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
004010X096A1

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

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

REF- Transaction Type Identification
01 128 Reference Identification Qualifier R
87
02 127 Transmission Type Code R
004010X096DA1 004010X096A1
03 352 Description N
N C040 Reference Identifier

NM1- Submitter Name
01 98 Entity Identifier Code R
41
02 1065 Entity Type Qualifier R
1 2
03 1035 Submitter Last or Organization Name R
04 1036 Submitter First Name S
05 1037 Submitter Middle Name S
06 1038 Name Prefix N
07 1039 Name Suffix N
08 66 Identification Code Qualifier R
46
09 67 Submitter Identifier R
10 706 Entity Relationship Code N
11 98 Entity Identifier Code N

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

NM1- Receiver Name
01 98 Entity Identifier Code R
40
02 1065 Entity Type Qualifier R
2
03 1035 Receiver Name R
04 1036 Name First N
05 1037 Name Middle N
06 1038 Name Prefix N
07 1039 Name Suffix N
08 66 Information Receiver Identification Number R
46
09 67 Receiver Primary Identifier R
10 706 Entity Relationship Code N
11 98 Entity Identifier Code N

HL- Billing/Pay-To Provider Hierarchical Level
01 628 Hierarchical ID Number R
02 734 Hierarchical Parent ID Number N
03 735 Hierarchical Level Code R
20
04 736 Hierarchical Child Code R
1

PRV- Billing/Pay-To Provider Specialty Information
01 1221 Provider Code R
BI PT
02 128 Reference Identification Qualifier R
ZZ
03 127 Provider Taxonomy Code R
04 156 State or Province Code N
External Source: states
N C035 Provider Specialty Information
06 1223 Provider Organization Code N

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

NM1- Billing Provider Name
01 98 Entity Identifier Code R
85
02 1065 Entity Type Qualifier R
2
03 1035 Billing Provider Last or Organizational Name R
04 1036 Name First N
05 1037 Name Middle N
06 1038 Name Prefix N
07 1039 Name Suffix N
08 66 Identification Code Qualifier R
24 34 XX
09 67 Billing Provider Identifier R
10 706 Entity Relationship Code N
11 98 Entity Identifier Code N

N3- Billing Provider Address
01 166 Billing Provider Address Line R
02 166 Billing Provider Address Line S

N4- Billing Provider City/State/ZIP Code
01 19 Billing Provider City Name R
02 156 Billing Provider State or Province Code R
External Source: states
03 116 Billing Provider Postal Zone or ZIP Code R
04 26 Country Code S
External Source: country
05 309 Location Qualifier N
06 310 Location Identifier N

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

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

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

NM1- Pay-To Provider Name
01 98 Entity Identifier Code R
87
02 1065 Entity Type Qualifier R
2
03 1035 Pay-to Provider Last or Organizational Name R
04 1036 Name First N
05 1037 Name Middle N
06 1038 Name Prefix N
07 1039 Name Suffix N
08 66 Identification Code Qualifier R
24 34 XX
09 67 Pay-to Provider Identifier R
10 706 Entity Relationship Code N
11 98 Entity Identifier Code N

N3- Pay-To Provider Address
01 166 Pay-to Provider Address Line R
02 166 Pay-to Provider Address Line S

N4- Pay-To Provider City/State/ZIP Code
01 19 Pay-to Provider City Name R
02 156 Pay-to Provider State Code R
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
01 128 Reference Identification Qualifier R
0B 1A 1B 1C 1D 1G 1H 1J B3 BQ EI FH G2 G5 LU SY X5
02 127 Pay-to Provider Additional Identifier R
03 352 Description N
N C040 Reference Identifier

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

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

NM1- Subscriber Name
01 98 Entity Identifier Code R
IL
02 1065 Entity Type Qualifier R
1 2
03 1035 Subscriber Last Name R
04 1036 Subscriber First Name S
05 1037 Subscriber Middle Name S
06 1038 Name Prefix N
07 1039 Subscriber Name Suffix S
08 66 Identification Code Qualifier S
MI ZZ
09 67 Subscriber Primary Identifier S
10 706 Entity Relationship Code N
11 98 Entity Identifier Code N

N3- Subscriber Address
01 166 Subscriber Address Line R
02 166 Subscriber Address Line S

N4- Subscriber City/State/ZIP Code
01 19 Subscriber City Name R
02 156 Subscriber State Code R
External Source: states
03 116 Subscriber Postal Zone or ZIP Code R
04 26 Country Code S
External Source: country
05 309 Location Qualifier N
06 310 Location Identifier N

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

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

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

NM1- Credit/Debit Card Account Holder Name
01 98 Entity Identifier Code R
AO
02 1065 Entity Type Qualifier R
1 2
03 1035 Credit or Debit Card Holder Last or Organizational Name R
04 1036 Credit or Debit Card Holder First Name S
05 1037 Credit or Debit Card Holder Middle Name S
06 1038 Name Prefix N
07 1039 Credit or Debit Card Holder Name Suffix S
08 66 Identification Code Qualifier R
MI
09 67 Credit or Debit Card Number R
10 706 Entity Relationship Code N
11 98 Entity Identifier Code N

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

NM1- Payer Name
01 98 Entity Identifier Code R
PR
02 1065 Entity Type Qualifier R
2
03 1035 Payer Name R
04 1036 Name First N
05 1037 Name Middle N
06 1038 Name Prefix N
07 1039 Name Suffix N
08 66 Identification Code Qualifier R
PI XV
09 67 Payer Identifier R
10 706 Entity Relationship Code N
11 98 Entity Identifier Code N

N3- Payer Address
01 166 Payer Address Line R
02 166 Payer Address Line S

N4- Payer City/State/ZIP Code
01 19 Payer City Name R
02 156 Payer State Code R
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- Payer Secondary Identification
01 128 Reference Identification Qualifier R
2U FY NF TJ
02 127 Payer Additional Identifier R
03 352 Description N
N C040 Reference Identifier

NM1- Responsible Party Name
01 98 Entity Identifier Code R
QD
02 1065 Entity Type Qualifier R
1 2
03 1035 Responsible Party Last or Organization Name R
04 1036 Responsible Party First Name S
05 1037 Responsible Party Middle Name S
06 1038 Name Prefix N
07 1039 Responsible Party Suffix Name S
08 66 Identification Code Qualifier N
09 67 Identification Code N
10 706 Entity Relationship Code N
11 98 Entity Identifier Code N

N3- Responsible Party Address
01 166 Responsible Party Address Line R
02 166 Responsible Party Address Line S

N4- Responsible Party City/State/ZIP Code
01 19 Responsible Party City Name R
02 156 Responsible Party State Code R
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

CLM- Claim Information
01 1028 Patient Account Number R
02 782 Total Claim Charge Amount R
03 1032 Claim Filing Indicator Code N
04 1343 Non-Institutional Claim Type Code N
R C023 Type of Bill
01 1331 Facility Type Code R
02 1332 Facility Code Qualifier R
A
03 1325 Claim Frequency Code R
0 1 2 3 4 5 6 7 8 9 A B C D E F G H I J K L M N O X Y Z
06 1073 Provider or Supplier Signature Indicator R
N Y
07 1359 Medicare Assignment Code S
A C
08 1073 Benefits Assignment Certification Indicator R
N Y
09 1363 Release of Information Code R
A I M N O Y
10 1351 Patient Signature Source Code N
N C024 Property and Casualty Related Causes Codes
12 1366 Special Program Indicator N
01 02 03 05 07 08 09
13 1073 Yes/No Condition or Response Code N
14 1338 Level of Service Code N
15 1073 Yes/No Condition or Response Code N
16 1360 Provider Agreement Code N
17 1029 Claim Status Code N
18 1073 Explanation of Benefits Indicator R
N Y
19 1383 Claim Submission Reason Code N
20 1514 Delay Reason Code S
1 2 3 4 5 6 7 8 9 10 11

