identifier

NM1- Credit/Debit Card Account Holder Name

01	98	Entity Identifier Code	R
	AO
02	1065	Entity Type Qualifier	R
	1 2
03	1035	Credit or Debit Card Holder Last or Organizational Name	R
04	1036	Credit or Debit Card Holder First Name	S
05	1037	Credit or Debit Card Holder Middle Name	S
06	1038	Name Prefix	N
07	1039	Credit or Debit Card Holder Name Suffix	S
08	66	Identification Code Qualifier	R
	MI
09	67	Credit or Debit Card Number	R
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

REF- Credit/Debit Card Information

01	128	Reference Identification Qualifier	R
	AB BB
02	127	Credit or Debit Card Authorization Number	R
03	352	Description	N
N		C040	Reference Identifier

NM1- Payer Name

01	98	Entity Identifier Code	R
	PR
02	1065	Entity Type Qualifier	R
	2
03	1035	Payer Name	R
04	1036	Name First	N
05	1037	Name Middle	N
06	1038	Name Prefix	N
07	1039	Name Suffix	N
08	66	Identification Code Qualifier	R
	PI XV
09	67	Payer Identifier	R
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

N3- Payer Address

01	166	Payer Address Line	R
02	166	Payer Address Line	S

N4- Payer City/State/ZIP Code

01	19	Payer City Name	R
02	156	Payer State Code	R
	AA AB AE AK AL AP AR AS AZ BC CA CO CT DC DE FL FM GA GU HI IA ID IL IN KS KY LA MA MB MD ME MH MI MN MO MP MS MT NB NC ND NE NF NH NJ NM NS NT NV NY OH OK ON OR PA PE PQ PR RI SC SD SK TN TX UT VA VI VT WA WI WV WY YT
03	116	Payer Postal Zone or ZIP Code	R
04	26	Payer Country Code	S
	External Source: country
05	309	Location Qualifier	N
06	310	Location Identifier	N

REF- Payer Secondary Identification

01	128	Reference Identification Qualifier	R
	2U FY NF TJ
02	127	Payer Additional Identifier	R
03	352	Description	N
N		C040	Reference Identifier

NM1- Responsible Party Name

01	98	Entity Identifier Code	R
	QD
02	1065	Entity Type Qualifier	R
	1 2
03	1035	Responsible Party Last or Organization Name	R
04	1036	Responsible Party First Name	S
05	1037	Responsible Party Middle Name	S
06	1038	Name Prefix	N
07	1039	Responsible Party Suffix Name	S
08	66	Identification Code Qualifier	N
09	67	Identification Code	N
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

N3- Responsible Party Address

01	166	Responsible Party Address Line	R
02	166	Responsible Party Address Line	S

N4- Responsible Party City/State/ZIP Code

01	19	Responsible Party City Name	R
02	156	Responsible Party State Code	R
	AA AB AE AK AL AP AR AS AZ BC CA CO CT DC DE FL FM GA GU HI IA ID IL IN KS KY LA MA MB MD ME MH MI MN MO MP MS MT NB NC ND NE NF NH NJ NM NS NT NV NY OH OK ON OR PA PE PQ PR RI SC SD SK TN TX UT VA VI VT WA WI WV WY YT
03	116	Responsible Party Postal Zone or ZIP Code	R
04	26	Responsible Party Country Code	S
	External Source: country
05	309	Location Qualifier	N
06	310	Location Identifier	N

CLM- Claim Information

01	1028	Patient Account Number	R
02	782	Total Claim Charge Amount	R
03	1032	Claim Filing Indicator Code	N
04	1343	Non-Institutional Claim Type Code	N
R		C023	Type of Bill
01	1331	Facility Type Code	R
02	1332	Facility Code Qualifier	R
	A
03	1325	Claim Frequency Code	R
06	1073	Provider or Supplier Signature Indicator	R
	N Y
07	1359	Medicare Assignment Code	S
	A C
08	1073	Benefits Assignment Certification Indicator	R
	N Y
09	1363	Release of Information Code	R
	A I M N O Y
10	1351	Patient Signature Source Code	N
S		C024	Property and Casualty Related Causes Codes
01	1362	Related Causes Code	R
	AA AB AP EM OA
02	1362	Related Causes Code	S
	AA AB AP EM OA
03	1362	Related Causes Code	S
	AA AB AP EM OA
04	156	Auto Accident State or Province Code	S
	AA AB AE AK AL AP AR AS AZ BC CA CO CT DC DE FL FM GA GU HI IA ID IL IN KS KY LA MA MB MD ME MH MI MN MO MP MS MT NB NC ND NE NF NH NJ NM NS NT NV NY OH OK ON OR PA PE PQ PR RI SC SD SK TN TX UT VA VI VT WA WI WV WY YT
05	26	Country Code	S
	External Source: country
12	1366	Special Program Indicator	S
	01 02 03 05 07 08 09
13	1073	Yes/No Condition or Response Code	N
14	1338	Level of Service Code	N
15	1073	Yes/No Condition or Response Code	N
16	1360	Provider Agreement Code	N
7	1029	Claim Status Code	N
18	1073	Explanation of Benefits Indicator	R
	N Y
19	1383	Claim Submission Reason Code	N
20	1514	Delay Reason Code	S
	1 2 3 4 5 6 7 8 9 10 11

DTP- Discharge Hour

01	374	Date Time Qualifier	R
	096
02	1250	Date Time Period Format Qualifier	R
	TM
03	1251	Discharge Hour	R

DTP- Statement Dates

01	374	Date Time Qualifier	R
	434
02	1250	Date Time Period Format Qualifier	R
	D8 RD8
03	1251	Statement From or To Date	R

DTP- Admission Date/Hour

01	374	Date Time Qualifier	R
	435
02	1250	Date Time Period Format Qualifier	R
	DT
03	1251	Admission Date and Hour	R

CL1- Institutional Claim Code

01	1315	Admission Type Code	S
02	1314	Admission Source Code	S
03	1352	Patient Status Code	S
04	1345	Nursing Home Residential Status Code	N

PWK- Claim Supplemental Information

01	755	Attachment Report Type Code	R
	AS B2 B3 B4 CT DA DG DS EB MT NN OB OZ PN PO PZ RB RR RT
02	756	Attachment Transmission Code	R
	AA BM EL EM FX
03	757	Report Copies Needed	N
04	98	Entity Identifier Code	N
05	66	Identification Code Qualifier	S
	AC
06	67	Attachment Control Number	S
07	352	Attachment Description	S
N		C002	Actions Indicated
09	1525	Request Category Code	N

CN1- Contract Information

01	1166	Contract Type Code	R
	01 02 03 04 05 06 09
02	782	Contract Amount	S
03	332	Contract Percentage	S
04	127	Contract Code	S
05	338	Terms Discount Percentage	S
06	799	Contract Version Identifier	S

