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
	004010X098A1

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- Transmission Type Identification R0203

01	128	Reference Identification Qualifier	R
	87
02	127	Transmission Type Code	R
	004010X098DA1 004010X098A1
03	352	Description	N
N	REF04	C040	Reference Identifier

NM1- Submitter Name P0809 C1110

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 P0304 P0506 P0708

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 P0809 C1110

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	Identification Code Qualifier	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
	External Source: states
N		C035	Provider Specialty Information
06	1223	Provider Organization Code	N

CUR- Foreign Currency Information C0807 C0907 L101112 C1110 C1210 L131415 C1413 C1513 L161718 C1716 C1816 L192021 C2019 C2119

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 P0809 C1110

01	98	Entity Identifier Code	R
	85
02	1065	Entity Type Qualifier	R
	1 2
03	1035	Billing Provider Last or Organizational Name	R
04	1036	Billing Provider First Name	S
05	1037	Billing Provider Middle Name	S
06	1038	Name Prefix	N
07	1039	Billing Provider Name Suffix	S
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 1	R
02	166	Billing Provider Address Line 2	S

N4- Billing Provider City/State/ZIP Code C0605

01	19	Billing Provider City Name	R
02	156	Billing Provider State or Province Code	R
	External Source: states
03	116	Billing Provider Postal Zone or ZIP Code	R
04	26	Billing Provider Country Code	S
	External Source: country
05	309	Location Qualifier	N
06	310	Location Identifier	N

REF- Billing Provider Secondary Identification R0203

01	128	Reference Identification Qualifier	R
	0B 1A 1B 1C 1D 1G 1H 1J B3 BQ EI FH G2 G5 LU SY U3 X5
02	127	Billing Provider Additional Identifier	R
03	352	Description	N
N	REF04	C040	Reference Identifier

REF- Credit/Debit Card Billing Information R0203

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	REF04	C040	Reference Identifier

PER- Billing Provider Contact Information P0304 P0506 P0708

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 P0809 C1110

01	98	Entity Identifier Code	R
	87
02	1065	Entity Type Qualifier	R
	1 2
03	1035	Pay-To Provider Last or Organizational Name	R
04	1036	Pay-To Provider First Name	S
05	1037	Pay-To Provider Middle Name	S
06	1038	Name Prefix	N
07	1039	Pay-To Provider Name Suffix	S
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 1	R
02	166	Pay-To Provider Address Line 2	S

N4- Pay-To Provider City/State/ZIP Code C0605

01	19	Pay-To Provider City Name	R
02	156	Pay-To Provider State Code	R
	External Source: states
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 R0203

01	128	Reference Identification Qualifier	R
	0B 1A 1B 1C 1D 1G 1H 1J B3 BQ EI FH G2 G5 LU SY U3 X5
02	127	Pay-To Provider Identifier	R
03	352	Description	N
N	REF04	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	Relationship Code	S
	18
03	127	Insured Group or Policy Number	S
04	93	Insured Group Name	S
05	1336	Insurance Type Code	S
	12 13 14 15 16 41 42 43 47
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 MB MC OF TV VA WC ZZ

PAT- Patient Information P0506 P0708

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	S
	D8
06	1251	Insured Individual Death Date	S
07	355	Unit or Basis for Measurement Code	S
	01
08	81	Patient Weight	S
09	1073	Pregnancy Indicator	S
	Y

NM1- Subscriber Name P0809 C1110

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 1	R
02	166	Subscriber Address Line 2	S

N4- Subscriber City/State/ZIP Code C0605

01	19	Subscriber City Name	R
02	156	Subscriber State Code	R
	External Source: states
03	116	Subscriber 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

DMG- Subscriber Demographic Information P0102

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 R0203

01	128	Reference Identification Qualifier	R
	1W 23 IG SY
02	127	Subscriber Supplemental Identifier	R
03	352	Description	N
N	REF04	C040	Reference Identifier

REF- Property and Casualty Claim Number R0203

01	128	Reference Identification Qualifier	R
	Y4
02	127	Property Casualty Claim Number	R
03	352	Description	N
N	REF04	C040	Reference Identifier

NM1- Destination Payer Name P0809 C1110

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- Destination Payer Address

01	166	Payer Address Line 1	R
02	166	Payer Address Line 2	S

N4- Destination Payer City/State/ZIP Code C0605

01	19	Payer City Name	R
02	156	Payer State Code	R
	External Source: states
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- Destination Payer Secondary Identification R0203

01	128	Reference Identification Qualifier	R
	2U FY NF TJ
02	127	Payer Additional Identifier	R
03	352	Description	N
N	REF04	C040	Reference Identifier

NM1- Responsible Party Name P0809 C1110

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 1	R
02	166	Responsible Party Address Line 2	S

N4- Responsible Party City/State/ZIP Code C0605

01	19	Responsible Party City Name	R
02	156	Responsible Party State Code	R
	External Source: states
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

NM1- Credit/Debit Card Holder Name P0809 C1110

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 R0203

01	128	Reference Identification Qualifier	R
	AB BB
02	127	Credit or Debit Card Authorization Number	R
03	352	Description	N
N	REF04	C040	Reference Identifier

CLM- Claim Information

01	1028	Patient Account Number	R
2	782	Total Claim Charge Amount	R
03	1032	Claim Filing Indicator Code	N
04	1343	Non-Institutional Claim Type Code	N
R		C023	Place of Service Code
01	1331	Facility Type Code	R
	External Source: pos
02	1332	Facility Code Qualifier	N
03	1325	Claim Frequency Code	R
06	1073	Provider or Supplier Signature Indicator	R
	N Y
07	1359	Medicare Assignment Code	R
	A B C P
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	S
	B C M P S
S		C024	Accident/Employment/Related Causes
01	1362	Related Causes Code	R
	AA AP EM OA
02	1362	Related Causes Code	S
	AA AP EM OA
03	1362	Related Causes Code	S
	AA AP EM OA
04	156	Auto Accident State or Province Code	S
	External Source: states
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	Participation Agreement	S
	P
17	1029	Claim Status Code	N
18	1073	Yes/No Condition or Response Code	N
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- Date - Initial Treatment

01	374	Date Time Qualifier	R
	454
02	1250	Date Time Period Format Qualifier	R
	D8
3	1251	Initial Treatment Date	R

DTP- Date - Date Last Seen

01	374	Date Time Qualifier	R
	304
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Last Seen Date	R

DTP- Date - Onset of Current Illness/Symptom

01	374	Date Time Qualifier	R
	431
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Onset of Current Illness or Injury Date	R

DTP- Date - Acute Manifestation

01	374	Date Time Qualifier	R
	453
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Acute Manifestation Date	R

DTP- Date - Similar Illness/Symptom Onset

01	374	Date Time Qualifier	R
	438
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Similar Illness or Symptom Date	R

DTP- Date - Accident

01	374	Date Time Qualifier	R
	439
02	1250	Date Time Period Format Qualifier	R
	D8 DT
03	1251	Accident Date	R

DTP- Date - Last Menstrual Period

01	374	Date Time Qualifier	R
	484
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Last Menstrual Period Date	R

DTP- Date - Last X-Ray

01	374	Date Time Qualifier	R
	455
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Last X-Ray Date	R

DTP- Date - Hearing and Vision Prescription Date

01	374	Date Time Qualifier	R
	471
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Prescription Date	R

DTP- Date - Disability Begin

01	374	Date Time Qualifier	R
	360
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Disability From Date	R

DTP- Date - Disability End

01	374	Date Time Qualifier	R
	361
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Disability To Date	R

DTP- Date - Last Worked

01	374	Date Time Qualifier	R
	297
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Last Worked Date	R

DTP- Date - Authorized Return to Work

01	374	Date Time Qualifier	R
	296
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Work Return Date	R

DTP- Date - Admission

01	374	Date Time Qualifier	R
	435
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Related Hospitalization Admission Date	R

DTP- Date - Discharge

01	374	Date Time Qualifier	R
	096
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Related Hospitalization Discharge Date	R

DTP- Date - Assumed and Relinquished Care Dates

01	374	Date Time Qualifier	R
	090 091
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Assumed or Relinquished Care Date	R

PWK- Claim Supplemental Information P0506

01	755	Attachment Report Type Code	R
	77 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	Description	N
N	PWK08	C002	Actions Indicated
09	1525	Request Category Code	N

CN1- Contract Information

01	1166	Contract Type Code	R
	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- 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

AMT- Patient Amount Paid

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

AMT- Total Purchased Service Amount

01	522	Amount Qualifier Code	R
	NE
02	782	Total Purchased Service Amount	R
03	478	Credit/Debit Flag Code	N

REF- Service Authorization Exception Code R0203

01	128	Reference Identification Qualifier	R
	4N
02	127	Service Authorization Exception Code	R
	1 2 3 4 5 6 7
03	352	Description	N
N	REF04	C040	Reference Identifier

REF- Mandatory Medicare (Section 4081) Crossover Indicator R0203

01	128	Reference Identification Qualifier	R
	F5
02	127	Medicare Section 4081 Indicator	R
	Y N
03	352	Description	N
N	REF04	C040	Reference Identifier

REF- Mammography Certification Number R0203

01	128	Reference Identification Qualifier	R
	EW
02	127	Mammography Certification Number	R
03	352	Description	N
N	REF04	C040	Reference Identifier

REF- Prior Authorization or Referral Number R0203

01	128	Reference Identification Qualifier	R
	9F G1
02	127	Prior Authorization or Referral Number	R
03	352	Description	N
N	REF04	C040	Reference Identifier

REF- Original Reference Number (ICN/DCN) R0203

01	128	Reference Identification Qualifier	R
	F8
02	127	Claim Original Reference Number	R
03	352	Description	N
N	REF04	C040	Reference Identifier

REF- Clinical Laboratory Improvement Amendment (CLIA) Number R0203

01	128	Reference Identification Qualifier	R
	X4
02	127	Clinical Laboratory Improvement Amendment Number	R
03	352	Description	N
N	REF04	C040	Reference Identifier

REF- Repriced Claim Number R0203

01	128	Reference Identification Qualifier	R
	9A
02	127	Repriced Claim Reference Number	R
03	352	Description	N
N	REF04	C040	Reference Identifier

REF- Adjusted Repriced Claim Number R0203

01	128	Reference Identification Qualifier	R
	9C
02	127	Adjusted Repriced Claim Reference Number	R
03	352	Description	N
N	REF04	C040	Reference Identifier

REF- Investigational Device Exemption Number R0203

01	128	Reference Identification Qualifier	R
	LX
02	127	Investigational Device Exemption Identifier	R
03	352	Description	N
N	REF04	C040	Reference Identifier

REF- Claim Identification Number for Clearing Houses and Other Transmission Intermediaries R0203

01	128	Reference Identification Qualifier	R
	D9
02	127	Clearinghouse Trace Number	R
03	352	Description	N
N	REF04	C040	Reference Identifier

REF- Ambulatory Patient Group (APG) R0203

01	128	Reference Identification Qualifier	R
	1S
02	127	Ambulatory Patient Group Number	R
03	352	Description	N
N	REF04	C040	Reference Identifier

REF- Medical Record Number R0203

01	128	Reference Identification Qualifier	R
	EA
02	127	Medical Record Number	R
03	352	Description	N
N	REF04	C040	Reference Identifier

REF- Demonstration Project Identifier R0203

01	128	Reference Identification Qualifier	R
	P4
02	127	Demonstration Project Identifier	R
03	352	Description	N
N	REF04	C040	Reference Identifier

K3- File Information

01	449	Fixed Format Information	R
02	1333	Record Format Code	N
N	K303	C001	Composite Unit of Measure