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

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

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

CL1- Institutional Claim Code
01 1315 Admission Type Code S
02 1314 Admission Source Code S
03 1352 Patient Status Code S
04 1345 Nursing Home Residential Status Code N

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

CN1- Contract Information
01 1166 Contract Type Code R
01 02 03 04 05 06 09
02 782 Contract Amount S
03 332 Contract Percentage S
04 127 Contract Code S
05 338 Terms Discount Percentage S
06 799 Contract Version Identifier S

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

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

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

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

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

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

REF- Claim Identification Number For Clearinghouses and Other Transmission Intermediaries
01 128 Reference Identification Qualifier R
D9
02 127 Value Added Network Trace Number R
03 352 Description N
N C040 Reference Identifier

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

REF- Original Reference Number (ICN/DCN)
01 128 Reference Identification Qualifier R
F8
02 127 Claim Original Reference Number R
03 352 Description N
N C040 Reference Identifier

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

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

REF- Peer Review Organization (PRO) Approval Number
01 128 Reference Identification Qualifier R
G4
02 127 Peer Review Authorization Number R
03 352 Description N
N C040 Reference Identifier

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

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

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

K3- File Information
01 449 Fixed Format Information R
02 1333 Record Format Code N
N C001 Composite Unit of Measure

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

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

CR6- Home Health Care Information
01 923 Prognosis Indicator R
1 2 3 4 5 6 7 8
02 373 Service From Date R
03 1250 Date Time Period Format Qualifier S
RD8
04 1251 Home Health Certification Period S
05 373 Diagnosis Date R
06 1073 Skilled Nursing Facility Indicator R
N U Y
07 1073 Medicare Coverage Indicator R
N Y
08 1322 Certification Type Indicator R
I R S
09 373 Surgery Date S
10 235 Product or Service ID Qualifier S
HC ID
11 1137 Surgical Procedure Code S
12 373 Physician Order Date S
13 373 Last Visit Date S
14 373 Physician Contact Date S
15 1250 Date Time Period Format Qualifier S
RD8
16 1251 Last Admission Period S
17 1384 Patient Discharge Facility Type Code R
A B C D E F G H L M O R S T
18 373 Diagnosis Date S
19 373 Diagnosis Date S
20 373 Diagnosis Date S
21 373 Diagnosis Date S

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

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

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

HI- Principal, Admitting, E-Code and Patient Reason for Visit Diagnosis Information
R C022 Health Care Code Information
01 1270 Code List Qualifier Code R
BK
02 1271 Industry Code R
03 1250 Date Time Period Format Qualifier N
04 1251 Date Time Period N
05 782 Monetary Amount N
06 380 Quantity N
07 799 Version Identifier N
S C022 Health Care Code Information
01 1270 Code List Qualifier Code R
BJ ZZ
02 1271 Industry Code R
03 1250 Date Time Period Format Qualifier N
04 1251 Date Time Period N
05 782 Monetary Amount N
06 380 Quantity N
07 799 Version Identifier N
S C022 Health Care Code Information
01 1270 Code List Qualifier Code R
BN
02 1271 Industry Code R
03 1250 Date Time Period Format Qualifier N
04 1251 Date Time Period N
05 782 Monetary Amount N
06 380 Quantity N
07 799 Version Identifier N
N C022 Health Care Code Information
N C022 Health Care Code Information
N C022 Health Care Code Information
N C022 Health Care Code Information
N C022 Health Care Code Information
N C022 Health Care Code Information
N C022 Health Care Code Information
N C022 Health Care Code Information
N C022 Health Care Code Information

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

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

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

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

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

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

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

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

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

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

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

CR7- Home Health Care Plan Information
01 921 Discipline Type Code R
AI MS OT PT SN ST
02 1470 Visits Prior to Recertification Date Count R
03 1470 Total Visits Projected This Certification Count R

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

NM1- Attending Physician Name
01 98 Entity Identifier Code R
71
02 1065 Entity Type Qualifier R
1 2
03 1035 Attending Physician Last Name R
04 1036 Attending Physician First Name S
05 1037 Attending Physician Middle Name S
06 1038 Name Prefix N
07 1039 Attending Physician Name Suffix S
08 66 Identification Code Qualifier R
24 34 XX
09 67 Attending Physician Primary Identifier R
10 706 Entity Relationship Code N
11 98 Entity Identifier Code N

PRV- Attending Physician Specialty Information
01 1221 Provider Code R
AT SU
02 128 Reference Identification Qualifier R
ZZ
03 127 Provider Taxonomy Code R
04 156 State or Province Code N
External Source: states
N C035 Provider Specialty Information
06 1223 Provider Organization Code N

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

NM1- Operating Physician Name
01 98 Entity Identifier Code R
72
02 1065 Entity Type Qualifier R
1
03 1035 Operating Physician Last Name R
04 1036 Operating Physician First Name R
05 1037 Operating Physician Middle Name S
06 1038 Name Prefix N
07 1039 Operating Physician Name Suffix S
08 66 Identification Code Qualifier R
24 34 XX
09 67 Operating Physician Primary Identifier R
10 706 Entity Relationship Code N
11 98 Entity Identifier Code N

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

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

NM1- Other Provider Name
01 98 Entity Identifier Code R
73
02 1065 Entity Type Qualifier R
1 2
03 1035 Other Physician Last Name R
04 1036 Other Physician First Name S
05 1037 Other Provider Middle Name S
06 1038 Name Prefix N
07 1039 Other Provider Name Suffix S
08 66 Identification Code Qualifier R
24 34 XX
09 67 Other Physician Identifier R
10 706 Entity Relationship Code N
11 98 Entity Identifier Code N

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

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

NM1- Service Facility Name
01 98 Entity Identifier Code R
FA
02 1065 Entity Type Qualifier R
2
03 1035 Laboratory or Facility Name R
04 1036 Name First N
05 1037 Name Middle N
06 1038 Name Prefix N
07 1039 Name Suffix N
08 66 Identification Code Qualifier S
24 34 XX
09 67 Laboratory or Facility Primary Identifier S
10 706 Entity Relationship Code N
11 98 Entity Identifier Code N

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

N3- Service Facility Address
01 166 Laboratory or Facility Address Line R
02 166 Laboratory or Facility Address Line S

N4- Service Facility City/State/Zip Code
01 19 Laboratory or Facility City Name R
02 156 Laboratory or Facility State or Province Code R
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 Secondary Identification
01 128 Reference Identification Qualifier R
0B 1A 1B 1C 1D 1G 1H 1J EI FH G2 G5 LU N5 X5
02 127 Laboratory or Facility Secondary Identifier R
03 352 Description N
N C040 Reference Identifier