AMT- Payer Estimated Amount Due

01	522	Amount Qualifier Code	R
	C5
02	782	Estimated Claim Due Amount	R
03	478	Credit/Debit Flag Code	N

AMT- Patient Estimated Amount Due

01	522	Amount Qualifier Code	R
	F3
02	782	Patient Responsibility Amount	R
03	478	Credit/Debit Flag Code	N

AMT- Patient Paid Amount

01	522	Amount Qualifier Code	R
	F5
02	782	Patient Amount Paid	R
03	478	Credit/Debit Flag Code	N

AMT- Credit/Debit Card Maximum Amount

01	522	Amount Qualifier Code	R
	MA
02	782	Credit or Debit Card Maximum Amount	R
03	478	Credit/Debit Flag Code	N

REF- Adjusted Repriced Claim Number

01	128	Reference Identification Qualifier	R
	9C
02	127	Adjusted Repriced Claim Reference Number	R
03	352	Description	N
N		C040	Reference Identifier

REF- Repriced Claim Number

01	128	Reference Identification Qualifier	R
	9A
02	127	Repriced Claim Reference Number	R
03	352	Description	N
N		C040	Reference Identifier

REF- Claim Identification Number For Clearinghouses and Other Transmission Intermediaries

01	128	Reference Identification Qualifier	R
	D9
02	127	Value Added Network Trace Number	R
03	352	Description	N
N		C040	Reference Identifier

REF- Document Identification Code

01	128	Reference Identification Qualifier	R
	DD
02	127	Document Control Identifier	R
03	352	Description	N
N		C040	Reference Identifier

REF- Original Reference Number (ICN/DCN)

01	128	Reference Identification Qualifier	R
	F8
02	127	Claim Original Reference Number	R
03	352	Description	N
N		C040	Reference Identifier

REF- Investigational Device Exemption Number

01	128	Reference Identification Qualifier	R
	LX
02	127	Investigational Device Exemption Identifier	R
03	352	Description	N
N		C040	Reference Identifier

REF- Service Authorization Exception Code

01	128	Reference Identification Qualifier	R
	4N
02	127	Service Authorization Exception Code	R
03	352	Description	N
N		C040	Reference Identifier

REF- Peer Review Organization (PRO) Approval Number

01	128	Reference Identification Qualifier	R
	G4
02	127	Peer Review Authorization Number	R
03	352	Description	N
N		C040	Reference Identifier

REF- Prior Authorization or Referral Number

01	128	Reference Identification Qualifier	R
	9F G1
02	127	Prior Authorization Number	R
03	352	Description	N
N		C040	Reference Identifier

REF- Medical Record Number

01	128	Reference Identification Qualifier	R
	EA
02	127	Medical Record Number	R
03	352	Description	N
N		C040	Reference Identifier

REF- Demonstration Project Identifier

01	128	Reference Identification Qualifier	R
	P4
02	127	Demonstration Project Identifier	R
03	352	Description	N
N		C040	Reference Identifier

K3- File Information

01	449	Fixed Format Information	R
02	1333	Record Format Code	N
N		C001	Composite Unit of Measure

NTE- Claim Note

01	363	Note Reference Code	R
	ALG DCP DGN DME MED NTR ODT RHB RLH RNH SET SFM SPT UPI
02	352	Claim Note Text	R

NTE- Billing Note

01	363	Note Reference Code	R
	ADD
02	352	Billing Note Text	R

CR6- Home Health Care Information

01	923	Prognosis Indicator	R
	1 2 3 4 5 6 7 8
02	373	Service From Date	R
03	1250	Date Time Period Format Qualifier	S
	RD8
04	1251	Home Health Certification Period	S
05	373	Diagnosis Date	R
06	1073	Skilled Nursing Facility Indicator	R
	N U Y
07	1073	Medicare Coverage Indicator	R
	N Y
08	1322	Certification Type Indicator	R
	I R S
09	373	Surgery Date	S
10	235	Product or Service ID Qualifier	S
	HC ID
11	1137	Surgical Procedure Code	S
12	373	Physician Order Date	S
13	373	Last Visit Date	S
14	373	Physician Contact Date	S
15	1250	Date Time Period Format Qualifier	S
	RD8
16	1251	Last Admission Period	S
17	1384	Patient Discharge Facility Type Code	R
	A B C D E F G H L M O R S T
18	373	Diagnosis Date	S
19	373	Diagnosis Date	S
20	373	Diagnosis Date	S
21	373	Diagnosis Date	S

CRC- Home Health Functional Limitations

01	1136	Code Category	R
	75
02	1073	Certification Condition Indicator	R
	N Y
03	1321	Functional Limitation Code	R
	AA AL BL CO DY EL HL LB OL PA SL
04	1321	Functional Limitation Code	S
05	1321	Functional Limitation Code	S
06	1321	Functional Limitation Code	S
07	1321	Functional Limitation Code	S

CRC- Home Health Activities Permitted

01	1136	Certification Condition Indicator	R
	76
02	1073	Functional Limitation Code	R
	N Y
03	1321	Activities Permitted Code	R
	BR CA CB CR EP IH NR PW TR UT WA WR
04	1321	Activities Permitted Code	S
05	1321	Activities Permitted Code	S
06	1321	Activities Permitted Code	S
07	1321	Activities Permitted Code	S

CRC- Home Health Mental Status

01	1136	Certification Condition Indicator	R
	77
02	1073	Functional Limitation Code	R
	N Y
03	1321	Mental Status Code	R
	AG CM DI DP FO LE MC OT
04	1321	Mental Status Code	S
05	1321	Mental Status Code	S
06	1321	Mental Status Code	S
07	1321	Mental Status Code	S

HI- Principal, Admitting, E-Code and Patient Reason for Visit Diagnosis Information

R		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BK
02	1271	Industry Code	R
03	1250	Date Time Period Format Qualifier	N
04	1251	Date Time Period	N
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BJ ZZ
02	1271	Industry Code	R
03	1250	Date Time Period Format Qualifier	N
04	1251	Date Time Period	N
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BN
02	1271	Industry Code	R
03	1250	Date Time Period Format Qualifier	N
04	1251	Date Time Period	N
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
N		C022	Health Care Code Information
S		C022	Health Care Code Information
01	1270	Code List Qualifier Code	S
02	1271	Industry Code	S
03	1250	Date Time Period Format Qualifier	S
04	1251	Date Time Period	S
05	782	Monetary Amount	S
06	380	Quantity	S
07	799	Version Identifier	S
N		C022	Health Care Code Information
N		C022	Health Care Code Information
N		C022	Health Care Code Information
N		C022	Health Care Code Information
N		C022	Health Care Code Information
N		C022	Health Care Code Information
N		C022	Health Care Code Information