NTE- Claim Note

01	363	Note Reference Code	R
	ADD CER DCP DGN PMT TPO
02	352	Claim Note Text	R

CR1- Ambulance Transport Information P0102 P0506

01	355	Unit or Basis for Measurement Code	S
	LB
02	81	Patient Weight	S
03	1316	Ambulance Transport Code	R
	I R T X
04	1317	Ambulance Transport Reason Code	R
	A B C D E
05	355	Unit or Basis for Measurement Code	R
	DH
06	380	Transport Distance	R
07	166	Address Information	N
08	166	Address Information	N
09	352	Round Trip Purpose Description	S
10	352	Stretcher Purpose Description	S

CR2- Spinal Manipulation Service Information P0102 C0403 P0506

01	609	Treatment Series Number	N
02	380	Treatment Count	N
03	1367	Subluxation Level Code	N
	C1 C2 C3 C4 C5 C6 C7 CO IL L1 L2 L3 L4 L5 OC SA T1 T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12
04	1367	Subluxation Level Code	N
	C1 C2 C3 C4 C5 C6 C7 CO IL L1 L2 L3 L4 L5 OC SA T1 T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12
05	355	Unit or Basis for Measurement Code	N
	DA MO WK YR
06	380	Treatment Period Count	N
07	380	Monthly Treatment Count	N
08	1342	Patient Condition Code	R
	A C D E F G M
09	1073	Complication Indicator	N
	N Y
10	352	Patient Condition Description	S
11	352	Patient Condition Description	S
12	1073	X-ray Availability Indicator	S
	N Y

CRC- Ambulance Certification

01	1136	Code Category	R
	07
02	1073	Certification Condition Indicator	R
	N Y
03	1321	Condition Code	R
	01 02 03 04 05 06 07 08 09 60
04	1321	Condition Code	S
	01 02 03 04 05 06 07 08 09 60
05	1321	Condition Code	S
	01 02 03 04 05 06 07 08 09 60
06	1321	Condition Code	S
	01 02 03 04 05 06 07 08 09 60
07	1321	Condition Code	S
	01 02 03 04 05 06 07 08 09 60

CRC- Patient Condition Information: Vision

01	1136	Code Category	R
	E1 E2 E3
02	1073	Certification Condition Indicator	R
	N Y
03	1321	Condition Code	R
	L1 L2 L3 L4 L5
04	1321	Condition Code	S
	L1 L2 L3 L4 L5
05	1321	Condition Code	S
	L1 L2 L3 L4 L5
06	1321	Condition Code	S
	L1 L2 L3 L4 L5
07	1321	Condition Code	S
	L1 L2 L3 L4 L5

CRC- Homebound Indicator

01	1136	Code Category	R
	75
02	1073	Certification Condition Indicator	R
	Y
03	1321	Homebound Indicator	R
	IH
04	1321	Condition Indicator	N
05	1321	Condition Indicator	N
06	1321	Condition Indicator	N
07	1321	Condition Indicator	N

CRC- EPSDT Referral

01	1136	Code Category	R
	ZZ
02	1073	Certification Condition Indicator	R
	N Y
03	1321	Condition Code	R
	AV NU S2 ST
04	1321	Condition Code	S
	AV NU S2 ST
05	1321	Condition Code	S
	AV NU S2 ST
06	1321	Condition Indicator	N
07	1321	Condition Indicator	N

HI- Health Care Diagnosis Code

R		C022	Principal Diagnosis
01	1270	Diagnosis Type Code	R
	BK
02	1271	Diagnosis 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	Diagnosis
01	1270	Diagnosis Type Code	R
	BF
02	1271	Diagnosis 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	Diagnosis
01	1270	Diagnosis Type Code	R
	BF
02	1271	Diagnosis 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	Diagnosis
01	1270	Diagnosis Type Code	R
	BF
02	1271	Diagnosis 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	Diagnosis
01	1270	Diagnosis Type Code	R
	BF
02	1271	Diagnosis 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	Diagnosis
01	1270	Diagnosis Type Code	R
	BF
02	1271	Diagnosis 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	Diagnosis
01	1270	Diagnosis Type Code	R
	BF
02	1271	Diagnosis 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	Diagnosis
01	1270	Diagnosis Type Code	R
	BF
02	1271	Diagnosis 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	HI09	C022	Health Care Code Information
N	HI10	C022	Health Care Code Information
N	HI11	C022	Health Care Code Information
N	HI12	C022	Health Care Code Information

HCP- Claim Pricing/Repricing Information R0113 P0910 P1112

01	1473	Pricing/Repricing Methodology	R
	00 01 02 03 04 05 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 Ambulatory Patient Group Code	S
7	782	Repriced Approved Ambulatory Patient Group Amount	S
08	234	Product/Service ID	N
09	235	Product/Service ID Qualifier	N
10	234	Product/Service ID	N
11	355	Unit or Basis for Measurement Code	N
12	380	Quantity	N
13	901	Reject Reason Code	S
	T1 T2 T3 T4 T5 T6
14	1526	Policy Compliance Code	S
	1 2 3 4 5
15	1527	Exception Code	S
	1 2 3 4 5 6

CR7- Home Health Care Plan Information

01	921	Discipline Type Code	R
	AI MS OT PT SN ST
02	1470	Total Visits Rendered Count	R
03	1470	Certification Period Projected Visit Count	R

HSD- Health Care Services Delivery P0102 C0605

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 A B C D E F G H J K L N O S W SA SB SC SD SG SL SP SX SY SZ
08	679	Delivery Pattern Time Code	S
	D E F

NM1- Referring Provider Name P0809 C1110

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
	External Source: states
N	PRV05	C035	Provider Specialty Information
06	1223	Provider Organization Code	N

REF- Referring Provider Secondary Identification R0203

01	128	Reference Identification Qualifier	R
	0B 1B 1C 1D 1G 1H EI G2 LU N5 SY X5
02	127	Referring Provider Secondary Identifier	R
03	352	Description	N
N	REF04	C040	Reference Identifier

NM1- Rendering Provider Name P0809 C1110

01	98	Entity Identifier Code	R
	82
02	1065	Entity Type Qualifier	R
	1 2
03	1035	Rendering Provider Last or Organization Name	R
04	1036	Rendering Provider First Name	S
05	1037	Rendering Provider Middle Name	S
06	1038	Name Prefix	N
07	1039	Rendering Provider Name Suffix	S
08	66	Identification Code Qualifier	R
	24 34 XX
09	67	Rendering Provider Identifier	R
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

PRV- Rendering Provider Specialty Information

01	1221	Provider Code	R
	PE
02	128	Reference Identification Qualifier	R
	ZZ
03	127	Provider Taxonomy Code	R
04	156	State or Province Code	N
	External Source: states
N	PRV05	C035	Provider Specialty Information
06	1223	Provider Organization Code	N

REF- Rendering Provider Secondary Identification R0203

01	128	Reference Identification Qualifier	R
	0B 1B 1C 1D 1G 1H EI G2 LU N5 SY X5
02	127	Rendering Provider Secondary Identifier	R
03	352	Description	N
N	REF04	C040	Reference Identifier

NM1- Purchased Service Provider Name P0809 C1110

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

REF- Purchased Service Provider Secondary Identification R0203

01	128	Reference Identification Qualifier	R
	0B 1A 1B 1C 1D 1G 1H EI G2 LU N5 SY U3 X5
02	127	Purchased Service Provider Secondary Identifier	R
03	352	Description	N
N	REF04	C040	Reference Identifier

NM1- Service Facility Location P0809 C1110

01	98	Entity Identifier Code	R
	77 FA LI TL
02	1065	Entity Type Qualifier	R
	2
03	1035	Laboratory or Facility Name	S
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

N3- Service Facility Location Address

01	166	Laboratory or Facility Address Line 1	R
02	166	Laboratory or Facility Address Line 2	S

N4- Service Facility Location City/State/ZIP C0605

01	19	Laboratory or Facility City Name	R
02	156	Laboratory or Facility State or Province Code	R
	External Source: states
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 Location Secondary Identification R0203

01	128	Reference Identification Qualifier	R
	0B 1A 1B 1C 1D 1G 1H G2 LU N5 TJ X4 X5
02	127	Laboratory or Facility Secondary Identifier	R
03	352	Description	N
N	REF04	C040	Reference Identifier

NM1- Supervising Provider Name P0809 C1110

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

REF- Supervising Provider Secondary Identification R0203

01	128	Reference Identification Qualifier	R
	0B 1B 1C 1D 1G 1H EI G2 LU N5 SY X5
02	127	Supervising Provider Secondary Identifier	R
03	352	Description	N
N	REF04	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	R
	AP C1 CP GP HM IP LD LT MB MC MI MP OT PP SP
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 MB MC OF TV VA WC ZZ

CAS- Claim Level Adjustments L050607 C0605 C0705 L080910 C0908 C1008 L111213 C1211 C1311 L141516 C1514 C1614 L171819 C1817 C1917

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	Adjustment 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- Coordination of Benefits (COB) Payer Paid Amount

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

AMT- Coordination of Benefits (COB) Approved Amount

01	522	Amount Qualifier Code	R
	AAE
02	782	Approved Amount	R
03	478	Credit/Debit Flag Code	N

AMT- Coordination of Benefits (COB) 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) Patient Responsibility Amount

01	522	Amount Qualifier Code	R
	F2
02	782	Other Payer Patient Responsibility Amount	R
03	478	Credit/Debit Flag Code	N

AMT- Coordination of Benefits (COB) Covered Amount

01	522	Amount Qualifier Code	R
	AU
02	782	Other Payer Covered Amount	R
03	478	Credit/Debit Flag Code	N

AMT- Coordination of Benefits (COB) Discount Amount

01	522	Amount Qualifier Code	R
	D8
02	782	Other Payer Discount Amount	R
03	478	Credit/Debit Flag Code	N

AMT- Coordination of Benefits (COB) Per Day Limit Amount

01	522	Amount Qualifier Code	R
	DY
02	782	Other Payer Per Day Limit Amount	R
03	478	Credit/Debit Flag Code	N

AMT- Coordination of Benefits (COB) Patient Paid Amount

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

AMT- Coordination of Benefits (COB) Tax Amount

01	522	Amount Qualifier Code	R
	T
02	782	Other Payer Tax Amount	R
03	478	Credit/Debit Flag Code	N

AMT- Coordination of Benefits (COB) Total Claim Before Taxes Amount

01	522	Amount Qualifier Code	R
	T2
02	782	Other Payer Pre-Tax Claim Total Amount	R
03	478	Credit/Debit Flag Code	N

DMG- 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	Race or Ethnicity Code	N
6	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	Benefits Assignment Certification Indicator	R
	N Y
04	1351	Patient Signature Source Code	S
	B C M P S
05	1360	Provider Agreement Code	N
06	1363	Release of Information Code	R
	A I M N O Y

MOA- Medicare Outpatient Adjudication Information

01	954	Reimbursement Rate	S
02	782	HCPCS Payable Amount	S
03	127	Remark Code	S
	External Source: remark_code
04	127	Remark Code	S
	External Source: remark_code
05	127	Remark Code	S
	External Source: remark_code
06	127	Remark Code	S
	External Source: remark_code
07	127	Remark Code	S
	External Source: remark_code
08	782	End Stage Renal Disease Payment Amount	S
09	782	Non-Payable Professional Component Billed Amount	S

NM1- Other Subscriber Name P0809 C1110

01	98	Entity Identifier 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	Name Prefix	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 1	R
02	166	Other Insured Address Line 2	S