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

CAS- Claim Level Adjustment
01 1033 Claim Adjustment Group Code R
CO CR OA PI PR
02 1034 Adjustment Reason Code R
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 A0 A1 A2 A3 A4 A5 A6 A7 A8 B1 B2 B3 B4 B5 B6 B7 B8 B9 B10 B11 B12 B13 B14 B15 B16 B17 B18 B19 B20 B21 B22 B23 D1 D2 D3 D4 D5 D6 D7 D8 D9 D10 D11 D12 D13 D14 D15 W1
03 782 Adjustment Amount R
04 380 Adjustment Quantity S
05 1034 Adjustment Reason Code S
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 A0 A1 A2 A3 A4 A5 A6 A7 A8 B1 B2 B3 B4 B5 B6 B7 B8 B9 B10 B11 B12 B13 B14 B15 B16 B17 B18 B19 B20 B21 B22 B23 D1 D2 D3 D4 D5 D6 D7 D8 D9 D10 D11 D12 D13 D14 D15 W1
06 782 Adjustment Amount S
07 380 Adjustment Quantity S
08 1034 Adjustment Reason Code S
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 A0 A1 A2 A3 A4 A5 A6 A7 A8 B1 B2 B3 B4 B5 B6 B7 B8 B9 B10 B11 B12 B13 B14 B15 B16 B17 B18 B19 B20 B21 B22 B23 D1 D2 D3 D4 D5 D6 D7 D8 D9 D10 D11 D12 D13 D14 D15 W1
09 782 Adjustment Amount S
10 380 Adjustment Quantity S
11 1034 Adjustment Reason Code S
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 A0 A1 A2 A3 A4 A5 A6 A7 A8 B1 B2 B3 B4 B5 B6 B7 B8 B9 B10 B11 B12 B13 B14 B15 B16 B17 B18 B19 B20 B21 B22 B23 D1 D2 D3 D4 D5 D6 D7 D8 D9 D10 D11 D12 D13 D14 D15 W1
12 782 Adjustment Amount S
13 380 Adjustment Quantity S
14 1034 Adjustment Reason Code S
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 A0 A1 A2 A3 A4 A5 A6 A7 A8 B1 B2 B3 B4 B5 B6 B7 B8 B9 B10 B11 B12 B13 B14 B15 B16 B17 B18 B19 B20 B21 B22 B23 D1 D2 D3 D4 D5 D6 D7 D8 D9 D10 D11 D12 D13 D14 D15 W1
15 782 Adjustment Amount S
16 380 Adjustment Quantity S
17 1034 Adjustment Reason Code S
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 A0 A1 A2 A3 A4 A5 A6 A7 A8 B1 B2 B3 B4 B5 B6 B7 B8 B9 B10 B11 B12 B13 B14 B15 B16 B17 B18 B19 B20 B21 B22 B23 D1 D2 D3 D4 D5 D6 D7 D8 D9 D10 D11 D12 D13 D14 D15 W1
18 782 Adjustment Amount S
19 380 Adjustment Quantity S

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

AMT- Coordination of Benefits (COB) Total Allowed Amount
01 522 Amount Qualifier Code R
B6
02 782 Allowed Amount R
03 478 Credit/Debit Flag Code N

AMT- Coordination of Benefits (COB) Total Submitted Charges
01 522 Amount Qualifier Code R
T3
02 782 Coordination of Benefits Total Submitted Charge Amount R
03 478 Credit/Debit Flag Code N

AMT- Diagnostic Related Group (DRG) Outlier Amount
01 522 Amount Qualifier Code R
ZZ
02 782 Claim DRG Outlier Amount R
03 478 Credit/Debit Flag Code N

AMT- Coordination of Benefits (COB) Total Medicare Paid Amount
01 522 Amount Qualifier Code R
N1
02 782 Total Medicare Paid Amount R
03 478 Credit/Debit Flag Code N

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

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

AMT- Coordination of Benefits (COB) Medicare A Trust Fund Paid Amount
01 522 Amount Qualifier Code R
AA
02 782 Paid From Part A Medicare Trust Fund Amount R
03 478 Credit/Debit Flag Code N

AMT- Coordination of Benefits (COB) Medicare B Trust Fund Paid Amount
01 522 Amount Qualifier Code R
B1
02 782 Paid From Part B Medicare Trust Fund Amount R
03 478 Credit/Debit Flag Code N

AMT- Coordination of Benefits (COB) Total Non-Covered Amount
01 522 Amount Qualifier Code R
A8
02 782 Non-Covered Charge Amount R
03 478 Credit/Debit Flag Code N

AMT- Coordination of Benefits (COB) Total Denied Amount
01 522 Amount Qualifier Code R
YT
02 782 Claim Total Denied Charge Amount R
03 478 Credit/Debit Flag Code N