HI- Diagnosis Related Group (DRG) Information

R		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	DR
02	1271	Diagnosis Related Group (DRG) Code	R
03	1250	Date Time Period Format Qualifier	N
04	1251	Date Time Period	N
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
N		C022	Health Care Code Information
N		C022	Health Care Code Information
N		C022	Health Care Code Information
N		C022	Health Care Code Information
N		C022	Health Care Code Information
N		C022	Health Care Code Information
N		C022	Health Care Code Information
N		C022	Health Care Code Information
N		C022	Health Care Code Information
N		C022	Health Care Code Information
N		C022	Health Care Code Information

HI- Other Diagnosis Information

R		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BF
02	1271	Other Diagnosis	R
03	1250	Date Time Period Format Qualifier	N
04	1251	Date Time Period	N
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BF
02	1271	Other Diagnosis	R
03	1250	Date Time Period Format Qualifier	N
04	1251	Date Time Period	N
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BF
02	1271	Other Diagnosis	R
03	1250	Date Time Period Format Qualifier	N
04	1251	Date Time Period	N
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BF
02	1271	Other Diagnosis	R
03	1250	Date Time Period Format Qualifier	N
04	1251	Date Time Period	N
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BF
02	1271	Other Diagnosis	R
03	1250	Date Time Period Format Qualifier	N
04	1251	Date Time Period	N
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BF
02	1271	Other Diagnosis	R
03	1250	Date Time Period Format Qualifier	N
04	1251	Date Time Period	N
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BF
02	1271	Other Diagnosis	R
03	1250	Date Time Period Format Qualifier	N
04	1251	Date Time Period	N
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BF
02	1271	Other Diagnosis	R
03	1250	Date Time Period Format Qualifier	N
04	1251	Date Time Period	N
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BF
02	1271	Other Diagnosis	R
03	1250	Date Time Period Format Qualifier	N
04	1251	Date Time Period	N
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BF
02	1271	Other Diagnosis	R
03	1250	Date Time Period Format Qualifier	N
04	1251	Date Time Period	N
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BF
02	1271	Other Diagnosis	R
03	1250	Date Time Period Format Qualifier	N
04	1251	Date Time Period	N
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BF
02	1271	Other Diagnosis	R
03	1250	Date Time Period Format Qualifier	N
04	1251	Date Time Period	N
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N

HI- Principal Procedure Information

R		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BP BR
02	1271	Principal Procedure Code	R
03	1250	Date Time Period Format Qualifier	S
	D8
04	1251	Date Time Period	S
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
N		C022	Health Care Code Information
N		C022	Health Care Code Information
N		C022	Health Care Code Information
N		C022	Health Care Code Information
N		C022	Health Care Code Information
N		C022	Health Care Code Information
N		C022	Health Care Code Information
N		C022	Health Care Code Information
N		C022	Health Care Code Information
N		C022	Health Care Code Information
N		C022	Health Care Code Information

HI- Other Procedure Information

R		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BO BQ
02	1271	Procedure Code	R
03	1250	Date Time Period Format Qualifier	S
	D8
04	1251	Procedure Date	S
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BO BQ
02	1271	Procedure Code	R
03	1250	Date Time Period Format Qualifier	S
	D8
04	1251	Procedure Date	S
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BO BQ
02	1271	Procedure Code	R
03	1250	Date Time Period Format Qualifier	S
	D8
04	1251	Procedure Date	S
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BO BQ
02	1271	Procedure Code	R
03	1250	Date Time Period Format Qualifier	S
	D8
04	1251	Procedure Date	S
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BO BQ
02	1271	Procedure Code	R
03	1250	Date Time Period Format Qualifier	S
	D8
04	1251	Procedure Date	S
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BO BQ
02	1271	Procedure Code	R
03	1250	Date Time Period Format Qualifier	S
	D8
04	1251	Procedure Date	S
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BO BQ
02	1271	Procedure Code	R
03	1250	Date Time Period Format Qualifier	S
	D8
04	1251	Procedure Date	S
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BO BQ
02	1271	Procedure Code	R
03	1250	Date Time Period Format Qualifier	S
	D8
04	1251	Procedure Date	S
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BO BQ
02	1271	Procedure Code	R
03	1250	Date Time Period Format Qualifier	S
	D8
04	1251	Procedure Date	S
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BO BQ
02	1271	Procedure Code	R
03	1250	Date Time Period Format Qualifier	S
	D8
04	1251	Procedure Date	S
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BO BQ
02	1271	Procedure Code	R
03	1250	Date Time Period Format Qualifier	S
	D8
04	1251	Procedure Date	S
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BO BQ
02	1271	Procedure Code	R
03	1250	Date Time Period Format Qualifier	S
	D8
04	1251	Procedure Date	S
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N

HI- Occurrence Span Information

R		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BI
02	1271	Occurrence Span Code	R
03	1250	Date Time Period Format Qualifier	R
	RD8
04	1251	Occurrence or Occurrence Span Code Associated Date	R
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BI
02	1271	Occurrence Span Code	R
03	1250	Date Time Period Format Qualifier	R
	RD8
04	1251	Occurrence or Occurrence Span Code Associated Date	R
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BI
02	1271	Occurrence Span Code	R
03	1250	Date Time Period Format Qualifier	R
	RD8
04	1251	Occurrence or Occurrence Span Code Associated Date	R
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BI
02	1271	Occurrence Span Code	R
03	1250	Date Time Period Format Qualifier	R
	RD8
04	1251	Occurrence or Occurrence Span Code Associated Date	R
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BI
02	1271	Occurrence Span Code	R
03	1250	Date Time Period Format Qualifier	R
	RD8
04	1251	Occurrence or Occurrence Span Code Associated Date	R
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BI
02	1271	Occurrence Span Code	R
03	1250	Date Time Period Format Qualifier	R
	RD8
04	1251	Occurrence or Occurrence Span Code Associated Date	R
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BI
02	1271	Occurrence Span Code	R
03	1250	Date Time Period Format Qualifier	R
	RD8
04	1251	Occurrence or Occurrence Span Code Associated Date	R
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BI
02	1271	Occurrence Span Code	R
03	1250	Date Time Period Format Qualifier	R
	RD8
04	1251	Occurrence or Occurrence Span Code Associated Date	R
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BI
02	1271	Occurrence Span Code	R
03	1250	Date Time Period Format Qualifier	R
	RD8
04	1251	Occurrence or Occurrence Span Code Associated Date	R
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BI
02	1271	Occurrence Span Code	R
03	1250	Date Time Period Format Qualifier	R
	RD8
04	1251	Occurrence or Occurrence Span Code Associated Date	R
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BI
02	1271	Occurrence Span Code	R
03	1250	Date Time Period Format Qualifier	R
	RD8
04	1251	Occurrence or Occurrence Span Code Associated Date	R
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BI
02	1271	Occurrence Span Code	R
03	1250	Date Time Period Format Qualifier	R
	RD8
04	1251	Occurrence or Occurrence Span Code Associated Date	R
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N