N4- Other Subscriber City/State/ZIP Code C0605

01	19	Other Insured City Name	S
02	156	Other Insured State Code	S
	External Source: states
03	116	Other Insured Postal Zone or ZIP Code	S
04	26	Subscriber Country Code	S
	External Source: country
05	309	Location Qualifier	N
06	310	Location Identifier	N

REF- Other Subscriber Secondary Identification R0203

01	128	Reference Identification Qualifier	R
	1W 23 IG SY
02	127	Other Insured Additional Identifier	R
03	352	Description	N
N	REF04	C040	Reference Identifier

NM1- Other Payer Name P0809 C1110

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

PER- Other Payer Contact Information P0304 P0506 P0708

01	366	Contact Function Code	R
	IC
02	93	Other Payer 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

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 Identifier R0203

01	128	Reference Identification Qualifier	R
	2U F8 FY NF TJ
02	127	Other Payer Secondary Identifier	R
03	352	Description	N
N	REF04	C040	Reference Identifier

REF- Other Payer Prior Authorization or Referral Number R0203

01	128	Reference Identification Qualifier	R
	9F G1
02	127	Other Payer Prior Authorization or Referral Number	R
03	352	Description	N
N	REF04	C040	Reference Identifier

REF- Other Payer Claim Adjustment Indicator R0203

01	128	Reference Identification Qualifier	R
	T4
02	127	Other Payer Claim Adjustment Indicator	R
	Y
03	352	Description	N
N	REF04	C040	Reference Identifier

NM1- Other Payer Patient Information P0809 C1110

01	98	Entity Identifier Code	R
	QC
02	1065	Entity Type Qualifier	R
	1
03	1035	Patient Last 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
	MI
09	67	Other Payer Patient Primary Identifier	R
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

REF- Other Payer Patient Identification R0203

01	128	Reference Identification Qualifier	R
	1W 23 IG SY
02	127	Other Payer Patient Secondary Identifier	R
03	352	Description	N
N	REF04	C040	Reference Identifier

NM1- Other Payer Referring Provider P0809 C1110

01	98	Entity Identifier Code	R
	DN P3
02	1065	Entity Type Qualifier	R
	1 2
03	1035	Referring Provider Last 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 R0203

01	128	Reference Identification Qualifier	R
	1B 1C 1D EI G2 LU N5
02	127	Other Payer Referring Provider Identifier	R
03	352	Description	N
N	REF04	C040	Reference Identifier

NM1- Other Payer Rendering Provider P0809 C1110

01	98	Entity Identifier Code	R
	82
02	1065	Entity Type Qualifier	R
	1 2
03	1035	Rendering Provider 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 Rendering Provider Secondary Identification R0203

01	128	Reference Identification Qualifier	R
	1B 1C 1D EI G2 LU N5
02	127	Other Payer Rendering Provider Secondary Identifier	R
03	352	Description	N
N	REF04	C040	Reference Identifier

NM1- Other Payer Purchased Service Provider P0809 C1110

01	98	Entity Identifier Code	R
	QB
02	1065	Entity Type Qualifier	R
	1 2
03	1035	Purchased Service Provider 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 Purchased Service Provider Identification R0203

01	128	Reference Identification Qualifier	R
	1A 1B 1C 1D EI G2 LU N5
02	127	Other Payer Purchased Service Provider Identifier	R
03	352	Description	N
N	REF04	C040	Reference Identifier

NM1- Other Payer Service Facility Location P0809 C1110

01	98	Entity Identifier Code	R
	77 FA LI TL
02	1065	Entity Type Qualifier	R
	2
03	1035	Service Facility 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 Service Facility Location Identification R0203

01	128	Reference Identification Qualifier	R
	1A 1B 1C 1D G2 LU N5
02	127	Other Payer Service Facility Location Identifier	R
03	352	Description	N
N	REF04	C040	Reference Identifier

NM1- Other Payer Supervising Provider P0809 C1110

01	98	Entity Identifier Code	R
	DQ
02	1065	Entity Type Qualifier	R
	1
03	1035	Supervising Provider Last 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 Supervising Provider Identification R0203

01	128	Reference Identification Qualifier	R
	1B 1C 1D EI G2 N5
02	127	Other Payer Supervising Provider Identifier	R
03	352	Description	N
N	REF04	C040	Reference Identifier

LX- Service Line

554

Line Counter

SV1- Professional Service P0304

R		C003	Procedure Identifier
01	235	Product or Service ID Qualifier	R
	HC IV N4 ZZ
02	234	Procedure Code	R
03	1339	Procedure Modifier 1	S
04	1339	Procedure Modifier 2	S
05	1339	Procedure Modifier 3	S
06	1339	Procedure Modifier 4	S
07	352	Description	N
02	782	Line Item Change Amount	R
03	355	Unit or Basis for Measurement Code	R
	F2 MJ UN
04	380	Service Unit Count	R
05	1331	Place of Service Code	S
	External Source: pos
06	1365	Service Type Code	N
S		C004	Diagnosis Code Pointer
01	1328	Diagnosis Code Pointer	R
	1 2 3 4 5 6 7 8
02	1328	Diagnosis Code Pointer	S
	1 2 3 4 5 6 7 8
03	1328	Diagnosis Code Pointer	S
	1 2 3 4 5 6 7 8
04	1328	Diagnosis Code Pointer	S
	1 2 3 4 5 6 7 8
08	782	Monetary Amount	N
09	1073	Emergency Indicator	S
	Y
10	1340	Multiple Procedure Code	N
11	1073	EPSDT Indicator	S
	Y
12	1073	Family Planning Indicator	S
	Y
13	1364	Review Code	N
14	1341	National or Local Assigned Review Value	N
15	1327	Co-Pay Status Code	S
	0
16	1334	Health Care Professional Shortage Area Code	N
17	127	Reference Identification	N
18	116	Postal Code	N
19	782	Monetary Amount	N
20	1337	Level of Care Code	N
21	1360	Provider Agreement Code	N

SV5- Durable Medical Equipment Service

R		C003	Composite Medical Procedure Identifier
01	235	Procedure Identifier	R
	HC
02	234	Procedure Code	R
03	1339	Procedure Modifier 1	N
04	1339	Procedure Modifier 2	N
05	1339	Procedure Modifier 3	N
06	1339	Procedure Modifier 4	N
07	352	Description	N
02	355	Unit or Basis for Measurement Code	R
	DA
03	380	Length of Medical Necessity	R
04	782	DME Rental Price	S
05	782	DME Purchase Price	S
06	594	Rental Unit Price Indicator	S
	1 4 6
07	923	Prognosis Code	N

PWK- DMERC CMN Indicator P0506

01	755	Attachment Report Type Code	R
	CT
02	756	Attachment Transmission Code	R
	AB AD AF AG NS
03	757	Report Copies Needed	N
04	98	Entity Identifier Code	N
05	66	Identification Code Qualifier	N
06	67	Identification Code	N
07	352	Description	N
N	PWK08	C002	Actions Indicated
09	1525	Request Category Code	N

CR1- Ambulance Transport Information P0102 P0506

01	355	Unit or Basis for Measurement Code	S
	LB
02	81	Patient Weight	S
03	1316	Ambulance Transport Code	R
	I R T X
04	1317	Ambulance Transport Reason Code	R
	A B C D E
05	355	Unit or Basis for Measurement Code	R
	DH
06	380	Transport Distance	R
07	166	Address Information	N
08	166	Address Information	N
09	352	Round Trip Purpose Description	S
10	352	Stretcher Purpose Description	S

CR2- Spinal Manipulation Service Information P0102 C0403 P0506

01	609	Treatment Series Number	N
02	380	Treatment Count	N
03	1367	Subluxation Level Code	N
	C1 C2 C3 C4 C5 C6 C7 CO IL L1 L2 L3 L4 L5 OC SA T1 T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12
04	1367	Subluxation Level Code	N
	C1 C2 C3 C4 C5 C6 C7 CO IL L1 L2 L3 L4 L5 OC SA T1 T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12
05	355	Unit or Basis for Measurement Code	N
	DA MO WK YR
06	380	Treatment Period Count	N
07	380	Monthly Treatment Count	N
08	1342	Patient Condition Code	R
	A C D E F G M
09	1073	Complication Indicator	N
	N Y
10	352	Patient Condition Description	S
11	352	Patient Condition Description	S
12	1073	X-ray Availability Indicator	S
	N Y

CR3- Durable Medical Equipment Certification P0203

01	1322	Certification Type Code	R
	I R S
02	355	Unit or Basis for Measurement Code	R
	MO
03	380	Durable Medical Equipment Duration	R
04	1335	Insulin Dependent Code	N
05	352	Description	N

CR5- Home Oxygen Therapy Information

01	1322	Certification Type Code.Oxygen Therapy	R
	I R S
02	380	Treatment Period Count	R
03	1348	Oxygen Equipment Type Code	N
04	1348	Oxygen Equipment Type Code	N
05	352	Description	N
06	380	Quantity	N
07	380	Quantity	N
08	380	Quantity	N
09	352	Description	N
10	380	Arterial Blood Gas Quantity	S
11	380	Oxygen Saturation Quantity	S
12	1349	Oxygen Test Condition Code	R
	E R S
13	1350	Oxygen Test Finding Code	S
	1
14	1350	Oxygen Test Finding Code	S
	2
15	1350	Oxygen Test Finding Code	S
	3
16	380	Quantity	N
17	1382	Oxygen Delivery System Code	N
18	1348	Oxygen Equipment Type Code	N

CRC- Ambulance Certification

01	1136	Code Category	R
	07
02	1073	Certification Condition Indicator	R
	N Y
03	1321	Condition Code	R
	01 02 03 04 05 06 07 08 09 60
04	1321	Condition Code	S
	01 02 03 04 05 06 07 08 09 60
05	1321	Condition Code	S
	01 02 03 04 05 06 07 08 09 60
06	1321	Condition Code	S
	01 02 03 04 05 06 07 08 09 60
07	1321	Condition Code	S
	01 02 03 04 05 06 07 08 09 60

CRC- Hospice Employee Indicator

01	1136	Code Category	R
	70
02	1073	Hospice Employed Provider Indicator	R
	N Y
03	1321	Condition Indicator	R
	65
04	1321	Condition Indicator	N
05	1321	Condition Indicator	N
06	1321	Condition Indicator	N
07	1321	Condition Indicator	N

CRC- DMERC Condition Indicator

01	1136	Code Category	R
	09 11
02	1073	Certification Condition Indicator	R
	N Y
03	1321	Condition Indicator	R
	37 38 AL P1 ZV
04	1321	Condition Indicator	S
	37 38 AL P1 ZV
05	1321	Condition Indicator	S
	37 38 AL P1 ZV
06	1321	Condition Indicator	S
	37 38 AL P1 ZV
07	1321	Condition Indicator	S
	37 38 AL P1 ZV

DTP- Date - Service Date

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

DTP- Date - Certification Revision Date

01	374	Date Time Qualifier	R
	607
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Certification Revision Date	R

DTP- Date - Begin Therapy Date

01	374	Date Time Qualifier	R
	463
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Begin Therapy Date	R

DTP- Date - Last Certification Date

01	374	Date Time Qualifier	R
	461
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Last Certification Date	R

DTP- Date - Date Last Seen

01	374	Date Time Qualifier	R
	304
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Last Seen Date	R

DTP- Date - Test

01	374	Date Time Qualifier	R
	738 739
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Test Performed Date	R

DTP- Date - Oxygen Saturation/Arterial Blood Gas Test

01	374	Date Time Qualifier	R
	119 480 481
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Oxygen Saturation Test Date	R

DTP- Date - Shipped

01	374	Date Time Qualifier	R
	011
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Shipped Date	R

DTP- Date - Onset of Current Symptom/Illness

01	374	Date Time Qualifier	R
	431
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Onset Date	R