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

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

MIA- Medicare Inpatient Adjudication Information
01 380 Covered Days or Visits Count R
02 380 Lifetime Reserve Days Count S
03 380 Lifetime Psychiatric Days Count S
04 782 Claim DRG Amount S
05 127 Remark Code S
M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 M13 M14 M15 M16 M17 M18 M19 M20 M21 M22 M23 M24 M25 M26 M27 M28 M29 M30 M31 M32 M33 M34 M35 M36 M37 M38 M39 M40 M41 M42 M43 M44 M45 M46 M47 M48 M49 M50 M51 M52 M53 M54 M55 M56 M57 M58 M59 M60 M61 M62 M63 M64 M65 M66 M67 M68 M69 M70 M71 M72 M73 M74 M75 M76 M77 M78 M79 M80 M81 M82 M83 M84 M85 M86 M87 M88 M89 M90 M91 M92 M93 M94 M95 M96 M97 M98 M99 M100 M101 M102 M103 M104 M105 M106 M107 M108 M109 M110 M111 M112 M113 M114 M115 M116 M117 M118 M119 M120 M121 M122 M123 M124 M125 M126 M127 M128 M129 M130 M131 M132 M133 M134 M135 M136 M137 M138 M139 M140 M141 M142 M143 M144 MA01 MA02 MA03 MA04 MA05 MA06 MA07 MA08 MA09 MA10 MA11 MA12 MA13 MA14 MA15 MA16 MA17 MA18 MA19 MA20 MA21 MA22 MA23 MA24 MA25 MA26 MA27 MA28 MA29 MA30 MA31 MA32 MA33 MA34 MA35 MA36 MA37 MA38 MA39 MA40 MA41 MA42 MA43 MA44 MA45 MA46 MA47 MA48 MA49 MA50 MA51 MA52 MA53 MA54 MA55 MA56 MA57 MA58 MA59 MA60 MA61 MA62 MA63 MA64 MA65 MA66 MA67 MA68 MA69 MA70 MA71 MA72 MA73 MA74 MA75 MA76 MA77 MA78 MA79 MA80 MA81 MA82 MA83 MA84 MA85 MA86 MA87 MA88 MA89 MA90 MA91 MA92 MA93 MA94 MA95 MA96 MA97 MA98 MA99 MA100 MA101 MA102 MA103 MA104 MA105 MA106 MA107 MA108 MA109 MA110 MA111 MA112 MA113 MA114 MA115 MA116 MA117 MA118 MA119 MA120 MA121 MA122 MA123 MA124 MA125 MA126 MA127 MA128 MA129 MA130 MA131 MA132 MA133 MA134 N1 N2 N3 N4 N5 N6 N7 N8 N9 N10 N11 N12 N13 N14 N15 N16 N17 N18 N19 N20 N21 N22 N23 N24 N25 N26 N27 N28 N29 N30 N31 N32 N33 N34 N35 N36 N37 N38 N39 N40 N41 N42 N43 N44 N45 N46 N47 N48 N49 N50 N51 N52 N53 N54 N55 N56 N57 N58 N59 N60 N61 N62 N63 N64 N65 N66 N67 N68 N69 N70 N71 N72 N73 N74 N75 N76 N77 N78 N79 N80 N81 N82 N83 N84 N85 N86 N87 N88 N89 N90 N91 N92 N93 N94 N95 N96 N97 N98 N99 N100 N101 N102 N103 N104 N105 N106 N107 N108 N109 N110 N111 N112 N113 N114 N115 N116 N117 N118 N119 N120 N121 N122 N123 N124 N125 N126 N127 N128 N129 N130 N131 N132 N133 N134 N135 N136 N137 N138 N139 N140 N141 N142 N143 N144 N145 N146 N147 N148 N149 N150 N151 N152 N153 N154 N155 N156
06 782 Claim Disproportionate Share Amount S
07 782 Claim MSP Pass-through Amount S
08 782 Claim PPS Capital Amount S
09 782 PPS-Capital FSP DRG Amount S
10 782 PPS-Capital HSP DRG Amount S
11 782 PPS-Capital DSH DRG Amount S
12 782 Old Capital Amount S
13 782 PPS-Capital IME Amount S
14 782 PPS-Operating Hospital Specific DRG Amount S
15 380 Cost Report Day Count S
16 782 PPS-Operating Federal Specific DRG Amount S
17 782 Claim PPS Capital Outlier Amount S
18 782 Claim Indirect Teaching Amount S
19 782 Nonpayable Professional Component Amount S
20 127 Remark Code S
M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 M13 M14 M15 M16 M17 M18 M19 M20 M21 M22 M23 M24 M25 M26 M27 M28 M29 M30 M31 M32 M33 M34 M35 M36 M37 M38 M39 M40 M41 M42 M43 M44 M45 M46 M47 M48 M49 M50 M51 M52 M53 M54 M55 M56 M57 M58 M59 M60 M61 M62 M63 M64 M65 M66 M67 M68 M69 M70 M71 M72 M73 M74 M75 M76 M77 M78 M79 M80 M81 M82 M83 M84 M85 M86 M87 M88 M89 M90 M91 M92 M93 M94 M95 M96 M97 M98 M99 M100 M101 M102 M103 M104 M105 M106 M107 M108 M109 M110 M111 M112 M113 M114 M115 M116 M117 M118 M119 M120 M121 M122 M123 M124 M125 M126 M127 M128 M129 M130 M131 M132 M133 M134 M135 M136 M137 M138 M139 M140 M141 M142 M143 M144 MA01 MA02 MA03 MA04 MA05 MA06 MA07 MA08 MA09 MA10 MA11 MA12 MA13 MA14 MA15 MA16 MA17 MA18 MA19 MA20 MA21 MA22 MA23 MA24 MA25 MA26 MA27 MA28 MA29 MA30 MA31 MA32 MA33 MA34 MA35 MA36 MA37 MA38 MA39 MA40 MA41 MA42 MA43 MA44 MA45 MA46 MA47 MA48 MA49 MA50 MA51 MA52 MA53 MA54 MA55 MA56 MA57 MA58 MA59 MA60 MA61 MA62 MA63 MA64 MA65 MA66 MA67 MA68 MA69 MA70 MA71 MA72 MA73 MA74 MA75 MA76 MA77 MA78 MA79 MA80 MA81 MA82 MA83 MA84 MA85 MA86 MA87 MA88 MA89 MA90 MA91 MA92 MA93 MA94 MA95 MA96 MA97 MA98 MA99 MA100 MA101 MA102 MA103 MA104 MA105 MA106 MA107 MA108 MA109 MA110 MA111 MA112 MA113 MA114 MA115 MA116 MA117 MA118 MA119 MA120 MA121 MA122 MA123 MA124 MA125 MA126 MA127 MA128 MA129 MA130 MA131 MA132 MA133 MA134 N1 N2 N3 N4 N5 N6 N7 N8 N9 N10 N11 N12 N13 N14 N15 N16 N17 N18 N19 N20 N21 N22 N23 N24 N25 N26 N27 N28 N29 N30 N31 N32 N33 N34 N35 N36 N37 N38 N39 N40 N41 N42 N43 N44 N45 N46 N47 N48 N49 N50 N51 N52 N53 N54 N55 N56 N57 N58 N59 N60 N61 N62 N63 N64 N65 N66 N67 N68 N69 N70 N71 N72 N73 N74 N75 N76 N77 N78 N79 N80 N81 N82 N83 N84 N85 N86 N87 N88 N89 N90 N91 N92 N93 N94 N95 N96 N97 N98 N99 N100 N101 N102 N103 N104 N105 N106 N107 N108 N109 N110 N111 N112 N113 N114 N115 N116 N117 N118 N119 N120 N121 N122 N123 N124 N125 N126 N127 N128 N129 N130 N131 N132 N133 N134 N135 N136 N137 N138 N139 N140 N141 N142 N143 N144 N145 N146 N147 N148 N149 N150 N151 N152 N153 N154 N155 N156
21 127 Remark Code S