HI- Occurrence Information

R		022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BH
02	1271	Occurrence Code	R
03	1250	Date Time Period Format Qualifier	R
	D8
04	1251	Occurrence or Occurrence Span Code Associated Date	R
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BH
02	1271	Occurrence Code	R
03	1250	Date Time Period Format Qualifier	R
	D8
04	1251	Occurrence or Occurrence Span Code Associated Date	R
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BH
02	1271	Occurrence Code	R
03	1250	Date Time Period Format Qualifier	R
	D8
04	1251	Occurrence or Occurrence Span Code Associated Date	R
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BH
02	1271	Occurrence Code	R
03	1250	Date Time Period Format Qualifier	R
	D8
04	1251	Occurrence or Occurrence Span Code Associated Date	R
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BH
02	1271	Occurrence Code	R
03	1250	Date Time Period Format Qualifier	R
	D8
04	1251	Occurrence or Occurrence Span Code Associated Date	R
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BH
02	1271	Occurrence Code	R
03	1250	Date Time Period Format Qualifier	R
	D8
04	1251	Occurrence or Occurrence Span Code Associated Date	R
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BH
02	1271	Occurrence Code	R
03	1250	Date Time Period Format Qualifier	R
	D8
04	1251	Occurrence or Occurrence Span Code Associated Date	R
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BH
02	1271	Occurrence Code	R
03	1250	Date Time Period Format Qualifier	R
	D8
04	1251	Occurrence or Occurrence Span Code Associated Date	R
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BH
02	1271	Occurrence Code	R
03	1250	Date Time Period Format Qualifier	R
	D8
04	1251	Occurrence or Occurrence Span Code Associated Date	R
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BH
02	1271	Occurrence Code	R
03	1250	Date Time Period Format Qualifier	R
	D8
04	1251	Occurrence or Occurrence Span Code Associated Date	R
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BH
02	1271	Occurrence Code	R
03	1250	Date Time Period Format Qualifier	R
	D8
04	1251	Occurrence or Occurrence Span Code Associated Date	R
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BH
02	1271	Occurrence Code	R
03	1250	Date Time Period Format Qualifier	R
	D8
04	1251	Occurrence or Occurrence Span Code Associated Date	R
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N

HI- Value Information

R		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BE
02	1271	Value Code	R
03	1250	Date Time Period Format Qualifier	N
04	1251	Date Time Period	N
05	782	Value Code Associated Amount	R
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Health Care Code Information
01	1270	fier Code	R
	BE
02	1271	Value Code	R
03	1250	Date Time Period Format Qualifier	N
04	1251	Date Time Period	N
05	782	Value Code Associated Amount	R
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BE
02	1271	Value Code	R
03	1250	Date Time Period Format Qualifier	N
04	1251	Date Time Period	N
05	782	Value Code Associated Amount	R
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BE
02	1271	Value Code	R
03	1250	Date Time Period Format Qualifier	N
04	1251	Date Time Period	N
05	782	Value Code Associated Amount	R
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BE
02	1271	Value Code	R
03	1250	Date Time Period Format Qualifier	N
04	1251	Date Time Period	N
05	782	Value Code Associated Amount	R
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BE
02	1271	Value Code	R
03	1250	Date Time Period Format Qualifier	N
04	1251	Date Time Period	N
05	782	Value Code Associated Amount	R
06	380	Quantity	N
07	799	n Identifier	N
S		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BE
02	1271	Value Code	R
03	1250	Date Time Period Format Qualifier	N
04	1251	Date Time Period	N
05	782	Value Code Associated Amount	R
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BE
02	1271	Value Code	R
03	1250	Date Time Period Format Qualifier	N
04	1251	Date Time Period	N
05	782	Value Code Associated Amount	R
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BE
02	1271	Value Code	R
03	1250	Date Time Period Format Qualifier	N
04	1251	Date Time Period	N
05	782	Value Code Associated Amount	R
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BE
02	1271	Value Code	R
03	1250	Date Time Period Format Qualifier	N
04	1251	Date Time Period	N
05	782	Value Code Associated Amount	R
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BE
02	1271	Value Code	R
03	1250	Date Time Period Format Qualifier	N
04	1251	Date Time Period	N
05	782	Value Code Associated Amount	R
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BE
02	1271	Value Code	R
03	1250	Date Time Period Format Qualifier	N
04	1251	Date Time Period	N
05	782	Value Code Associated Amount	R
06	380	Quantity	N
07	799	Version Identifier	N

HI- Condition Information

R		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BG
02	1271	Condition Code	R
03	1250	Date Time Period Format Qualifier	N
04	1251	Date Time Period	N
05	782	netary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
R		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BG
02	1271	Condition Code	R
03	1250	Date Time Period Format Qualifier	N
04	1251	Date Time Period	N
05	782	netary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
R		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BG
02	1271	Condition Code	R
03	1250	Date Time Period Format Qualifier	N
04	1251	Date Time Period	N
05	782	netary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
R		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BG
02	1271	Condition Code	R
03	1250	Date Time Period Format Qualifier	N
04	1251	Date Time Period	N
05	782	netary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
R		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BG
02	1271	Condition Code	R
03	1250	Date Time Period Format Qualifier	N
04	1251	Date Time Period	N
05	782	netary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
R		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BG
02	1271	Condition Code	R
03	1250	Date Time Period Format Qualifier	N
04	1251	Date Time Period	N
05	782	netary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
R		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BG
02	1271	Condition Code	R
03	1250	Date Time Period Format Qualifier	N
04	1251	Date Time Period	N
05	782	netary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
R		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BG
02	1271	Condition Code	R
03	1250	Date Time Period Format Qualifier	N
04	1251	Date Time Period	N
05	782	netary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
R		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BG
02	1271	Condition Code	R
03	1250	Date Time Period Format Qualifier	N
04	1251	Date Time Period	N
05	782	netary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
R		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BG
02	1271	Condition Code	R
03	1250	Date Time Period Format Qualifier	N
04	1251	Date Time Period	N
05	782	netary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
R		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BG
02	1271	Condition Code	R
03	1250	Date Time Period Format Qualifier	N
04	1251	Date Time Period	N
05	782	netary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
R		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BG
02	1271	Condition Code	R
03	1250	Date Time Period Format Qualifier	N
04	1251	Date Time Period	N
05	782	netary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N