DTP- Date - Last X-ray

01	374	Date Time Qualifier	R
	455
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Last X-Ray Date	R

DTP- Date - Acute Manifestation

01	374	Date Time Qualifier	R
	453
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Acute Manifestation Date	R

DTP- Date - Initial Treatment

01	374	Date Time Qualifier	R
	454
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Initial Treatment Date	R

DTP- Date - Similar Illness/Symptom Onset

01	374	Date Time Qualifier	R
	438
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Similar Illness or Symptom Date	R

MEA- Test Result R03050608 C0504 C0604 L07030506 E0803

01	737	Measurement Reference Identification Code	R
	OG TR
02	738	Measurement Qualifier	R
	GRA HT R1 R2 R3 R4 ZO
03	739	Test Results	R
N		C001	Composite Unit of Measure
05	740	Range Minimum	N
06	741	Range Maximum	N
07	935	Measurement Significance Code	N
08	936	Measurement Attribute Code	N
09	752	Surface/Layer/Position Code	N
10	1373	Measurement Method or Device	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

REF- Repriced Line Item Reference Number R0203

01	128	Reference Identification Qualifier	R
	9B
02	127	Repriced Line Item Reference Number	R
03	352	Description	N
N	REF04	C040	Reference Identifier

REF- Adjusted Repriced Line Item Reference Number R0203

01	128	Reference Identification Qualifier	R
	9D
02	127	Adjusted Repriced Line Item Reference Number	R
03	352	Description	N
N	REF04	C040	Reference Identifier

REF- Prior Authorization or Referral Number R0203

01	128	Reference Identification Qualifier	R
	9F G1
02	127	Prior Authorization or Referral Number	R
03	352	Description	N
N	REF04	C040	Reference Identifier

REF- Line Item Control Number R0203

01	128	Reference Identification Qualifier	R
	6R
02	127	Line Item Control Number	R
03	352	Description	N
N	REF04	C040	Reference Identifier

REF- Mammography Certification Number R0203

01	128	Reference Identification Qualifier	R
	EW
02	127	Mammography Certification Number	R
03	352	Description	N
N	REF04	C040	Reference Identifier

REF- Clinical Laboratory Improvement Amendment (CLIA) Identification R0203

01	128	Reference Identification Qualifier	R
	X4
02	127	Clinical Laboratory Improvement Amendment Number	R
03	352	Description	N
N	REF04	C040	Reference Identifier

REF- Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification R0203

01	128	Reference Identification Qualifier	R
	F4
02	127	Referring CLIA Number	R
03	352	Description	N
N	REF04	C040	Reference Identifier

REF- Immunization Batch Number R0203

01	128	Reference Identification Qualifier	R
	BT
02	127	Immunization Batch Number	R
03	352	Description	N
N	REF04	C040	Reference Identifier

REF- Ambulatory Patient Group (APG) R0203

01	128	Reference Identification Qualifier	R
	1S
02	127	Ambulatory Patient Group Number	R
03	352	Description	N
N	REF04	C040	Reference Identifier

REF- Oxygen Flow Rate R0203

01	128	Reference Identification Qualifier	R
	TP
02	127	Oxygen Flow Rate	R
03	352	Description	N
N	REF04	C040	Reference Identifier

REF- Universal Product Number (UPN) R0203

01	128	Reference Identification Qualifier	R
	OZ VP
02	127	Universal Product Number	R
03	352	Description	N
N	REF04	C040	Reference Identifier

AMT- Sales Tax Amount

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

AMT- Approved Amount

01	522	Amount Qualifier Code	R
	AAE
02	782	Approved Amount	R
03	478	Credit/Debit Flag Code	N

AMT- Postage Claimed Amount

01	522	Amount Qualifier Code	R
	F4
02	782	Postage Claimed Amount	R
03	478	Credit/Debit Flag Code	N

K3- File Information

01	449	Fixed Format Information	R
02	1333	Record Format Code	N
N	K303	C001	Composite Unit of Measure

NTE- Line Note

01	363	Note Reference Code	R
	ADD DCP PMT TPO
02	352	Line Note Text	R

PS1- Purchased Service Information

01	127	Purchased Service Provider Identifier	R
02	782	Purchased Service Charge Amount	R
03	156	State or Province Code	N
	External Source: states

HSD- Health Care Services Delivery P0102 C0605

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 34 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 A B C D E F G H J K L N O W SA SB SC SD SG SL SP SX SY SZ
08	679	Delivery Pattern Time Code	S
	D E F

HCP- Line Pricing/Repricing Information R0113 P0910 P1112

01	1473	Pricing/Repricing 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 Ambulatory Patient Group Code	S
7	782	Repriced Approved Ambulatory Patient Group Amount	S
08	234	Product/Service ID	N
09	235	Product or Service ID Qualifier	S
	HC IV ZZ
10	234	Producedure Code	S
11	355	Unit or Basis for Measurement Code	S
	DA UN
12	380	Repriced Approved Service Unit Count	S
13	901	Reject Reason Code	S
	T1 T2 T3 T4 T5 T6
14	1526	Policy Compliance Code	S
	1 2 3 4 5
15	1527	Exception Code	S
	1 2 3 4 5 6

LIN- Drug Identification

01	350	Assignment ID	N
02	235	Product or Service ID Qualifier	R
	N4
03	234	National Drug Code	R
04	235	Product/Service ID Qualifier	N
	N4
05	234	Product/Service ID	N
06	235	Product/Service ID Qualifier	N
	N4
07	234	Product/Service ID	N
08	235	Product/Service ID Qualifier	N
	N4
09	234	Product/Service ID	N
10	235	Product/Service ID Qualifier	N
	N4
11	234	Product/Service ID	N
12	235	Product/Service ID Qualifier	N
	N4
13	234	Product/Service ID	N
14	235	Product/Service ID Qualifier	N
	N4
15	234	Product/Service ID	N
16	235	Product/Service ID Qualifier	N
	N4
17	234	Product/Service ID	N
18	235	Product/Service ID Qualifier	N
	N4
19	234	Product/Service ID	N
20	235	Product/Service ID Qualifier	N
	N4
21	234	Product/Service ID	N
22	235	Product/Service ID Qualifier	N
	N4
23	234	Product/Service ID	N
24	235	Product/Service ID Qualifier	N
	N4
25	234	Product/Service ID	N
26	235	Product/Service ID Qualifier	N
	N4
27	234	Product/Service ID	N
28	235	Product/Service ID Qualifier	N
	N4
29	234	Product/Service ID	N
30	235	Product/Service ID Qualifier	N
	N4
31	234	Product/Service ID	N

CTP- Drug Pricing

01	687	Trade Code Class	N
02	236	Price Identifier Code	N
03	212	Drug Unit Price	R
04	380	National Drug Unit Count	R
R		C001	Unit or Basis of Measurement
01	355	Unit or Basis for Measurement Code	R
	F2 GR ML UN
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
06	648	Price Multiplier Qualifier	N
07	649	Multiplier	N
08	782	Monetary Amount	N
09	639	Basis or Unit Price Code	N
10	499	Condition Value	N
11	289	Multiple Price Quantity	N

REF- Prescription Number R0203

01	128	Reference Identification Qualifier	R
	XZ
02	127	Prescription Number	R
03	352	Description	N
N	REF04	C040	Reference Identifier

NM1- Rendering Provider Name P0809 C1110

01	98	Entity Identifier Code	R
	82
02	1065	Entity Type Qualifier	R
	1 2
03	1035	Rendering Provider Last or Organization Name	R
04	1036	Rendering Provider First Name	S
05	1037	Rendering Provider Middle Name	S
06	1038	Name Prefix	N
07	1039	Rendering Provider Name Suffix	S
08	66	Identification Code Qualifier	R
	24 34 XX
09	67	Rendering Provider Identifier	R
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

PRV- Rendering Provider Specialty Information

01	1221	Provider Code	R
	PE
02	128	Reference Identification Qualifier	R
	ZZ
03	127	Provider Taxonomy Code	R
04	156	State or Province Code	N
	External Source: states
N	PRV05	C035	Provider Specialty Information
06	1223	Provider Organization Code	N

REF- Rendering Provider Secondary Identification R0203

01	128	Reference Identification Qualifier	R
	0B 1B 1C 1D 1G 1H EI G2 LU N5 SY X5
02	127	Rendering Provider Secondary Identifier	R
03	352	Description	N
N	REF04	C040	Reference Identifier

NM1- Purchased Service Provider Name P0809 C1110

01	98	Entity Identifier Code	R
	QB
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	S
	24 34 XX
09	67	Purchased Service Provider Identifier	S
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

REF- Purchased Service Provider Secondary Identification R0203

01	128	Reference Identification Qualifier	R
	0B 1A 1B 1C 1D 1G 1H EI G2 LU N5 SY U3 X5
02	127	Purchased Service Provider Secondary Identifier	R
03	352	Description	N
N	REF04	C040	Reference Identifier

NM1- Service Facility Location P0809 C1110

01	98	Entity Identifier Code	R
	77 FA LI TL
02	1065	Entity Type Qualifier	R
	2
03	1035	Laboratory or Facility Name	S
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

N3- Service Facility Location Address

01	166	Laboratory or Facility Address Line 1	R
02	166	Laboratory or Facility Address Line 2	S

N4- Service Facility Location City/State/ZIP C0605

01	19	Laboratory or Facility City Name	R
02	156	Laboratory or Facility State or Province Code	R
	External Source: states
03	116	Laboratory or Facility Postal Zone or ZIP Code	R
04	26	Service Facility Location Country Code	S
	External Source: country
05	309	Location Qualifier	N
06	310	Location Identifier	N

REF- Service Facility Location Secondary Identification R0203

01	128	Reference Identification Qualifier	R
	0B 1A 1B 1C 1D 1G 1H G2 LU N5 TJ X4 X5
02	127	Service Facility Location Secondary Identifier	R
03	352	Description	N
N	REF04	C040	Reference Identifier

NM1- Supervising Provider Name P0809 C1110

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

REF- Supervising Provider Secondary Identification R0203

01	128	Reference Identification Qualifier	R
	0B 1B 1C 1D 1G 1H EI G2 LU N5 SY X5
02	127	Supervising Provider Secondary Identifier	R
03	352	Description	N
N	REF04	C040	Reference Identifier

NM1- Ordering Provider Name P0809 C1110

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

N3- Ordering Provider Address

01	166	Ordering Provider Address Line 1	R
02	166	Ordering Provider Address Line 2	S

N4- Ordering Provider City/State/ZIP Code C0605

01	19	Ordering Provider City Name	R
02	156	Ordering Provider State Code	R
	External Source: states
03	116	Ordering Provider Postal Zone or ZIP Code	R
04	26	Ordering Provider Country Code	S
	External Source: country
05	309	Location Qualifier	N
06	310	Location Identifier	N

REF- Ordering Provider Secondary Identification R0203

01	128	Reference Identification Qualifier	R
	0B 1B 1C 1D 1G 1H EI G2 LU N5 SY X5
02	127	Ordering Provider Secondary Identifier	R
03	352	Description	N
N	REF04	C040	Reference Identifier

PER- Ordering Provider Contact Information P0304 P0506 P0708

01	366	Contact Function Code	R
	IC
02	93	Ordering 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- Referring Provider Name P0809 C1110

01	98	Entity Identifier Code	R
	DN P3
02	1065	Entity Type Qualifier	R
	1
03	1035	Referring Provider Last Name	R
04	1036	Referring Provider First Name	R
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
	External Source: states
N	PRV05	C035	Provider Specialty Information
06	1223	Provider Organization Code	N