M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 M13 M14 M15 M16 M17 M18 M19 M20 M21 M22 M23 M24 M25 M26 M27 M28 M29 M30 M31 M32 M33 M34 M35 M36 M37 M38 M39 M40 M41 M42 M43 M44 M45 M46 M47 M48 M49 M50 M51 M52 M53 M54 M55 M56 M57 M58 M59 M60 M61 M62 M63 M64 M65 M66 M67 M68 M69 M70 M71 M72 M73 M74 M75 M76 M77 M78 M79 M80 M81 M82 M83 M84 M85 M86 M87 M88 M89 M90 M91 M92 M93 M94 M95 M96 M97 M98 M99 M100 M101 M102 M103 M104 M105 M106 M107 M108 M109 M110 M111 M112 M113 M114 M115 M116 M117 M118 M119 M120 M121 M122 M123 M124 M125 M126 M127 M128 M129 M130 M131 M132 M133 M134 M135 M136 M137 M138 M139 M140 M141 M142 M143 M144 MA01 MA02 MA03 MA04 MA05 MA06 MA07 MA08 MA09 MA10 MA11 MA12 MA13 MA14 MA15 MA16 MA17 MA18 MA19 MA20 MA21 MA22 MA23 MA24 MA25 MA26 MA27 MA28 MA29 MA30 MA31 MA32 MA33 MA34 MA35 MA36 MA37 MA38 MA39 MA40 MA41 MA42 MA43 MA44 MA45 MA46 MA47 MA48 MA49 MA50 MA51 MA52 MA53 MA54 MA55 MA56 MA57 MA58 MA59 MA60 MA61 MA62 MA63 MA64 MA65 MA66 MA67 MA68 MA69 MA70 MA71 MA72 MA73 MA74 MA75 MA76 MA77 MA78 MA79 MA80 MA81 MA82 MA83 MA84 MA85 MA86 MA87 MA88 MA89 MA90 MA91 MA92 MA93 MA94 MA95 MA96 MA97 MA98 MA99 MA100 MA101 MA102 MA103 MA104 MA105 MA106 MA107 MA108 MA109 MA110 MA111 MA112 MA113 MA114 MA115 MA116 MA117 MA118 MA119 MA120 MA121 MA122 MA123 MA124 MA125 MA126 MA127 MA128 MA129 MA130 MA131 MA132 MA133 MA134 N1 N2 N3 N4 N5 N6 N7 N8 N9 N10 N11 N12 N13 N14 N15 N16 N17 N18 N19 N20 N21 N22 N23 N24 N25 N26 N27 N28 N29 N30 N31 N32 N33 N34 N35 N36 N37 N38 N39 N40 N41 N42 N43 N44 N45 N46 N47 N48 N49 N50 N51 N52 N53 N54 N55 N56 N57 N58 N59 N60 N61 N62 N63 N64 N65 N66 N67 N68 N69 N70 N71 N72 N73 N74 N75 N76 N77 N78 N79 N80 N81 N82 N83 N84 N85 N86 N87 N88 N89 N90 N91 N92 N93 N94 N95 N96 N97 N98 N99 N100 N101 N102 N103 N104 N105 N106 N107 N108 N109 N110 N111 N112 N113 N114 N115 N116 N117 N118 N119 N120 N121 N122 N123 N124 N125 N126 N127 N128 N129 N130 N131 N132 N133 N134 N135 N136 N137 N138 N139 N140 N141 N142 N143 N144 N145 N146 N147 N148 N149 N150 N151 N152 N153 N154 N155 N156
22 127 Remark Code S
M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 M13 M14 M15 M16 M17 M18 M19 M20 M21 M22 M23 M24 M25 M26 M27 M28 M29 M30 M31 M32 M33 M34 M35 M36 M37 M38 M39 M40 M41 M42 M43 M44 M45 M46 M47 M48 M49 M50 M51 M52 M53 M54 M55 M56 M57 M58 M59 M60 M61 M62 M63 M64 M65 M66 M67 M68 M69 M70 M71 M72 M73 M74 M75 M76 M77 M78 M79 M80 M81 M82 M83 M84 M85 M86 M87 M88 M89 M90 M91 M92 M93 M94 M95 M96 M97 M98 M99 M100 M101 M102 M103 M104 M105 M106 M107 M108 M109 M110 M111 M112 M113 M114 M115 M116 M117 M118 M119 M120 M121 M122 M123 M124 M125 M126 M127 M128 M129 M130 M131 M132 M133 M134 M135 M136 M137 M138 M139 M140 M141 M142 M143 M144 MA01 MA02 MA03 MA04 MA05 MA06 MA07 MA08 MA09 MA10 MA11 MA12 MA13 MA14 MA15 MA16 MA17 MA18 MA19 MA20 MA21 MA22 MA23 MA24 MA25 MA26 MA27 MA28 MA29 MA30 MA31 MA32 MA33 MA34 MA35 MA36 MA37 MA38 MA39 MA40 MA41 MA42 MA43 MA44 MA45 MA46 MA47 MA48 MA49 MA50 MA51 MA52 MA53 MA54 MA55 MA56 MA57 MA58 MA59 MA60 MA61 MA62 MA63 MA64 MA65 MA66 MA67 MA68 MA69 MA70 MA71 MA72 MA73 MA74 MA75 MA76 MA77 MA78 MA79 MA80 MA81 MA82 MA83 MA84 MA85 MA86 MA87 MA88 MA89 MA90 MA91 MA92 MA93 MA94 MA95 MA96 MA97 MA98 MA99 MA100 MA101 MA102 MA103 MA104 MA105 MA106 MA107 MA108 MA109 MA110 MA111 MA112 MA113 MA114 MA115 MA116 MA117 MA118 MA119 MA120 MA121 MA122 MA123 MA124 MA125 MA126 MA127 MA128 MA129 MA130 MA131 MA132 MA133 MA134 N1 N2 N3 N4 N5 N6 N7 N8 N9 N10 N11 N12 N13 N14 N15 N16 N17 N18 N19 N20 N21 N22 N23 N24 N25 N26 N27 N28 N29 N30 N31 N32 N33 N34 N35 N36 N37 N38 N39 N40 N41 N42 N43 N44 N45 N46 N47 N48 N49 N50 N51 N52 N53 N54 N55 N56 N57 N58 N59 N60 N61 N62 N63 N64 N65 N66 N67 N68 N69 N70 N71 N72 N73 N74 N75 N76 N77 N78 N79 N80 N81 N82 N83 N84 N85 N86 N87 N88 N89 N90 N91 N92 N93 N94 N95 N96 N97 N98 N99 N100 N101 N102 N103 N104 N105 N106 N107 N108 N109 N110 N111 N112 N113 N114 N115 N116 N117 N118 N119 N120 N121 N122 N123 N124 N125 N126 N127 N128 N129 N130 N131 N132 N133 N134 N135 N136 N137 N138 N139 N140 N141 N142 N143 N144 N145 N146 N147 N148 N149 N150 N151 N152 N153 N154 N155 N156
23 127 Remark Code S
M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 M13 M14 M15 M16 M17 M18 M19 M20 M21 M22 M23 M24 M25 M26 M27 M28 M29 M30 M31 M32 M33 M34 M35 M36 M37 M38 M39 M40 M41 M42 M43 M44 M45 M46 M47 M48 M49 M50 M51 M52 M53 M54 M55 M56 M57 M58 M59 M60 M61 M62 M63 M64 M65 M66 M67 M68 M69 M70 M71 M72 M73 M74 M75 M76 M77 M78 M79 M80 M81 M82 M83 M84 M85 M86 M87 M88 M89 M90 M91 M92 M93 M94 M95 M96 M97 M98 M99 M100 M101 M102 M103 M104 M105 M106 M107 M108 M109 M110 M111 M112 M113 M114 M115 M116 M117 M118 M119 M120 M121 M122 M123 M124 M125 M126 M127 M128 M129 M130 M131 M132 M133 M134 M135 M136 M137 M138 M139 M140 M141 M142 M143 M144 MA01 MA02 MA03 MA04 MA05 MA06 MA07 MA08 MA09 MA10 MA11 MA12 MA13 MA14 MA15 MA16 MA17 MA18 MA19 MA20 MA21 MA22 MA23 MA24 MA25 MA26 MA27 MA28 MA29 MA30 MA31 MA32 MA33 MA34 MA35 MA36 MA37 MA38 MA39 MA40 MA41 MA42 MA43 MA44 MA45 MA46 MA47 MA48 MA49 MA50 MA51 MA52 MA53 MA54 MA55 MA56 MA57 MA58 MA59 MA60 MA61 MA62 MA63 MA64 MA65 MA66 MA67 MA68 MA69 MA70 MA71 MA72 MA73 MA74 MA75 MA76 MA77 MA78 MA79 MA80 MA81 MA82 MA83 MA84 MA85 MA86 MA87 MA88 MA89 MA90 MA91 MA92 MA93 MA94 MA95 MA96 MA97 MA98 MA99 MA100 MA101 MA102 MA103 MA104 MA105 MA106 MA107 MA108 MA109 MA110 MA111 MA112 MA113 MA114 MA115 MA116 MA117 MA118 MA119 MA120 MA121 MA122 MA123 MA124 MA125 MA126 MA127 MA128 MA129 MA130 MA131 MA132 MA133 MA134 N1 N2 N3 N4 N5 N6 N7 N8 N9 N10 N11 N12 N13 N14 N15 N16 N17 N18 N19 N20 N21 N22 N23 N24 N25 N26 N27 N28 N29 N30 N31 N32 N33 N34 N35 N36 N37 N38 N39 N40 N41 N42 N43 N44 N45 N46 N47 N48 N49 N50 N51 N52 N53 N54 N55 N56 N57 N58 N59 N60 N61 N62 N63 N64 N65 N66 N67 N68 N69 N70 N71 N72 N73 N74 N75 N76 N77 N78 N79 N80 N81 N82 N83 N84 N85 N86 N87 N88 N89 N90 N91 N92 N93 N94 N95 N96 N97 N98 N99 N100 N101 N102 N103 N104 N105 N106 N107 N108 N109 N110 N111 N112 N113 N114 N115 N116 N117 N118 N119 N120 N121 N122 N123 N124 N125 N126 N127 N128 N129 N130 N131 N132 N133 N134 N135 N136 N137 N138 N139 N140 N141 N142 N143 N144 N145 N146 N147 N148 N149 N150 N151 N152 N153 N154 N155 N156
24 782 PPS-Capital Exception Amount S