HI- Treatment Code Information

R		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	TC
02	1271	Treatment Code	R
03	1250	Date Time Period Format Qualifier	N
04	1251	Date Time Period	N
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
R		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	TC
02	1271	Treatment Code	R
03	1250	Date Time Period Format Qualifier	N
04	1251	Date Time Period	N
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
R		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	TC
02	1271	Treatment Code	R
03	1250	Date Time Period Format Qualifier	N
04	1251	Date Time Period	N
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
R		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	TC
02	1271	Treatment Code	R
03	1250	Date Time Period Format Qualifier	N
04	1251	Date Time Period	N
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
R		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	TC
02	1271	Treatment Code	R
03	1250	Date Time Period Format Qualifier	N
04	1251	Date Time Period	N
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
R		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	TC
02	1271	Treatment Code	R
03	1250	Date Time Period Format Qualifier	N
04	1251	Date Time Period	N
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
R		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	TC
02	1271	Treatment Code	R
03	1250	Date Time Period Format Qualifier	N
04	1251	Date Time Period	N
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
R		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	TC
02	1271	Treatment Code	R
03	1250	Date Time Period Format Qualifier	N
04	1251	Date Time Period	N
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
R		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	TC
02	1271	Treatment Code	R
03	1250	Date Time Period Format Qualifier	N
04	1251	Date Time Period	N
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
R		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	TC
02	1271	Treatment Code	R
03	1250	Date Time Period Format Qualifier	N
04	1251	Date Time Period	N
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
R		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	TC
02	1271	Treatment Code	R
03	1250	Date Time Period Format Qualifier	N
04	1251	Date Time Period	N
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
R		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	TC
02	1271	Treatment Code	R
03	1250	Date Time Period Format Qualifier	N
04	1251	Date Time Period	N
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N

QTY- Claim Quantity

01	673	Quantity Qualifier	R
	CA CD LA NA
02	380	Claim Days Count	R
R		C001	Composite Unit of Measure
01	355	Unit or Basis for Measurement Code	R
	DA
02	1018	Exponent	N
03	649	Multiplier	N
04	355	Unit or Basis for Measurement Code	N
05	1018	Exponent	N
06	649	Multiplier	N
07	355	Unit or Basis for Measurement Code	N
08	1018	Exponent	N
09	649	Multiplier	N
10	355	Unit or Basis for Measurement Code	N
11	1018	Exponent	N
12	649	Multiplier	N
13	355	Unit or Basis for Measurement Code	N
14	1018	Exponent	N
15	649	Multiplier	N
04	61	Free-Form Message	N

HCP- Claim Pricing/Repricing Information

01	1473	Pricing Methodology	R
	00 01 02 03 04 05 06 07 08 09 10 11 12 13 14
02	782	Repriced Allowed Amount	R
03	782	Repriced Saving Amount	S
04	127	Repricing Organization Identifier	S
05	118	Repricing Per Diem or Flat Rate Amount	S
06	127	Repriced Approved DRG Code	S
07	782	Repriced Approved Amount	S
08	234	Repriced Approved Revenue Code	S
09	235	Product or Service ID Qualifier	S
	HC
10	234	Repriced Approved HCPCS Code	S
11	355	Unit or Basis for Measurement Code	S
	DA UN
12	380	Repriced Approved Service Unit Count	S
13	901	Rejection Message	S
	T1 T2 T3 T4 T5 T6
14	1526	Policy Compliance Code	S
	1 2 3 4 5
15	1527	Exception Reason Code	S
	1 2 3 4 5 6

CR7- Home Health Care Plan Information

01	921	Disipline Type Code	R
	AI MS OT PT SN ST
02	1470	Visits Prior to Recertification Date Count	R
03	1470	Total Visits Projected This Certification Count	R

HSD- Health Care Services Delivery

01	673	Visits	S
	VS
02	380	Number of Visits	S
03	355	Frequency Period	S
	DA MO Q1 WK
04	1167	Frequency Count	S
05	615	Duration of Visits Units	S
	7 35
06	616	Duration of Visits, Number of Units	S
07	678	Ship, Delivery or Calendar Pattern Code	S
	1 2 3 4 5 6 7 8 9 A B C D E F G H J K L N O S SA SB SC SD SG SL SP SX SY SZ W
08	679	Delivery Pattern Time Code	S
	D E F

NM1- Attending Physician Name

01	98	Entity Identifier Code	R
	71
02	1065	Entity Type Qualifier	R
	1 2
03	1035	Attending Physician Last Name	R
04	1036	Attending Physician First Name	S
05	1037	Attending Physician Middle Name	S
06	1038	Name Prefix	N
07	1039	Attending Physician Name Suffix	S
08	66	Identification Code Qualifier	R
	24 34 XX
09	67	Attending Physician Primary Identifier	R
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

PRV- Attending Physician Specialty Information

01	1221	Provider Code	R
	AT SU
02	128	Reference Identification Qualifier	R
	ZZ
03	127	Provider Taxonomy Code	R
04	156	State or Province Code	N
N		C035	Provider Specialty Information
06	1223	Provider Organization Code	N

REF- Attending Physician Secondary Identification

01	128	Reference Identification Qualifier	R
	0B 1A 1B 1C 1D 1G 1H EI G2 LU N5 SY X5
02	127	Attending Physician Secondary Identifier	R
03	352	Description	N
N		C040	Reference Identifier

NM1- Operating Physician Name

01	98	Entity Identifier Code	R
	72
02	1065	Entity Type Qualifier	R
	1
03	1035	Operating Physician Last Name	R
04	1036	Operating Physician First Name	R
05	1037	Operating Physician Middle Name	S
06	1038	Name Prefix	N
07	1039	Operating Physician Name Suffix	S
08	66	Identification Code Qualifier	R
	24 34 XX
09	67	Operating Physician Primary Identifier	R
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

PRV- Operating Physician Specialty Information

01	1221	Provider Code	R
	OP
02	128	Reference Identification Qualifier	R
	ZZ
03	127	Provider Taxonomy Code	R
04	156	State or Province Code	N
N		C035	Provider Specialty Information
06	1223	Provider Organization Code	N

REF- Operating Physician Secondary Identification

1	128	Reference Identification Qualifier	R
	0B 1A 1B 1C 1D 1G 1H EI G2 LU N5 SY X5
02	127	Operating Physician Secondary Identifier	R
03	352	Description	N
N		C040	Reference Identifier

NM1- Other Provider Name

01	98	Entity Identifier Code	R
	73
02	1065	Entity Type Qualifier	R
	1 2
03	1035	Other Physician Last Name	R
04	1036	Other Physician First Name	S
05	1037	Other Provider Middle Name	S
06	1038	Name Prefix	N
07	1039	Other Provider Name Suffix	S
08	66	Identification Code Qualifier	R
	24 34 XX
09	67	Other Physician Identifier	R
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