REF- Referring Provider Secondary Identification R0203

01	128	Reference Identification Qualifier	R
	0B 1B 1C 1D 1G 1H EI G2 LU N5 SY X5
02	127	Referring Provider Secondary Identifier	R
03	352	Description	N
N	REF04	C040	Reference Identifier

NM1- Other Payer Prior Authorization or Referral Number P0809 C1110

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	Other Payer Identification Number	R
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

REF- Other Payer Prior Authorization or Referral Number R0203

01	128	Reference Identification Qualifier	R
	9F G1
02	127	Other Payer Prior Authorization or Referral Number	R
03	352	Description	N
N	REF04	C040	Reference Identifier

SVD- Line Adjudication Information

01	67	Other Payer Primary Identifier	R
02	782	Service Line Paid Amount	R
R		C003	Procedure Identifier
01	235	Product or Service ID Qualifier	R
	HC IV ZZ
02	234	Procedure Code	R
03	1339	Procedure Modifier 1	S
04	1339	Procedure Modifier 2	S
05	1339	Procedure Modifier 3	S
06	1339	Procedure Modifier 4	S
07	352	Procedure Code Description	S
04	234	Product/Service ID	N
05	380	Paid Service Unit Count	R
06	554	Bundled Line Number	S

CAS- Line Adjustment L050607 C0605 C0705 L080910 C0908 C1008 L111213 C1211 C1311 L141516 C1514 C1614 L171819 C1817 C1917

01	1033	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	Adjustment 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

DTP- Line 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

LQ- Form Identification Code C0102

01	1270	Form Identification Code	R
	AS UT
02	1271	Form Identifier	R

FRM- Supporting Documentation R02030405

01	350	Question Number/Letter	R
02	1073	Question Response	S
	N W Y
03	127	Question Response	S
04	373	Question Response	S

05	332	Question Response	S

HL- Patient Hierarchical Level

01	628	Hierarchical ID Number	R
02	734	Hierarchical Parent ID Number	R
03	735	Hierarchical Level Code	R
	23
04	736	Hierarchical Child Code	R
	0

PAT- Patient Information P0506 P0708

01	1069	Patients Relationship to Insured	R
	01 04 05 07 09 10 15 17 19 20 21 22 23 24 29 32 33 34 36 39 40 41 43 53 G8
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	S
	D8
06	1251	Patient Death Date	S
07	355	Unit or Basis for Measurement Code	S
	01
08	81	Patient Weight	S
09	1073	Pregnancy Indicator	S
	Y

NM1- Patient Name P0809 C1110

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

N3- Patient Address

01	166	Patient Address Line 1	R
02	166	Patient Address Line 2	S

N4- Patient City/State/ZIP Code C0605

01	19	Patient City Name	R
02	156	Patient State Code	R
	External Source: states
03	116	Patient Postal Zone or ZIP Code	R
04	26	Patient Country Code	S
	External Source: country
05	309	Location Qualifier	N
06	310	Location Identifier	N

DMG- Patient Demographic Information

01	1250	Date Time Period Format Qualifier	R
	D8
02	1251	Patient Birth Date	R
03	1068	Patient 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- Patient Secondary Identification R0203

01	128	Reference Identification Qualifier	R
	1W 23 IG SY
02	127	Patient Secondary Identifier	R
03	352	Description	N
N	REF04	C040	Reference Identifier

REF- Property and Casualty Claim Number R0203

01	128	Reference Identification Qualifier	R
	Y4
02	127	Property Casualty Claim Number	R
03	352	Description	N
N	REF04	C040	Reference Identifier

CLM- Claim Information

01	1028	Patient Account Number	R
2	782	Total Claim Charge Amount	R
03	1032	Claim Filing Indicator Code	N
04	1343	Non-Institutional Claim Type Code	N
R		C023	Place of Service Code
01	1331	Facility Type Code	R
	External Source: pos
02	1332	Facility Code Qualifier	N
03	1325	Claim Frequency Code	R
06	1073	Provider or Supplier Signature Indicator	R
	N Y
07	1359	Medicare Assignment Code	R
	A B C P
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	S
	B C M P S
S		C024	Accident/Employment/Related Causes
01	1362	Related Causes Code	R
	AA AP EM OA
02	1362	Related Causes Code	S
	AA AP EM OA
03	1362	Related Causes Code	S
	AA AP EM OA
04	156	Auto Accident State or Province Code	S
	External Source: states
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	Participation Agreement	S
	P
17	1029	Claim Status Code	N
18	1073	Yes/No Condition or Response Code	N
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- Date - Initial Treatment

01	374	Date Time Qualifier	R
	454
02	1250	Date Time Period Format Qualifier	R
	D8
3	1251	Initial Treatment Date	R

DTP- Date - Date Last Seen

01	374	Date Time Qualifier	R
	304
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Last Seen Date	R

DTP- Date - Onset of Current Illness/Symptom

01	374	Date Time Qualifier	R
	431
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Onset of Current Illness or Injury Date	R

DTP- Date - Acute Manifestation

01	374	Date Time Qualifier	R
	453
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Acute Manifestation Date	R

DTP- Date - Similar Illness/Symptom Onset

01	374	Date Time Qualifier	R
	438
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Similar Illness or Symptom Date	R

DTP- Date - Accident

01	374	Date Time Qualifier	R
	439
02	1250	Date Time Period Format Qualifier	R
	D8 DT
03	1251	Accident Date	R

DTP- Date - Last Menstrual Period

01	374	Date Time Qualifier	R
	484
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Last Menstrual Period Date	R

DTP- Date - Last X-Ray

01	374	Date Time Qualifier	R
	455
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Last X-Ray Date	R

DTP- Date - Hearing and Vision Prescription Date

01	374	Date Time Qualifier	R
	471
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Prescription Date	R

DTP- Date - Disability Begin

01	374	Date Time Qualifier	R
	360
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Disability From Date	R

DTP- Date - Disability End

01	374	Date Time Qualifier	R
	361
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Disability To Date	R

DTP- Date - Last Worked

01	374	Date Time Qualifier	R
	297
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Last Worked Date	R

DTP- Date - Authorized Return to Work

01	374	Date Time Qualifier	R
	296
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Work Return Date	R

DTP- Date - Admission

01	374	Date Time Qualifier	R
	435
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Related Hospitalization Admission Date	R

DTP- Date - Discharge

01	374	Date Time Qualifier	R
	096
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Related Hospitalization Discharge Date	R

DTP- Date - Assumed and Relinquished Care Dates

01	374	Date Time Qualifier	R
	090 091
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Assumed or Relinquished Care Date	R

PWK- Claim Supplemental Information P0506

01	755	Attachment Report Type Code	R
	77 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	Description	N
N	PWK08	C002	Actions Indicated
09	1525	Request Category Code	N

CN1- Contract Information

01	1166	Contract Type Code	R
	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- 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

AMT- Patient Amount Paid

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

AMT- Total Purchased Service Amount

01	522	Amount Qualifier Code	R
	NE
02	782	Total Purchased Service Amount	R
03	478	Credit/Debit Flag Code	N

REF- Service Authorization Exception Code R0203

01	128	Reference Identification Qualifier	R
	4N
02	127	Service Authorization Exception Code	R
	1 2 3 4 5 6 7
03	352	Description	N
N	REF04	C040	Reference Identifier

REF- Mandatory Medicare (Section 4081) Crossover Indicator R0203

01	128	Reference Identification Qualifier	R
	F5
02	127	Medicare Section 4081 Indicator	R
	Y N
03	352	Description	N
N	REF04	C040	Reference Identifier

REF- Mammography Certification Number R0203

01	128	Reference Identification Qualifier	R
	EW
02	127	Mammography Certification Number	R
03	352	Description	N
N	REF04	C040	Reference Identifier

REF- Prior Authorization or Referral Number R0203

01	128	Reference Identification Qualifier	R
	9F G1
02	127	Prior Authorization or Referral Number	R
03	352	Description	N
N	REF04	C040	Reference Identifier

REF- Original Reference Number (ICN/DCN) R0203

01	128	Reference Identification Qualifier	R
	F8
02	127	Claim Original Reference Number	R
03	352	Description	N
N	REF04	C040	Reference Identifier

REF- Clinical Laboratory Improvement Amendment (CLIA) Number R0203

01	128	Reference Identification Qualifier	R
	X4
02	127	Clinical Laboratory Improvement Amendment Number	R
03	352	Description	N
N	REF04	C040	Reference Identifier

REF- Repriced Claim Number R0203

01	128	Reference Identification Qualifier	R
	9A
02	127	Repriced Claim Reference Number	R
03	352	Description	N
N	REF04	C040	Reference Identifier

REF- Adjusted Repriced Claim Number R0203

01	128	Reference Identification Qualifier	R
	9C
02	127	Adjusted Repriced Claim Reference Number	R
03	352	Description	N
N	REF04	C040	Reference Identifier

REF- Investigational Device Exemption Number R0203

01	128	Reference Identification Qualifier	R
	LX
02	127	Investigational Device Exemption Identifier	R
03	352	Description	N
N	REF04	C040	Reference Identifier

REF- Claim Identification Number for Clearing Houses and Other Transmission Intermediaries R0203

01	128	Reference Identification Qualifier	R
	D9
02	127	Clearinghouse Trace Number	R
03	352	Description	N
N	REF04	C040	Reference Identifier

REF- Ambulatory Patient Group (APG) R0203

01	128	Reference Identification Qualifier	R
	1S
02	127	Ambulatory Patient Group Number	R
03	352	Description	N
N	REF04	C040	Reference Identifier

REF- Medical Record Number R0203

01	128	Reference Identification Qualifier	R
	EA
02	127	Medical Record Number	R
03	352	Description	N
N	REF04	C040	Reference Identifier

REF- Demonstration Project Identifier R0203

01	128	Reference Identification Qualifier	R
	P4
02	127	Demonstration Project Identifier	R
03	352	Description	N
N	REF04	C040	Reference Identifier

K3- File Information

01	449	Fixed Format Information	R
02	1333	Record Format Code	N
N	K303	C001	Composite Unit of Measure

NTE- Claim Note

01	363	Note Reference Code	R
	ADD CER DCP DGN PMT TPO
02	352	Claim Note Text	R

CR1- Ambulance Transport Information P0102 P0506

01	355	Unit or Basis for Measurement Code	S
	LB
02	81	Patient Weight	S
03	1316	Ambulance Transport Code	R
	I R T X
04	1317	Ambulance Transport Reason Code	R
	A B C D E
05	355	Unit or Basis for Measurement Code	R
	DH
06	380	Transport Distance	R
07	166	Address Information	N
08	166	Address Information	N
09	352	Round Trip Purpose Description	S
10	352	Stretcher Purpose Description	S

CR2- Spinal Manipulation Service Information P0102 C0403 P0506

01	609	Treatment Series Number	N
02	380	Treatment Count	N
03	1367	Subluxation Level Code	N
	C1 C2 C3 C4 C5 C6 C7 CO IL L1 L2 L3 L4 L5 OC SA T1 T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12
04	1367	Subluxation Level Code	N
	C1 C2 C3 C4 C5 C6 C7 CO IL L1 L2 L3 L4 L5 OC SA T1 T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12
05	355	Unit or Basis for Measurement Code	N
	DA MO WK YR
06	380	Treatment Period Count	N
07	380	Monthly Treatment Count	N
08	1342	Patient Condition Code	R
	A C D E F G M
09	1073	Complication Indicator	N
	N Y
10	352	Patient Condition Description	S
11	352	Patient Condition Description	S
12	1073	X-ray Availability Indicator	S
	N Y