MOA- Medicare Outpatient Adjudication Information
01 954 Reimbursement Rate S
02 782 Claim HCPCS Payable Amount S
03 127 Remark Code S
M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 M13 M14 M15 M16 M17 M18 M19 M20 M21 M22 M23 M24 M25 M26 M27 M28 M29 M30 M31 M32 M33 M34 M35 M36 M37 M38 M39 M40 M41 M42 M43 M44 M45 M46 M47 M48 M49 M50 M51 M52 M53 M54 M55 M56 M57 M58 M59 M60 M61 M62 M63 M64 M65 M66 M67 M68 M69 M70 M71 M72 M73 M74 M75 M76 M77 M78 M79 M80 M81 M82 M83 M84 M85 M86 M87 M88 M89 M90 M91 M92 M93 M94 M95 M96 M97 M98 M99 M100 M101 M102 M103 M104 M105 M106 M107 M108 M109 M110 M111 M112 M113 M114 M115 M116 M117 M118 M119 M120 M121 M122 M123 M124 M125 M126 M127 M128 M129 M130 M131 M132 M133 M134 M135 M136 M137 M138 M139 M140 M141 M142 M143 M144 MA01 MA02 MA03 MA04 MA05 MA06 MA07 MA08 MA09 MA10 MA11 MA12 MA13 MA14 MA15 MA16 MA17 MA18 MA19 MA20 MA21 MA22 MA23 MA24 MA25 MA26 MA27 MA28 MA29 MA30 MA31 MA32 MA33 MA34 MA35 MA36 MA37 MA38 MA39 MA40 MA41 MA42 MA43 MA44 MA45 MA46 MA47 MA48 MA49 MA50 MA51 MA52 MA53 MA54 MA55 MA56 MA57 MA58 MA59 MA60 MA61 MA62 MA63 MA64 MA65 MA66 MA67 MA68 MA69 MA70 MA71 MA72 MA73 MA74 MA75 MA76 MA77 MA78 MA79 MA80 MA81 MA82 MA83 MA84 MA85 MA86 MA87 MA88 MA89 MA90 MA91 MA92 MA93 MA94 MA95 MA96 MA97 MA98 MA99 MA100 MA101 MA102 MA103 MA104 MA105 MA106 MA107 MA108 MA109 MA110 MA111 MA112 MA113 MA114 MA115 MA116 MA117 MA118 MA119 MA120 MA121 MA122 MA123 MA124 MA125 MA126 MA127 MA128 MA129 MA130 MA131 MA132 MA133 MA134 N1 N2 N3 N4 N5 N6 N7 N8 N9 N10 N11 N12 N13 N14 N15 N16 N17 N18 N19 N20 N21 N22 N23 N24 N25 N26 N27 N28 N29 N30 N31 N32 N33 N34 N35 N36 N37 N38 N39 N40 N41 N42 N43 N44 N45 N46 N47 N48 N49 N50 N51 N52 N53 N54 N55 N56 N57 N58 N59 N60 N61 N62 N63 N64 N65 N66 N67 N68 N69 N70 N71 N72 N73 N74 N75 N76 N77 N78 N79 N80 N81 N82 N83 N84 N85 N86 N87 N88 N89 N90 N91 N92 N93 N94 N95 N96 N97 N98 N99 N100 N101 N102 N103 N104 N105 N106 N107 N108 N109 N110 N111 N112 N113 N114 N115 N116 N117 N118 N119 N120 N121 N122 N123 N124 N125 N126 N127 N128 N129 N130 N131 N132 N133 N134 N135 N136 N137 N138 N139 N140 N141 N142 N143 N144 N145 N146 N147 N148 N149 N150 N151 N152 N153 N154 N155 N156
04 127 Remark Code S
M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 M13 M14 M15 M16 M17 M18 M19 M20 M21 M22 M23 M24 M25 M26 M27 M28 M29 M30 M31 M32 M33 M34 M35 M36 M37 M38 M39 M40 M41 M42 M43 M44 M45 M46 M47 M48 M49 M50 M51 M52 M53 M54 M55 M56 M57 M58 M59 M60 M61 M62 M63 M64 M65 M66 M67 M68 M69 M70 M71 M72 M73 M74 M75 M76 M77 M78 M79 M80 M81 M82 M83 M84 M85 M86 M87 M88 M89 M90 M91 M92 M93 M94 M95 M96 M97 M98 M99 M100 M101 M102 M103 M104 M105 M106 M107 M108 M109 M110 M111 M112 M113 M114 M115 M116 M117 M118 M119 M120 M121 M122 M123 M124 M125 M126 M127 M128 M129 M130 M131 M132 M133 M134 M135 M136 M137 M138 M139 M140 M141 M142 M143 M144 MA01 MA02 MA03 MA04 MA05 MA06 MA07 MA08 MA09 MA10 MA11 MA12 MA13 MA14 MA15 MA16 MA17 MA18 MA19 MA20 MA21 MA22 MA23 MA24 MA25 MA26 MA27 MA28 MA29 MA30 MA31 MA32 MA33 MA34 MA35 MA36 MA37 MA38 MA39 MA40 MA41 MA42 MA43 MA44 MA45 MA46 MA47 MA48 MA49 MA50 MA51 MA52 MA53 MA54 MA55 MA56 MA57 MA58 MA59 MA60 MA61 MA62 MA63 MA64 MA65 MA66 MA67 MA68 MA69 MA70 MA71 MA72 MA73 MA74 MA75 MA76 MA77 MA78 MA79 MA80 MA81 MA82 MA83 MA84 MA85 MA86 MA87 MA88 MA89 MA90 MA91 MA92 MA93 MA94 MA95 MA96 MA97 MA98 MA99 MA100 MA101 MA102 MA103 MA104 MA105 MA106 MA107 MA108 MA109 MA110 MA111 MA112 MA113 MA114 MA115 MA116 MA117 MA118 MA119 MA120 MA121 MA122 MA123 MA124 MA125 MA126 MA127 MA128 MA129 MA130 MA131 MA132 MA133 MA134 N1 N2 N3 N4 N5 N6 N7 N8 N9 N10 N11 N12 N13 N14 N15 N16 N17 N18 N19 N20 N21 N22 N23 N24 N25 N26 N27 N28 N29 N30 N31 N32 N33 N34 N35 N36 N37 N38 N39 N40 N41 N42 N43 N44 N45 N46 N47 N48 N49 N50 N51 N52 N53 N54 N55 N56 N57 N58 N59 N60 N61 N62 N63 N64 N65 N66 N67 N68 N69 N70 N71 N72 N73 N74 N75 N76 N77 N78 N79 N80 N81 N82 N83 N84 N85 N86 N87 N88 N89 N90 N91 N92 N93 N94 N95 N96 N97 N98 N99 N100 N101 N102 N103 N104 N105 N106 N107 N108 N109 N110 N111 N112 N113 N114 N115 N116 N117 N118 N119 N120 N121 N122 N123 N124 N125 N126 N127 N128 N129 N130 N131 N132 N133 N134 N135 N136 N137 N138 N139 N140 N141 N142 N143 N144 N145 N146 N147 N148 N149 N150 N151 N152 N153 N154 N155 N156
05 127 Remark Code S
M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 M13 M14 M15 M16 M17 M18 M19 M20 M21 M22 M23 M24 M25 M26 M27 M28 M29 M30 M31 M32 M33 M34 M35 M36 M37 M38 M39 M40 M41 M42 M43 M44 M45 M46 M47 M48 M49 M50 M51 M52 M53 M54 M55 M56 M57 M58 M59 M60 M61 M62 M63 M64 M65 M66 M67 M68 M69 M70 M71 M72 M73 M74 M75 M76 M77 M78 M79 M80 M81 M82 M83 M84 M85 M86 M87 M88 M89 M90 M91 M92 M93 M94 M95 M96 M97 M98 M99 M100 M101 M102 M103 M104 M105 M106 M107 M108 M109 M110 M111 M112 M113 M114 M115 M116 M117 M118 M119 M120 M121 M122 M123 M124 M125 M126 M127 M128 M129 M130 M131 M132 M133 M134 M135 M136 M137 M138 M139 M140 M141 M142 M143 M144 MA01 MA02 MA03 MA04 MA05 MA06 MA07 MA08 MA09 MA10 MA11 MA12 MA13 MA14 MA15 MA16 MA17 MA18 MA19 MA20 MA21 MA22 MA23 MA24 MA25 MA26 MA27 MA28 MA29 MA30 MA31 MA32 MA33 MA34 MA35 MA36 MA37 MA38 MA39 MA40 MA41 MA42 MA43 MA44 MA45 MA46 MA47 MA48 MA49 MA50 MA51 MA52 MA53 MA54 MA55 MA56 MA57 MA58 MA59 MA60 MA61 MA62 MA63 MA64 MA65 MA66 MA67 MA68 MA69 MA70 