PRV- Other Provider Specialty Information

01	1221	Provider Code	R
	OT PE
02	128	Reference Identification Qualifier	R
	ZZ
03	127	Provider Taxonomy Code	R
04	156	State or Province Code	N
N		C035	Provider Specialty Information
06	1223	Provider Organization Code	N

REF- Other Provider Secondary Identification

01	128	Reference Identification Qualifier	R
	0B 1A 1B 1C 1D 1G 1H EI G2 LU N5 SY X5
02	127	Other Provider Secondary Identifier	R
03	352	Description	N
N		C040	Reference Identifier

NM1- Referring Provider Name

01	98	Entity Identifier Code	R
	DN P3
02	1065	Entity Type Qualifier	R
	1 2
03	1035	Referring Provider Last Name	R
04	1036	Referring Provider First Name	S
05	1037	Referring Provider Middle Name	S
06	1038	Name Prefix	N
07	1039	Referring Provider Name Suffix	S
08	66	Identification Code Qualifier	S
	24 34 XX
09	67	Referring Provider Identifier	S
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

PRV- Referring Provider Specialty Information

01	1221	Provider Code	R
	RF
02	128	Reference Identification Qualifier	R
	ZZ
03	127	Provider Taxonomy Code	R
04	156	State or Province Code	N
N		C035	Provider Specialty Information
06	1223	Provider Organization Code	N

REF- Referring Provider Secondary Identification

01	128	Reference Identification Qualifier	R
	0B 1A 1B 1C 1D 1G B3 BQ EI G2 LU N5 SY X5
02	127	Referring Provider Secondary Identifier	R
03	352	Description	N
N		C040	Reference Identifier

NM1- Service Facility Name

01	98	Entity Identifier Code	R
	FA
02	1065	Entity Type Qualifier	R
	2
03	1035	Laboratory or Facility Name	R
04	1036	Name First	N
05	1037	Name Middle	N
06	1038	Name Prefix	N
07	1039	Name Suffix	N
08	66	Identification Code Qualifier	S
	24 34 XX
09	67	Laboratory or Facility Primary Identifier	S
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

PRV- Service Facility Specialty Information

01	1221	Provider Code	R
	RP
02	128	Reference Identification Qualifier	R
	ZZ
03	127	Provider Taxonomy Code	R
04	156	State or Province Code	N
N		C035	Provider Specialty Information
06	1223	Provider Organization Code	N

N3- Service Facility Address

01	166	Laboratory or Facility Address Line	R
02	166	Laboratory or Facility Address Line	S

N4- Service Facility City/State/Zip Code

01	19	Laboratory or Facility City Name	R
02	156	Laboratory or Facility State or Province Code	R
	AA AB AE AK AL AP AR AS AZ BC CA CO CT DC DE FL FM GA GU HI IA ID IL IN KS KY LA MA MB MD ME MH MI MN MO MP MS MT NB NC ND NE NF NH NJ NM NS NT NV NY OH OK ON OR PA PE PQ PR RI SC SD SK TN TX UT VA VI VT WA WI WV WY YT
03	116	Laboratory or Facility Postal Zone or Zip Code	R
04	26	Laboratory/Facility Country Code	S
	External Source: country
05	309	Location Qualifier	N
06	310	Location Identifier	N

REF- Service Facility Secondary Identification

01	128	Reference Identification Qualifier	R
	0B 1A 1B 1C 1D 1G 1H 1J EI FH G2 G5 LU N5 X5
02	127	Laboratory or Facility Secondary Identifier	R
03	352	Description	N
N		C040	Reference Identifier

SBR- Other Subscriber Information

01	1138	Payer Responsibility Sequence Number Code	R
	P S T
02	1069	Individual Relationship Code	R
	01 04 05 07 10 15 17 18 19 20 21 22 23 24 29 32 33 36 39 40 41 43 53 G8
03	127	Insured Group or Policy Number	S
04	93	Other Insured Group Name	S
05	1336	Insurance Type Code	N
06	1143	Coordination of Benefits Code	N
07	1073	Condition or Response Code	N
08	584	Employment Status Code	N
09	1032	Claim Filing Indicator Code	S
	09 10 11 12 13 14 15 16 AM BL CH CI DS HM LI LM MA MB MC OF TV VA WC ZZ

CAS- Claim Level Adjustment

01	1033	Claim Adjustment Group Code	R
	CO CR OA PI PR
02	1034	Adjustment Reason Code	R
	External Source: adjustment_reason
03	782	Adjustment Amount	R
04	380	Quantity	S
05	1034	Adjustment Reason Code	S
	External Source: adjustment_reason
06	782	Adjustment Amount	S
07	380	Adjustment Quantity	S
08	1034	Adjustment Reason Code	S
	External Source: adjustment_reason
09	782	Adjustment Amount	S
10	380	Adjustment Quantity	S
11	1034	Adjustment Reason Code	S
	External Source: adjustment_reason
12	782	Adjustment Amount	S
13	380	Adjustment Quantity	S
14	1034	Adjustment Reason Code	S
	External Source: adjustment_reason
15	782	Adjustment Amount	S
16	380	Adjustment Quantity	S
17	1034	Adjustment Reason Code	S
	External Source: adjustment_reason
18	782	Adjustment Amount	S
19	380	Adjustment Quantity	S

AMT- Payer Prior Payment

01	522	Amount Qualifier Code	R
	C4
02	782	Other Payer Patient Paid Amount	R
03	478	Credit/Debit Flag Code	N

AMT- Coordination of Benefits (COB) Total Allowed Amount

01	522	Amount Qualifier Code	R
	B6
02	782	Allowed Amount	R
03	478	Credit/Debit Flag Code	N

AMT- Coordination of Benefits (COB) Total Submitted Charges

01	522	Amount Qualifier Code	R
	T3
02	782	Coordination of Benefits Total Submitted Charge Amount	R
03	478	Credit/Debit Flag Code	N

AMT- Diagnostic Related Group (DRG) Outlier Amount

01	522	Amount Qualifier Code	R
	ZZ
02	782	Claim DRG Outlier Amount	R
03	478	Credit/Debit Flag Code	N

AMT- Coordination of Benefits (COB) Total Medicare Paid Amount

01	522	Amount Qualifier Code	R
	N1
02	782	Total Medicare Paid Amount	R
03	478	Credit/Debit Flag Code	N

AMT- dicare Paid Amount - 100%

01	522	Amount Qualifier Code	R
	KF
02	782	Medicare Paid at 100% Amount	R
03	478	Credit/Debit Flag Code	N

AMT- Medicare Paid Amount - 80%

01	522	Amount Qualifier Code	R
	PG
02	782	Medicare Paid at 80% Amount	R
03	478	Credit/Debit Flag Code	N