CRC- Ambulance Certification

01	1136	Code Category	R
	07
02	1073	Certification Condition Indicator	R
	N Y
03	1321	Condition Code	R
	01 02 03 04 05 06 07 08 09 60
04	1321	Condition Code	S
	01 02 03 04 05 06 07 08 09 60
05	1321	Condition Code	S
	01 02 03 04 05 06 07 08 09 60
06	1321	Condition Code	S
	01 02 03 04 05 06 07 08 09 60
07	1321	Condition Code	S
	01 02 03 04 05 06 07 08 09 60

CRC- Patient Condition Information: Vision

01	1136	Code Category	R
	E1 E2 E3
02	1073	Certification Condition Indicator	R
	N Y
03	1321	Condition Code	R
	L1 L2 L3 L4 L5
04	1321	Condition Code	S
	L1 L2 L3 L4 L5
05	1321	Condition Code	S
	L1 L2 L3 L4 L5
06	1321	Condition Code	S
	L1 L2 L3 L4 L5
07	1321	Condition Code	S
	L1 L2 L3 L4 L5

CRC- Homebound Indicator

01	1136	Code Category	R
	75
02	1073	Certification Condition Indicator	R
	Y
03	1321	Homebound Indicator	R
	IH
04	1321	Condition Indicator	N
05	1321	Condition Indicator	N
06	1321	Condition Indicator	N
07	1321	Condition Indicator	N

CRC- EPSDT Referral

01	1136	Code Category	R
	ZZ
02	1073	Certification Condition Indicator	R
	N Y
03	1321	Condition Code	R
	AV NU S2 ST
04	1321	Condition Code	S
	AV NU S2 ST
05	1321	Condition Code	S
	AV NU S2 ST
06	1321	Condition Indicator	N
07	1321	Condition Indicator	N

HI- Health Care Diagnosis Code

R		C022	Principal Diagnosis
01	1270	Diagnosis Type Code	R
	BK
02	1271	Diagnosis 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	Diagnosis
01	1270	Diagnosis Type Code	R
	BF
02	1271	Diagnosis 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	Diagnosis
01	1270	Diagnosis Type Code	R
	BF
02	1271	Diagnosis 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	Diagnosis
01	1270	Diagnosis Type Code	R
	BF
02	1271	Diagnosis 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	Diagnosis
01	1270	Diagnosis Type Code	R
	BF
02	1271	Diagnosis 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	Diagnosis
01	1270	Diagnosis Type Code	R
	BF
02	1271	Diagnosis 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	Diagnosis
01	1270	Diagnosis Type Code	R
	BF
02	1271	Diagnosis 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	Diagnosis
01	1270	Diagnosis Type Code	R
	BF
02	1271	Diagnosis 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	HI09	C022	Health Care Code Information
N	HI10	C022	Health Care Code Information
N	HI11	C022	Health Care Code Information
N	HI12	C022	Health Care Code Information

HCP- Claim Pricing/Repricing Information R0113 P0910 P1112

01	1473	Pricing/Repricing Methodology	R
	00 01 02 03 04 05 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 Ambulatory Patient Group Code	S
7	782	Repriced Approved Ambulatory Patient Group Amount	S
08	234	Product/Service ID	N
09	235	Product/Service ID Qualifier	N
10	234	Product/Service ID	N
11	355	Unit or Basis for Measurement Code	N
12	380	Quantity	N
13	901	Reject Reason Code	S
	T1 T2 T3 T4 T5 T6
14	1526	Policy Compliance Code	S
	1 2 3 4 5
15	1527	Exception Code	S
	1 2 3 4 5 6

CR7- Home Health Care Plan Information

01	921	Discipline Type Code	R
	AI MS OT PT SN ST
02	1470	Total Visits Rendered Count	R
03	1470	Certification Period Projected Visit Count	R

HSD- Health Care Services Delivery P0102 C0605

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 A B C D E F G H J K L N O S W SA SB SC SD SG SL SP SX SY SZ
08	679	Delivery Pattern Time Code	S
	D E F

NM1- Referring Provider Name P0809 C1110

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
	External Source: states
N	PRV05	C035	Provider Specialty Information
06	1223	Provider Organization Code	N

REF- Referring Provider Secondary Identification R0203

01	128	Reference Identification Qualifier	R
	0B 1B 1C 1D 1G 1H EI G2 LU N5 SY X5
02	127	Referring Provider Secondary Identifier	R
03	352	Description	N
N	REF04	C040	Reference Identifier

NM1- Rendering Provider Name P0809 C1110

01	98	Entity Identifier Code	R
	82
02	1065	Entity Type Qualifier	R
	1 2
03	1035	Rendering Provider Last or Organization Name	R
04	1036	Rendering Provider First Name	S
05	1037	Rendering Provider Middle Name	S
06	1038	Name Prefix	N
07	1039	Rendering Provider Name Suffix	S
08	66	Identification Code Qualifier	R
	24 34 XX
09	67	Rendering Provider Identifier	R
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

PRV- Rendering Provider Specialty Information

01	1221	Provider Code	R
	PE
02	128	Reference Identification Qualifier	R
	ZZ
03	127	Provider Taxonomy Code	R
04	156	State or Province Code	N
	External Source: states
N	PRV05	C035	Provider Specialty Information
06	1223	Provider Organization Code	N

REF- Rendering Provider Secondary Identification R0203

01	128	Reference Identification Qualifier	R
	0B 1B 1C 1D 1G 1H EI G2 LU N5 SY X5
02	127	Rendering Provider Secondary Identifier	R
03	352	Description	N
N	REF04	C040	Reference Identifier

NM1- Purchased Service Provider Name P0809 C1110

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

REF- Purchased Service Provider Secondary Identification R0203

01	128	Reference Identification Qualifier	R
	0B 1A 1B 1C 1D 1G 1H EI G2 LU N5 SY U3 X5
02	127	Purchased Service Provider Secondary Identifier	R
03	352	Description	N
N	REF04	C040	Reference Identifier

NM1- Service Facility Location P0809 C1110

01	98	Entity Identifier Code	R
	77 FA LI TL
02	1065	Entity Type Qualifier	R
	2
03	1035	Laboratory or Facility Name	S
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

N3- Service Facility Location Address

01	166	Laboratory or Facility Address Line 1	R
02	166	Laboratory or Facility Address Line 2	S

N4- Service Facility Location City/State/ZIP C0605

01	19	Laboratory or Facility City Name	R
02	156	Laboratory or Facility State or Province Code	R
	External Source: states
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 Location Secondary Identification R0203

01	128	Reference Identification Qualifier	R
	0B 1A 1B 1C 1D 1G 1H G2 LU N5 TJ X4 X5
02	127	Laboratory or Facility Secondary Identifier	R
03	352	Description	N
N	REF04	C040	Reference Identifier

NM1- Supervising Provider Name P0809 C1110

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

REF- Supervising Provider Secondary Identification R0203

01	128	Reference Identification Qualifier	R
	0B 1B 1C 1D 1G 1H EI G2 LU N5 SY X5
02	127	Supervising Provider Secondary Identifier	R
03	352	Description	N
N	REF04	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	R
	AP C1 CP GP HM IP LD LT MB MC MI MP OT PP SP
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 MB MC OF TV VA WC ZZ

CAS- Claim Level Adjustments L050607 C0605 C0705 L080910 C0908 C1008 L111213 C1211 C1311 L141516 C1514 C1614 L171819 C1817 C1917

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	Adjustment 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- Coordination of Benefits (COB) Payer Paid Amount

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

AMT- Coordination of Benefits (COB) Approved Amount

01	522	Amount Qualifier Code	R
	AAE
02	782	Approved Amount	R
03	478	Credit/Debit Flag Code	N

AMT- Coordination of Benefits (COB) 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) Patient Responsibility Amount

01	522	Amount Qualifier Code	R
	F2
02	782	Other Payer Patient Responsibility Amount	R
03	478	Credit/Debit Flag Code	N

AMT- Coordination of Benefits (COB) Covered Amount

01	522	Amount Qualifier Code	R
	AU
02	782	Other Payer Covered Amount	R
03	478	Credit/Debit Flag Code	N

AMT- Coordination of Benefits (COB) Discount Amount

01	522	Amount Qualifier Code	R
	D8
02	782	Other Payer Discount Amount	R
03	478	Credit/Debit Flag Code	N

AMT- Coordination of Benefits (COB) Per Day Limit Amount

01	522	Amount Qualifier Code	R
	DY
02	782	Other Payer Per Day Limit Amount	R
03	478	Credit/Debit Flag Code	N

AMT- Coordination of Benefits (COB) Patient Paid Amount

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

AMT- Coordination of Benefits (COB) Tax Amount

01	522	Amount Qualifier Code	R
	T
02	782	Other Payer Tax Amount	R
03	478	Credit/Debit Flag Code	N

AMT- Coordination of Benefits (COB) Total Claim Before Taxes Amount

01	522	Amount Qualifier Code	R
	T2
02	782	Other Payer Pre-Tax Claim Total Amount	R
03	478	Credit/Debit Flag Code	N

DMG- 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	Race or Ethnicity Code	N
6	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	Benefits Assignment Certification Indicator	R
	N Y
04	1351	Patient Signature Source Code	S
	B C M P S
05	1360	Provider Agreement Code	N
06	1363	Release of Information Code	R
	A I M N O Y

MOA- Medicare Outpatient Adjudication Information

01	954	Reimbursement Rate	S
02	782	HCPCS Payable Amount	S
03	127	Remark Code	S
	External Source: remark_code
04	127	Remark Code	S
	External Source: remark_code
05	127	Remark Code	S
	External Source: remark_code
06	127	Remark Code	S
	External Source: remark_code
07	127	Remark Code	S
	External Source: remark_code
08	782	End Stage Renal Disease Payment Amount	S
09	782	Non-Payable Professional Component Billed Amount	S

NM1- Other Subscriber Name P0809 C1110

01	98	Entity Identifier 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	Name Prefix	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 1	R
02	166	Other Insured Address Line 2	S

N4- Other Subscriber City/State/ZIP Code C0605

01	19	Other Insured City Name	S
02	156	Other Insured State Code	S
	External Source: states
03	116	Other Insured Postal Zone or ZIP Code	S
04	26	Subscriber Country Code	S
	External Source: country
05	309	Location Qualifier	N
06	310	Location Identifier	N

REF- Other Subscriber Secondary Identification R0203

01	128	Reference Identification Qualifier	R
	1W 23 IG SY
02	127	Other Insured Additional Identifier	R
03	352	Description	N
N	REF04	C040	Reference Identifier

NM1- Other Payer Name P0809 C1110

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

PER- Other Payer Contact Information P0304 P0506 P0708

01	366	Contact Function Code	R
	IC
02	93	Other Payer 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

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 Identifier R0203

01	128	Reference Identification Qualifier	R
	2U F8 FY NF TJ
02	127	Other Payer Secondary Identifier	R
03	352	Description	N
N	REF04	C040	Reference Identifier

REF- Other Payer Prior Authorization or Referral Number R0203

01	128	Reference Identification Qualifier	R
	9F G1
02	127	Other Payer Prior Authorization or Referral Number	R
03	352	Description	N
N	REF04	C040	Reference Identifier

REF- Other Payer Claim Adjustment Indicator R0203

01	128	Reference Identification Qualifier	R
	T4
02	127	Other Payer Claim Adjustment Indicator	R
	Y
03	352	Description	N
N	REF04	C040	Reference Identifier

NM1- Other Payer Patient Information P0809 C1110

01	98	Entity Identifier Code	R
	QC
02	1065	Entity Type Qualifier	R
	1
03	1035	Patient Last 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
	MI
09	67	Other Payer Patient Primary Identifier	R
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