MA71 MA72 MA73 MA74 MA75 MA76 MA77 MA78 MA79 MA80 MA81 MA82 MA83 MA84 MA85 MA86 MA87 MA88 MA89 MA90 MA91 MA92 MA93 MA94 MA95 MA96 MA97 MA98 MA99 MA100 MA101 MA102 MA103 MA104 MA105 MA106 MA107 MA108 MA109 MA110 MA111 MA112 MA113 MA114 MA115 MA116 MA117 MA118 MA119 MA120 MA121 MA122 MA123 MA124 MA125 MA126 MA127 MA128 MA129 MA130 MA131 MA132 MA133 MA134 N1 N2 N3 N4 N5 N6 N7 N8 N9 N10 N11 N12 N13 N14 N15 N16 N17 N18 N19 N20 N21 N22 N23 N24 N25 N26 N27 N28 N29 N30 N31 N32 N33 N34 N35 N36 N37 N38 N39 N40 N41 N42 N43 N44 N45 N46 N47 N48 N49 N50 N51 N52 N53 N54 N55 N56 N57 N58 N59 N60 N61 N62 N63 N64 N65 N66 N67 N68 N69 N70 N71 N72 N73 N74 N75 N76 N77 N78 N79 N80 N81 N82 N83 N84 N85 N86 N87 N88 N89 N90 N91 N92 N93 N94 N95 N96 N97 N98 N99 N100 N101 N102 N103 N104 N105 N106 N107 N108 N109 N110 N111 N112 N113 N114 N115 N116 N117 N118 N119 N120 N121 N122 N123 N124 N125 N126 N127 N128 N129 N130 N131 N132 N133 N134 N135 N136 N137 N138 N139 N140 N141 N142 N143 N144 N145 N146 N147 N148 N149 N150 N151 N152 N153 N154 N155 N156
06 127 Remark Code S
M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 M13 M14 M15 M16 M17 M18 M19 M20 M21 M22 M23 M24 M25 M26 M27 M28 M29 M30 M31 M32 M33 M34 M35 M36 M37 M38 M39 M40 M41 M42 M43 M44 M45 M46 M47 M48 M49 M50 M51 M52 M53 M54 M55 M56 M57 M58 M59 M60 M61 M62 M63 M64 M65 M66 M67 M68 M69 M70 M71 M72 M73 M74 M75 M76 M77 M78 M79 M80 M81 M82 M83 M84 M85 M86 M87 M88 M89 M90 M91 M92 M93 M94 M95 M96 M97 M98 M99 M100 M101 M102 M103 M104 M105 M106 M107 M108 M109 M110 M111 M112 M113 M114 M115 M116 M117 M118 M119 M120 M121 M122 M123 M124 M125 M126 M127 M128 M129 M130 M131 M132 M133 M134 M135 M136 M137 M138 M139 M140 M141 M142 M143 M144 MA01 MA02 MA03 MA04 MA05 MA06 MA07 MA08 MA09 MA10 MA11 MA12 MA13 MA14 MA15 MA16 MA17 MA18 MA19 MA20 MA21 MA22 MA23 MA24 MA25 MA26 MA27 MA28 MA29 MA30 MA31 MA32 MA33 MA34 MA35 MA36 MA37 MA38 MA39 MA40 MA41 MA42 MA43 MA44 MA45 MA46 MA47 MA48 MA49 MA50 MA51 MA52 MA53 MA54 MA55 MA56 MA57 MA58 MA59 MA60 MA61 MA62 MA63 MA64 MA65 MA66 MA67 MA68 MA69 MA70 MA71 MA72 MA73 MA74 MA75 MA76 MA77 MA78 MA79 MA80 MA81 MA82 MA83 MA84 MA85 MA86 MA87 MA88 MA89 MA90 MA91 MA92 MA93 MA94 MA95 MA96 MA97 MA98 MA99 MA100 MA101 MA102 MA103 MA104 MA105 MA106 MA107 MA108 MA109 MA110 MA111 MA112 MA113 MA114 MA115 MA116 MA117 MA118 MA119 MA120 MA121 MA122 MA123 MA124 MA125 MA126 MA127 MA128 MA129 MA130 MA131 MA132 MA133 MA134 N1 N2 N3 N4 N5 N6 N7 N8 N9 N10 N11 N12 N13 N14 N15 N16 N17 N18 N19 N20 N21 N22 N23 N24 N25 N26 N27 N28 N29 N30 N31 N32 N33 N34 N35 N36 N37 N38 N39 N40 N41 N42 N43 N44 N45 N46 N47 N48 N49 N50 N51 N52 N53 N54 N55 N56 N57 N58 N59 N60 N61 N62 N63 N64 N65 N66 N67 N68 N69 N70 N71 N72 N73 N74 N75 N76 N77 N78 N79 N80 N81 N82 N83 N84 N85 N86 N87 N88 N89 N90 N91 N92 N93 N94 N95 N96 N97 N98 N99 N100 N101 N102 N103 N104 N105 N106 N107 N108 N109 N110 N111 N112 N113 N114 N115 N116 N117 N118 N119 N120 N121 N122 N123 N124 N125 N126 N127 N128 N129 N130 N131 N132 N133 N134 N135 N136 N137 N138 N139 N140 N141 N142 N143 N144 N145 N146 N147 N148 N149 N150 N151 N152 N153 N154 N155 N156
07 127 Remark Code S
M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 M13 M14 M15 M16 M17 M18 M19 M20 M21 M22 M23 M24 M25 M26 M27 M28 M29 M30 M31 M32 M33 M34 M35 M36 M37 M38 M39 M40 M41 M42 M43 M44 M45 M46 M47 M48 M49 M50 M51 M52 M53 M54 M55 M56 M57 M58 M59 M60 M61 M62 M63 M64 M65 M66 M67 M68 M69 M70 M71 M72 M73 M74 M75 M76 M77 M78 M79 M80 M81 M82 M83 M84 M85 M86 M87 M88 M89 M90 M91 M92 M93 M94 M95 M96 M97 M98 M99 M100 M101 M102 M103 M104 M105 M106 M107 M108 M109 M110 M111 M112 M113 M114 M115 M116 M117 M118 M119 M120 M121 M122 M123 M124 M125 M126 M127 M128 M129 M130 M131 M132 M133 M134 M135 M136 M137 M138 M139 M140 M141 M142 M143 M144 MA01 MA02 MA03 MA04 MA05 MA06 MA07 MA08 MA09 MA10 MA11 MA12 MA13 MA14 MA15 MA16 MA17 MA18 MA19 MA20 MA21 MA22 MA23 MA24 MA25 MA26 MA27 MA28 MA29 MA30 MA31 MA32 MA33 MA34 MA35 MA36 MA37 MA38 MA39 MA40 MA41 MA42 MA43 MA44 MA45 MA46 MA47 MA48 MA49 MA50 MA51 MA52 MA53 MA54 MA55 MA56 MA57 MA58 MA59 MA60 MA61 MA62 MA63 MA64 MA65 MA66 MA67 MA68 MA69 MA70 MA71 MA72 MA73 MA74 MA75 MA76 MA77 MA78 MA79 MA80 MA81 MA82 MA83 MA84 MA85 MA86 MA87 MA88 MA89 MA90 MA91 MA92 MA93 MA94 MA95 MA96 MA97 MA98 MA99 MA100 MA101 MA102 MA103 MA104 MA105 MA106 MA107 MA108 MA109 MA110 MA111 MA112 MA113 MA114 MA115 MA116 MA117 MA118 MA119 MA120 MA121 MA122 MA123 MA124 MA125 MA126 MA127 MA128 MA129 MA130 MA131 MA132 MA133 MA134 N1 N2 N3 N4 N5 N6 N7 N8 N9 N10 N11 N12 N13 N14 N15 N16 N17 N18 N19 N20 N21 N22 N23 N24 N25 N26 N27 N28 N29 N30 N31 N32 N33 N34 N35 N36 N37 N38 N39 N40 N41 N42 N43 N44 N45 N46 N47 N48 N49 N50 N51 N52 N53 N54 N55 N56 N57 N58 N59 N60 N61 N62 N63 N64 N65 N66 N67 N68 N69 N70 N71 N72 N73 N74 N75 N76 N77 N78 N79 N80 N81 N82 N83 N84 N85 N86 N87 N88 N89 N90 N91 N92 N93 N94 N95 N96 N97 N98 N99 N100 N101 N102 N103 N104 N105 N106 N107 N108 N109 N110 N111 N112 N113 N114 N115 N116 N117 N118 N119 N120 N121 N122 N123 N124 N125 N126 N127 N128 N129 N130 N131 N132 N133 N134 N135 N136 N137 N138 N139 N140 N141 N142 N143 N144 N145 N146 N147 N148 N149 N150 N151 N152 N153 N154 N155 N156
08 782 Claim ESRD Payment Amount S
09 782 Nonpayable Professional Component Amount S