AMT- Coordination of Benefits (COB) Medicare A Trust Fund Paid Amount

01	522	Amount Qualifier Code	R
	AA
02	782	Paid From Part A Medicare Trust Fund Amount	R
03	478	Credit/Debit Flag Code	N

AMT- Coordination of Benefits (COB) Medicare B Trust Fund Paid Amount

01	522	Amount Qualifier Code	R
	B1
02	782	Paid From Part B Medicare Trust Fund Amount	R
03	478	Credit/Debit Flag Code	N

AMT- Coordination of Benefits (COB) Total Non-Covered Amount

01	522	Amount Qualifier Code	R
	A8
02	782	Non-Covered Charge Amount	R
03	478	Credit/Debit Flag Code	N

AMT- Coordination of Benefits (COB) Total Denied Amount

01	522	Amount Qualifier Code	R
	YT
02	782	Claim Total Denied Charge Amount	R
03	478	Credit/Debit Flag Code	N

DMG- Other Subscriber Demographic Information

01	1250	Date Time Period Format Qualifier	R
	D8
02	1251	Other Insured Birth Date	R
03	1068	Other Insured Gender Code	R
	F M U
04	1067	Marital Status Code	N
05	1109	nicity Code	N
06	1066	Citizenship Status Code	N
07	26	Country Code	N
	External Source: country
08	659	Basis of Verification Code	N
09	380	Quantity	N

OI- Other Insurance Coverage Information

01	1032	Claim Filing Indicator Code	N
02	1383	Claim Submission Reason Code	N
03	1073	Benefit Assignment Certification Indicator	R
	N Y
04	1351	Patient Signature Source Code	N
05	1360	Provider Agreement Code	N
06	1363	Release of Information Code	R
	A I M N O Y

MIA- Medicare Inpatient Adjudication Information

01	380	Covered Days or Visits Count	R
02	380	Lifetime Reserve Days Count	S
03	380	fetime Psychiatric Days Count	S
04	782	Claim DRG Amount	S
05	127	Remark Code	S
06	782	Claim Disproportionate Share Amount	S
07	782	Claim MSP Pass-through Amount	S
08	782	Claim PPS Capital Amount	S
09	782	PPS-Capital FSP DRG Amount	S
10	782	PPS-Capital HSP DRG Amount	S
11	782	PPS-Capital DSH DRG Amount	S
12	782	Old Capital Amount	S
13	782	PPS-Capital IME Amount	S
14	782	PPS-Operating Hospital Specific DRG Amount	S
15	380	Cost Report Day Count	S
16	782	PPS-Operating Federal Specific DRG Amount	S
17	782	Claim PPS Capital Outlier Amount	S
18	782	Claim Indirect Teaching Amount	S
19	782	Nonpayable Professional Component Amount	S
20	127	Remark Code	S
21	127	Remark Code	S
22	127	Remark Code	S
23	127	Remark Code	S
24	782	PPS-Capital Exception Amount	S

MOA- Medicare Outpatient Adjudication Information

01	954	Reimbursement Rate	S
02	782	Claim HCPCS Payable Amount	S
03	127	Remark Code	S
04	127	Remark Code	S
05	127	Remark Code	S
06	127	Remark Code	S
07	127	Remark Code	S
08	782	Claim ESRD Payment Amount	S
09	782	Nonpayable Professional Component Amount	S

NM1- Other Subscriber Name

01	98	Entity Qualifier Code	R
	IL
02	1065	Entity Type Qualifier	R
	1 2
03	1035	Other Insured Last Name	R
04	1036	Other Insured First Name	S
05	1037	Other Insured Middle Name	S
06	1038	fix	N
07	1039	Other Insured Name Suffix	S
08	66	Identification Code Qualifier	R
	MI ZZ
09	67	Other Insured Identifier	R
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

N3- Other Subscriber Address

01	166	Other Insured Address Line	R
02	166	Other Insured Address Line	S

N4- Other Subscriber City/State/ZIP Code

01	19	Other Insured City Name	R
02	156	Other Insured State Code	R
	AA AB AE AK AL AP AR AS AZ BC CA CO CT DC DE FL FM GA GU HI IA ID IL IN KS KY LA MA MB MD ME MH MI MN MO MP MS MT NB NC ND NE NF NH NJ NM NS NT NV NY OH OK ON OR PA PE PQ PR RI SC SD SK TN TX UT VA VI VT WA WI WV WY YT
03	116	Other Insured Postal Zone or Zip Code	R
04	26	Subscriber Country Code	S
	External Source: country
05	309	Location Qualifier	N
06	310	Location Identifier	N

REF- Other Subscriber Secondary Identification

01	128	Reference Identification Qualifier	R
	1W 23 IG SY
02	127	Other Insured Additional Identifier	R
03	352	Description	N
N		C040	Reference Identifier

NM1- Other Payer Name

01	98	Entity Identifier Code	R
	PR
02	1065	Entity Type Qualifier	R
	2
03	1035	Other Payer Last or Organization Name	R
04	1036	Name First	N
05	1037	Name Middle	N
06	1038	Name Prefix	N
07	1039	Name Suffix	N
08	66	Identification Code Qualifier	R
	PI XV
09	67	Other Payer Primary Identifier	R
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

N3- Other Payer Address

01	166	Other Payer's Address Line	R
02	166	Other Payer's Address Line	S

N4- Other Payer City/State/ZIP Code

01	19	Other Payer City Name	R
02	156	Other Payer State Code	R
	AA AB AE AK AL AP AR AS AZ BC CA CO CT DC DE FL FM GA GU HI IA ID IL IN KS KY LA MA MB MD ME MH MI MN MO MP MS MT NB NC ND NE NF NH NJ NM NS NT NV NY OH OK ON OR PA PE PQ PR RI SC SD SK TN TX UT VA VI VT WA WI WV WY YT
03	116	Other Payer Postal Zone or Zip Code	R
04	26	Payer Country Code	S
	External Source: country
05	309	Location Qualifier	N
06	310	Location Identifier	N

DTP- Claim Adjudication Date

01	374	Date Time Qualifier	R
	573
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Adjudication or Payment Date	R

REF- Other Payer Secondary Identification and Reference Number

01	128	Reference Identification Qualifier	R
	2U F8 FY NF TJ
02	127	Other Payer Secondary Identifier	R
03	352	Description	N
N		C040	Reference Identifier

REF- Other Payer Prior Authorization or Referral Number

01	128	Reference Identification Qualifier	R
	9F G1
02	127	Other Payer Prior Authorization or Referral Number	R
03	352	Description	N
N		C040	Reference Identifier