REF- Other Payer Patient Identification R0203

01	128	Reference Identification Qualifier	R
	1W 23 IG SY
02	127	Other Payer Patient Secondary Identifier	R
03	352	Description	N
N	REF04	C040	Reference Identifier

NM1- Other Payer Referring Provider P0809 C1110

01	98	Entity Identifier Code	R
	DN P3
02	1065	Entity Type Qualifier	R
	1 2
03	1035	Referring Provider Last 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 R0203

01	128	Reference Identification Qualifier	R
	1B 1C 1D EI G2 LU N5
02	127	Other Payer Referring Provider Identifier	R
03	352	Description	N
N	REF04	C040	Reference Identifier

NM1- Other Payer Rendering Provider P0809 C1110

01	98	Entity Identifier Code	R
	82
02	1065	Entity Type Qualifier	R
	1 2
03	1035	Rendering Provider 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 Rendering Provider Secondary Identification R0203

01	128	Reference Identification Qualifier	R
	1B 1C 1D EI G2 LU N5
02	127	Other Payer Rendering Provider Secondary Identifier	R
03	352	Description	N
N	REF04	C040	Reference Identifier

NM1- Other Payer Purchased Service Provider P0809 C1110

01	98	Entity Identifier Code	R
	QB
02	1065	Entity Type Qualifier	R
	1 2
03	1035	Purchased Service Provider 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 Purchased Service Provider Identification R0203

01	128	Reference Identification Qualifier	R
	1A 1B 1C 1D EI G2 LU N5
02	127	Other Payer Purchased Service Provider Identifier	R
03	352	Description	N
N	REF04	C040	Reference Identifier

NM1- Other Payer Service Facility Location P0809 C1110

01	98	Entity Identifier Code	R
	77 FA LI TL
02	1065	Entity Type Qualifier	R
	2
03	1035	Service Facility 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 Service Facility Location Identification R0203

01	128	Reference Identification Qualifier	R
	1A 1B 1C 1D G2 LU N5
02	127	Other Payer Service Facility Location Identifier	R
03	352	Description	N
N	REF04	C040	Reference Identifier

NM1- Other Payer Supervising Provider P0809 C1110

01	98	Entity Identifier Code	R
	DQ
02	1065	Entity Type Qualifier	R
	1
03	1035	Supervising Provider Last 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 Supervising Provider Identification R0203

01	128	Reference Identification Qualifier	R
	1B 1C 1D EI G2 N5
02	127	Other Payer Supervising Provider Identifier	R
03	352	Description	N
N	REF04	C040	Reference Identifier

LX- Service Line

554

Line Counter

SV1- Professional Service P0304

R		C003	Procedure Identifier
01	235	Product or Service ID Qualifier	R
	HC IV N4 ZZ
02	234	Procedure Code	R
03	1339	Procedure Modifier 1	S
04	1339	Procedure Modifier 2	S
05	1339	Procedure Modifier 3	S
06	1339	Procedure Modifier 4	S
07	352	Description	N
02	782	Line Item Change Amount	R
03	355	Unit or Basis for Measurement Code	R
	F2 MJ UN
04	380	Service Unit Count	R
05	1331	Place of Service Code	S
	External Source: pos
06	1365	Service Type Code	N
S		C004	Diagnosis Code Pointer
01	1328	Diagnosis Code Pointer	R
	1 2 3 4 5 6 7 8
02	1328	Diagnosis Code Pointer	S
	1 2 3 4 5 6 7 8
03	1328	Diagnosis Code Pointer	S
	1 2 3 4 5 6 7 8
04	1328	Diagnosis Code Pointer	S
	1 2 3 4 5 6 7 8
08	782	Monetary Amount	N
09	1073	Emergency Indicator	S
	Y
10	1340	Multiple Procedure Code	N
11	1073	EPSDT Indicator	S
	Y
12	1073	Family Planning Indicator	S
	Y
13	1364	Review Code	N
14	1341	National or Local Assigned Review Value	N
15	1327	Co-Pay Status Code	S
	0
16	1334	Health Care Professional Shortage Area Code	N
17	127	Reference Identification	N
18	116	Postal Code	N
19	782	Monetary Amount	N
20	1337	Level of Care Code	N
21	1360	Provider Agreement Code	N

SV5- Durable Medical Equipment Service

R		C003	Composite Medical Procedure Identifier
01	235	Procedure Identifier	R
	HC
02	234	Procedure Code	R
03	1339	Procedure Modifier 1	N
04	1339	Procedure Modifier 2	N
05	1339	Procedure Modifier 3	N
06	1339	Procedure Modifier 4	N
07	352	Description	N
02	355	Unit or Basis for Measurement Code	R
	DA
03	380	Length of Medical Necessity	R
04	782	DME Rental Price	S
05	782	DME Purchase Price	S
06	594	Rental Unit Price Indicator	S
	1 4 6
07	923	Prognosis Code	N

PWK- DMERC CMN Indicator P0506

01	755	Attachment Report Type Code	R
	CT
02	756	Attachment Transmission Code	R
	AB AD AF AG NS
03	757	Report Copies Needed	N
04	98	Entity Identifier Code	N
05	66	Identification Code Qualifier	N
06	67	Identification Code	N
07	352	Description	N
N	PWK08	C002	Actions Indicated
09	1525	Request Category Code	N

CR1- Ambulance Transport Information P0102 P0506

01	355	Unit or Basis for Measurement Code	S
	LB
02	81	Patient Weight	S
03	1316	Ambulance Transport Code	R
	I R T X
04	1317	Ambulance Transport Reason Code	R
	A B C D E
05	355	Unit or Basis for Measurement Code	R
	DH
06	380	Transport Distance	R
07	166	Address Information	N
08	166	Address Information	N
09	352	Round Trip Purpose Description	S
10	352	Stretcher Purpose Description	S

CR2- Spinal Manipulation Service Information P0102 C0403 P0506

01	609	Treatment Series Number	N
02	380	Treatment Count	N
03	1367	Subluxation Level Code	N
	C1 C2 C3 C4 C5 C6 C7 CO IL L1 L2 L3 L4 L5 OC SA T1 T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12
04	1367	Subluxation Level Code	N
	C1 C2 C3 C4 C5 C6 C7 CO IL L1 L2 L3 L4 L5 OC SA T1 T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12
05	355	Unit or Basis for Measurement Code	N
	DA MO WK YR
06	380	Treatment Period Count	N
07	380	Monthly Treatment Count	N
08	1342	Patient Condition Code	R
	A C D E F G M
09	1073	Complication Indicator	N
	N Y
10	352	Patient Condition Description	S
11	352	Patient Condition Description	S
12	1073	X-ray Availability Indicator	S
	N Y

CR3- Durable Medical Equipment Certification P0203

01	1322	Certification Type Code	R
	I R S
02	355	Unit or Basis for Measurement Code	R
	MO
03	380	Durable Medical Equipment Duration	R
04	1335	Insulin Dependent Code	N
05	352	Description	N

CR5- Home Oxygen Therapy Information

01	1322	Certification Type Code.Oxygen Therapy	R
	I R S
02	380	Treatment Period Count	R
03	1348	Oxygen Equipment Type Code	N
04	1348	Oxygen Equipment Type Code	N
05	352	Description	N
06	380	Quantity	N
07	380	Quantity	N
08	380	Quantity	N
09	352	Description	N
10	380	Arterial Blood Gas Quantity	S
11	380	Oxygen Saturation Quantity	S
12	1349	Oxygen Test Condition Code	R
	E R S
13	1350	Oxygen Test Finding Code	S
	1
14	1350	Oxygen Test Finding Code	S
	2
15	1350	Oxygen Test Finding Code	S
	3
16	380	Quantity	N
17	1382	Oxygen Delivery System Code	N
18	1348	Oxygen Equipment Type Code	N

CRC- Ambulance Certification

01	1136	Code Category	R
	07
02	1073	Certification Condition Indicator	R
	N Y
03	1321	Condition Code	R
	01 02 03 04 05 06 07 08 09 60
04	1321	Condition Code	S
	01 02 03 04 05 06 07 08 09 60
05	1321	Condition Code	S
	01 02 03 04 05 06 07 08 09 60
06	1321	Condition Code	S
	01 02 03 04 05 06 07 08 09 60
07	1321	Condition Code	S
	01 02 03 04 05 06 07 08 09 60

CRC- Hospice Employee Indicator

01	1136	Code Category	R
	70
02	1073	Hospice Employed Provider Indicator	R
	N Y
03	1321	Condition Indicator	R
	65
04	1321	Condition Indicator	N
05	1321	Condition Indicator	N
06	1321	Condition Indicator	N
07	1321	Condition Indicator	N

CRC- DMERC Condition Indicator

01	1136	Code Category	R
	09 11
02	1073	Certification Condition Indicator	R
	N Y
03	1321	Condition Indicator	R
	37 38 AL P1 ZV
04	1321	Condition Indicator	S
	37 38 AL P1 ZV
05	1321	Condition Indicator	S
	37 38 AL P1 ZV
06	1321	Condition Indicator	S
	37 38 AL P1 ZV
07	1321	Condition Indicator	S
	37 38 AL P1 ZV

DTP- Date - Service Date

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

DTP- Date - Certification Revision Date

01	374	Date Time Qualifier	R
	607
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Certification Revision Date	R

DTP- Date - Begin Therapy Date

01	374	Date Time Qualifier	R
	463
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Begin Therapy Date	R

DTP- Date - Last Certification Date

01	374	Date Time Qualifier	R
	461
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Last Certification Date	R

DTP- Date - Date Last Seen

01	374	Date Time Qualifier	R
	304
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Last Seen Date	R

DTP- Date - Test

01	374	Date Time Qualifier	R
	738 739
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Test Performed Date	R

DTP- Date - Oxygen Saturation/Arterial Blood Gas Test

01	374	Date Time Qualifier	R
	119 480 481
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Oxygen Saturation Test Date	R

DTP- Date - Shipped

01	374	Date Time Qualifier	R
	011
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Shipped Date	R

DTP- Date - Onset of Current Symptom/Illness

01	374	Date Time Qualifier	R
	431
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Onset Date	R

DTP- Date - Last X-ray

01	374	Date Time Qualifier	R
	455
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Last X-Ray Date	R

DTP- Date - Acute Manifestation

01	374	Date Time Qualifier	R
	453
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Acute Manifestation Date	R

DTP- Date - Initial Treatment

01	374	Date Time Qualifier	R
	454
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Initial Treatment Date	R

DTP- Date - Similar Illness/Symptom Onset

01	374	Date Time Qualifier	R
	438
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Similar Illness or Symptom Date	R

MEA- Test Result R03050608 C0504 C0604 L07030506 E0803

01	737	Measurement Reference Identification Code	R
	OG TR
02	738	Measurement Qualifier	R
	GRA HT R1 R2 R3 R4 ZO
03	739	Test Results	R
N	MEA04	C001	Composite Unit of Measure
05	740	Range Minimum	N
06	741	Range Maximum	N
07	935	Measurement Significance Code	N
08	936	Measurement Attribute Code	N
09	752	Surface/Layer/Position Code	N
10	1373	Measurement Method or Device	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

REF- Repriced Line Item Reference Number R0203

01	128	Reference Identification Qualifier	R
	9B
02	127	Repriced Line Item Reference Number	R
03	352	Description	N
N	REF04	C040	Reference Identifier

REF- Adjusted Repriced Line Item Reference Number R0203

01	128	Reference Identification Qualifier	R
	9D
02	127	Adjusted Repriced Line Item Reference Number	R
03	352	Description	N
N	REF04	C040	Reference Identifier