NM1- Other Payer Patient Information

01	98	Entity Identifier Code	R
	QC
02	1065	Entity Type Qualifier	R
	1
03	1035	Name Last or Organization Name	N
04	1036	Name First	N
05	1037	Name Middle	N
06	1038	Name Prefix	N
07	1039	Name Suffix	N
08	66	Identification Code Qualifier	R
	EI MI
09	67	Other Payer Patient Primary Identifier	R
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

REF- Other Payer identification Number

01	128	Reference Identification Qualifier	R
	1W IG SY
02	127	Other Payer Patient Secondary Identifier	R
03	352	Description	N
N		C040	Reference Identifier

NM1- Other Payer Attending Provider

01	98	Entity Identifier Code	R
	71
02	1065	Entity Type Qualifier	R
	1 2
03	1035	Name Last or Organization Name	N
04	1036	Name First	N
05	1037	Name Middle	N
06	1038	Name Prefix	N
07	1039	Name Suffix	N
08	66	Identification Code Qualifier	N
09	67	Identification Code	N
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

REF- Other Payer Attending Provider Identification

01	128	Reference Identification Qualifier	R
	1A 1B 1C 1D 1G 1H EI G2 LU N5
02	127	Other Payer Attending Provider Identifier	R
03	352	Description	N
N		C040	Reference Identifier

NM1- Other Payer Operating Provider

01	98	Entity Identifier Code	R
	72
02	1065	Entity Type Qualifier	R
	1
03	1035	Name Last or Organization Name	N
04	1036	Name First	N
05	1037	Name Middle	N
06	1038	Name Prefix	N
07	1039	Name Suffix	N
08	66	Identification Code Qualifier	N
09	67	Identification Code	N
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

REF- Other Payer Operating Provider Identification

01	128	Reference Identification Qualifier	R
	1A 1B 1C 1D 1G 1H EI G2 LU N5
02	127	Other Payer Operating Provider Identifier	R
03	352	Description	N
N		C040	Reference Identifier

NM1- Other Payer Other Provider

01	98	Entity Identifier Code	R
	73
02	1065	Entity Type Qualifier	R
	1 2
03	1035	Name Last or Organization Name	N
04	1036	Name First	N
05	1037	Name Middle	N
06	1038	Name Prefix	N
07	1039	Name Suffix	N
08	66	Identification Code Qualifier	N
09	67	Identification Code	N
10	706	Entity Relationship Code	N
11	98	fier Code	N

REF- Other Payer Other Provider Identification

01	128	Reference Identification Qualifier	R
	1A 1B 1C 1D 1G 1H EI G2 LU N5 SY
02	127	Other Payer Other Provider Identifier	R
03	352	on	N
N		C040	Reference Identifier

NM1- Other Payer Referring Provider

01	98	Entity Identifier Code	R
	DN P3
02	1065	Entity Type Qualifier	R
	1 2
03	1035	Name Last or Organization Name	N
04	1036	Name First	N
05	1037	Name Middle	N
06	1038	Name Prefix	N
07	1039	Name Suffix	N
08	66	Identification Code Qualifier	N
09	67	Identification Code	N
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

REF- Other Payer Referring Provider Identification

01	128	Reference Identification Qualifier	R
	1A 1B 1C 1D 1G B3 BQ EI G2 LU N5 SY X5
02	127	Other Payer Referring Provider Identifier	R
03	352	Description	N
N		C040	Reference Identifier

NM1- Other Payer Service Facility Provider

01	98	Entity Identifier Code	R
	FA
02	1065	Entity Type Qualifier	R
	2
03	1035	Name Last or Organization Name	N
04	1036	Name First	N
05	1037	Name Middle	N
06	1038	Name Prefix	N
07	1039	Name Suffix	N
08	66	ode Qualifier	N
09	67	Identification Code	N
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

REF- Other Payer Service Facility Provider Identification

01	128	Reference Identification Qualifier	R
	1B 1C 1D EI G2 LU N5
02	127	Other Payer Service Facility Provider Identifier	R
03	352	Description	N
N		C040	Reference Identifier

LX- Service Line Number

554

Assigned Number

SV2- Institutional Service Line

01	234	Service Line Revenue Code	R
S		C003	Service Line Procedure Code
01	235	Product or Service ID Qualifier	R
	HC IV N1 N2 N3 N4 ZZ
02	234	Procedure Code	R
03	1339	HCPCS Modifier 1	S
04	1339	HCPCS Modifier 2	S
05	1339	HCPCS Modifier 3	S
06	1339	HCPCS Modifier 4	S
07	352	Description	N
03	782	Line Item Charge Amount	R
04	355	Unit or Basis for Measurement Code	R
	DA F2 UN
05	380	Service Unit Count	R
06	1371	Service Line Rate	S
07	782	Line Item Denied Charge or Non-Covered Charge Amount	S
08	1073	Yes/No Condition or Response Code	N
09	1345	Status Code	N
10	1337	Level of Care Code	N

SV4- Prescription Number

01	127	Prescription Number	R
N		C003	Composite Medical Procedure Identifier
03	127	Reference Identification	N
04	1073	Yes/No Condition or Response Code	N
05	1329	Dispense as Written Code	N
06	1338	Level of Service Code	N
07	1356	Prescription Origin Code	N
08	352	Description	N
09	1073	Yes/No Condition or Response Code	N
10	1073	Yes/No Condition or Response Code	N
11	1370	Unit Dose Code	N
12	1319	Basis of Cost Determination Code	N
13	1320	Basis of Days Supply Determination Code	N
14	1330	Dosage Form Code	N
15	1327	Copay Status Code	N
16	1384	Patient Location Code	N
17	1337	Level of Care Code	N
18	1357	Prior Authorization Type Code	N

PWK- Line Supplemental Information

01	755	Attachment Report Type Code	R
	AS B2 B3 B4 CT DA DG DS EB MT NN OB OZ PN PO PZ RB RR RT
02	756	Attachment Transmission Code	R
	AA AB AD AF AG BM EL EM FX
03	757	Report Copies Needed	N
04	98	Entity Identifier Code	N
05	66	Identification Code Qualifier	S
	AC
06	67	Attachment Control Number	S
07	352	Description	N
N		C002	Actions Indicated
09	1525	Request Category Code	N

DTP- Service Line Date

01	374	Date Time Qualifier	R
	472
02	1250	Date Time Period Format Qualifier	R
	D8 RD8
03	1251	Service Date	R

DTP- Assessment Date

01	374	Date Time Qualifier	R
	866
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Assessment Date	R

AMT- Service Tax Amount

01	522	Amount Qualifier Code	R
	GT
02	782	Service Tax Amount	R
03	478	Credit/Debit Flag Code	N

AMT- Facility Tax Amount

01	522	Amount Qualifier Code	R
	N8
02	782	Facility Tax Amount	R
03	478	Credit/Debit Flag Code	N