REF- Prior Authorization or Referral Number R0203

01	128	Reference Identification Qualifier	R
	9F G1
02	127	Prior Authorization or Referral Number	R
03	352	Description	N
N	REF04	C040	Reference Identifier

REF- Line Item Control Number R0203

01	128	Reference Identification Qualifier	R
	6R
02	127	Line Item Control Number	R
03	352	Description	N
N	REF04	C040	Reference Identifier

REF- Mammography Certification Number R0203

01	128	Reference Identification Qualifier	R
	EW
02	127	Mammography Certification Number	R
03	352	Description	N
N	REF04	C040	Reference Identifier

REF- Clinical Laboratory Improvement Amendment (CLIA) Identification R0203

01	128	Reference Identification Qualifier	R
	X4
02	127	Clinical Laboratory Improvement Amendment Number	R
03	352	Description	N
N	REF04	C040	Reference Identifier

REF- Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification R0203

01	128	Reference Identification Qualifier	R
	F4
02	127	Referring CLIA Number	R
03	352	Description	N
N	REF04	C040	Reference Identifier

REF- Immunization Batch Number R0203

01	128	Reference Identification Qualifier	R
	BT
02	127	Immunization Batch Number	R
03	352	Description	N
N	REF04	C040	Reference Identifier

REF- Ambulatory Patient Group (APG) R0203

01	128	Reference Identification Qualifier	R
	1S
02	127	Ambulatory Patient Group Number	R
03	352	Description	N
N	REF04	C040	Reference Identifier

REF- Oxygen Flow Rate R0203

01	128	Reference Identification Qualifier	R
	TP
02	127	Oxygen Flow Rate	R
03	352	Description	N
N	REF04	C040	Reference Identifier

REF- Universal Product Number (UPN) R0203

01	128	Reference Identification Qualifier	R
	OZ VP
02	127	Universal Product Number	R
03	352	Description	N
N	REF04	C040	Reference Identifier

AMT- Sales Tax Amount

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

AMT- Approved Amount

01	522	Amount Qualifier Code	R
	AAE
02	782	Approved Amount	R
03	478	Credit/Debit Flag Code	N

AMT- Postage Claimed Amount

01	522	Amount Qualifier Code	R
	F4
02	782	Postage Claimed Amount	R
03	478	Credit/Debit Flag Code	N

K3- File Information

01	449	Fixed Format Information	R
02	1333	Record Format Code	N
N	K303	C001	Composite Unit of Measure

NTE- Line Note

01	363	Note Reference Code	R
	ADD DCP PMT TPO
02	352	Line Note Text	R

PS1- Purchased Service Information

01	127	Purchased Service Provider Identifier	R
02	782	Purchased Service Charge Amount	R
03	156	State or Province Code	N
	External Source: states

HSD- Health Care Services Delivery P0102 C0605

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 34 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 A B C D E F G H J K L N O W SA SB SC SD SG SL SP SX SY SZ
08	679	Delivery Pattern Time Code	S
	D E F

HCP- Line Pricing/Repricing Information R0113 P0910 P1112

01	1473	Pricing/Repricing 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 Ambulatory Patient Group Code	S
7	782	Repriced Approved Ambulatory Patient Group Amount	S
08	234	Product/Service ID	N
09	235	Product or Service ID Qualifier	S
	HC IV ZZ
10	234	Producedure Code	S
11	355	Unit or Basis for Measurement Code	S
	DA UN
12	380	Repriced Approved Service Unit Count	S
13	901	Reject Reason Code	S
	T1 T2 T3 T4 T5 T6
14	1526	Policy Compliance Code	S
	1 2 3 4 5
15	1527	Exception Code	S
	1 2 3 4 5 6

LIN- Drug Identification

01	350	Assignment ID	N
02	235	Product or Service ID Qualifier	R
	N4
03	234	National Drug Code	R
04	235	Product/Service ID Qualifier	N
	N4
05	234	Product/Service ID	N
06	235	Product/Service ID Qualifier	N
	N4
07	234	Product/Service ID	N
08	235	Product/Service ID Qualifier	N
	N4
09	234	Product/Service ID	N
10	235	Product/Service ID Qualifier	N
	N4
11	234	Product/Service ID	N
12	235	Product/Service ID Qualifier	N
	N4
13	234	Product/Service ID	N
14	235	Product/Service ID Qualifier	N
	N4
15	234	Product/Service ID	N
16	235	Product/Service ID Qualifier	N
	N4
17	234	Product/Service ID	N
18	235	Product/Service ID Qualifier	N
	N4
19	234	Product/Service ID	N
20	235	Product/Service ID Qualifier	N
	N4
21	234	Product/Service ID	N
22	235	Product/Service ID Qualifier	N
	N4
23	234	Product/Service ID	N
24	235	Product/Service ID Qualifier	N
	N4
25	234	Product/Service ID	N
26	235	Product/Service ID Qualifier	N
	N4
27	234	Product/Service ID	N
28	235	Product/Service ID Qualifier	N
	N4
29	234	Product/Service ID	N
30	235	Product/Service ID Qualifier	N
	N4
31	234	Product/Service ID	N

CTP- Drug Pricing

01	687	Trade Code Class	N
02	236	Price Identifier Code	N
03	212	Drug Unit Price	R
04	380	National Drug Unit Count	R
R		C001	Unit or Basis of Measurement
01	355	Unit or Basis for Measurement Code	R
	F2 GR ML UN
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
06	648	Price Multiplier Qualifier	N
07	649	Multiplier	N
08	782	Monetary Amount	N
09	639	Basis or Unit Price Code	N
10	499	Condition Value	N
11	289	Multiple Price Quantity	N

REF- Prescription Number R0203

01	128	Reference Identification Qualifier	R
	XZ
02	127	Prescription Number	R
03	352	Description	N
N	REF04	C040	Reference Identifier

NM1- Rendering Provider Name P0809 C1110

01	98	Entity Identifier Code	R
	82
02	1065	Entity Type Qualifier	R
	1 2
03	1035	Rendering Provider Last or Organization Name	R
04	1036	Rendering Provider First Name	S
05	1037	Rendering Provider Middle Name	S
06	1038	Name Prefix	N
07	1039	Rendering Provider Name Suffix	S
08	66	Identification Code Qualifier	R
	24 34 XX
09	67	Rendering Provider Identifier	R
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

PRV- Rendering Provider Specialty Information

01	1221	Provider Code	R
	PE
02	128	Reference Identification Qualifier	R
	ZZ
03	127	Provider Taxonomy Code	R
04	156	State or Province Code	N
	External Source: states
N	PRV05	C035	Provider Specialty Information
06	1223	Provider Organization Code	N

REF- Rendering Provider Secondary Identification R0203

01	128	Reference Identification Qualifier	R
	0B 1B 1C 1D 1G 1H EI G2 LU N5 SY X5
02	127	Rendering Provider Secondary Identifier	R
03	352	Description	N
N	REF04	C040	Reference Identifier

NM1- Purchased Service Provider Name P0809 C1110

01	98	Entity Identifier Code	R
	QB
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	S
	24 34 XX
09	67	Purchased Service Provider Identifier	S
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

REF- Purchased Service Provider Secondary Identification R0203

01	128	Reference Identification Qualifier	R
	0B 1A 1B 1C 1D 1G 1H EI G2 LU N5 SY U3 X5
02	127	Purchased Service Provider Secondary Identifier	R
03	352	Description	N
N	REF04	C040	Reference Identifier

NM1- Service Facility Location P0809 C1110

01	98	Entity Identifier Code	R
	77 FA LI TL
02	1065	Entity Type Qualifier	R
	2
03	1035	Laboratory or Facility Name	S
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

N3- Service Facility Location Address

01	166	Laboratory or Facility Address Line 1	R
02	166	Laboratory or Facility Address Line 2	S

N4- Service Facility Location City/State/ZIP C0605

01	19	Laboratory or Facility City Name	R
02	156	Laboratory or Facility State or Province Code	R
	External Source: states
03	116	Laboratory or Facility Postal Zone or ZIP Code	R
04	26	Service Facility Location Country Code	S
	External Source: country
05	309	Location Qualifier	N
06	310	Location Identifier	N

REF- Service Facility Location Secondary Identification R0203

01	128	Reference Identification Qualifier	R
	0B 1A 1B 1C 1D 1G 1H G2 LU N5 TJ X4 X5
02	127	Service Facility Location Secondary Identifier	R
03	352	Description	N
N		C040	Reference Identifier

NM1- Supervising Provider Name P0809 C1110

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

REF- Supervising Provider Secondary Identification R0203

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

NM1- Ordering Provider Name P0809 C1110

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

N3- Ordering Provider Address

01	166	Ordering Provider Address Line 1	R
02	166	Ordering Provider Address Line 2	S

N4- Ordering Provider City/State/ZIP Code C0605

01	19	Ordering Provider City Name	R
02	156	Ordering Provider State Code	R
	External Source: states
03	116	Ordering Provider Postal Zone or ZIP Code	R
04	26	Ordering Provider Country Code	S
	External Source: country
05	309	Location Qualifier	N
06	310	Location Identifier	N

REF- Ordering Provider Secondary Identification R0203

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

PER- Ordering Provider Contact Information P0304 P0506 P0708

01	366	Contact Function Code	R
	IC
02	93	Ordering 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- Referring Provider Name P0809 C1110

01	98	Entity Identifier Code	R
	DN P3
02	1065	Entity Type Qualifier	R
	1
03	1035	Referring Provider Last Name	R
04	1036	Referring Provider First Name	R
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
	External Source: states
N		C035	Provider Specialty Information
06	1223	Provider Organization Code	N

REF- Referring Provider Secondary Identification R0203

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

NM1- Other Payer Prior Authorization or Referral Number P0809 C1110

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	Other Payer Identification Number	R
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

REF- Other Payer Prior Authorization or Referral Number R0203

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

SVD- Line Adjudication Information

01	67	Other Payer Primary Identifier	R
02	782	Service Line Paid Amount	R
R		C003	Procedure Identifier
01	235	Product or Service ID Qualifier	R
	HC IV ZZ
02	234	Procedure Code	R
03	1339	Procedure Modifier 1	S
04	1339	Procedure Modifier 2	S
05	1339	Procedure Modifier 3	S
06	1339	Procedure Modifier 4	S
07	352	Procedure Code Description	S
04	234	Product/Service ID	N
05	380	Paid Service Unit Count	R
06	554	Bundled Line Number	S

CAS- Line Adjustment L050607 C0605 C0705 L080910 C0908 C1008 L111213 C1211 C1311 L141516 C1514 C1614 L171819 C1817 C1917

01	1033	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	Adjustment 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

DTP- Line 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

LQ- Form Identification Code C0102

01	1270	Form Identification Code	R
	AS UT
02	1271	Form Identifier	R

FRM- Supporting Documentation

01	350	Question Number/Letter	R
02	1073	Question Response	S
	N W Y
03	127	Question Response	S
04	373	Question Response	S

05	332	Question Response	S

SE- Transaction Set Trailer

01	96	Transaction Segment Count	R
02	329	Transaction Set Control Number	R

GE- Functional Group Trailer

01	97	Number of Transaction Sets Included	R
02	28	Group Control Number	R

TA1- Interchange Acknowledgement

01	I12	Interchange Control Number	R
02	I08	Interchange Date	R
03	I09	Interchange Time	R
04	I17	Interchange Acknowledgement Code	R
	A E R
05	I18	Interchange Note Code	R
	000 001 002 003 004 005 006 007 008 009 010 011 012 013 014 015 016 017 018 019 020 021 022 023 024 025 026 027 028 029 030 031

IEA- Interchange Control Trailer

01	I16	Number of Included Functional Groups	R
02	I12	Interchange Control Number	R