NM1- Other Subscriber Name
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 fix N
07 1039 Other Insured Name Suffix S
08 66 Identification Code Qualifier R
MI ZZ
09 67 Other Insured Identifier R
10 706 Entity Relationship Code N
11 98 Entity Identifier Code N

N3- Other Subscriber Address
01 166 Other Insured Address Line R
02 166 Other Insured Address Line S

N4- Other Subscriber City/State/ZIP Code
01 19 Other Insured City Name R
02 156 Other Insured State Code R
External Source: states
03 116 Other Insured Postal Zone or Zip Code R
04 26 Subscriber Country Code S
External Source: country
05 309 Location Qualifier N
06 310 Location Identifier N

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

NM1- Other Payer Name
01 98 Entity Identifier Code R
PR
02 1065 Entity Type Qualifier R
2
03 1035 Other Payer Last or Organization Name R
04 1036 Name First N
05 1037 Name Middle N
06 1038 Name Prefix N
07 1039 Name Suffix N
08 66 Identification Code Qualifier R
PI XV
09 67 Other Payer Primary Identifier R
10 706 Entity Relationship Code N
11 98 Entity Identifier Code N

N3- Other Payer Address
01 166 Other Payer Address Line R
02 166 Other Payer Address Line S

N4- Other Payer City/State/ZIP Code
01 19 Other Payer City Name R
02 156 Other Payer State Code R
External Source: states
03 116 Other Payer Postal Zone or Zip Code R
04 26 Payer Country Code S
External Source: country
05 309 Location Qualifier N
06 310 Location Identifier N

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

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

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

NM1- Other Payer Patient Information
01 98 Entity Identifier Code R
QC
02 1065 Entity Type Qualifier R
1
03 1035 Name Last or Organization Name N
04 1036 Name First N
05 1037 Name Middle N
06 1038 Name Prefix N
07 1039 Name Suffix N
08 66 Identification Code Qualifier R
EI MI
09 67 Other Payer Patient Primary Identifier R
10 706 Entity Relationship Code N
11 98 Entity Identifier Code N

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

NM1- Other Payer Attending Provider
01 98 Entity Identifier Code R
71
02 1065 Entity Type Qualifier R
1 2
03 1035 Name Last or Organization Name N
04 1036 Name First N
05 1037 Name Middle N
06 1038 Name Prefix N
07 1039 Name Suffix N
08 66 Identification Code Qualifier N
09 67 Identification Code N
10 706 Entity Relationship Code N
11 98 Entity Identifier Code N

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

NM1- Other Payer Operating Provider
01 98 Entity Identifier Code R
72
02 1065 Entity Type Qualifier R
1
03 1035 Name Last or Organization Name N
04 1036 Name First N
05 1037 Name Middle N
06 1038 Name Prefix N
07 1039 Name Suffix N
08 66 Identification Code Qualifier N
09 67 Identification Code N
10 706 Entity Relationship Code N
11 98 Entity Identifier Code N

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

NM1- Other Payer Other Provider
01 98 Entity Identifier Code R
73
02 1065 Entity Type Qualifier R
1 2
03 1035 Name Last or Organization Name N
04 1036 Name First N
05 1037 Name Middle N
06 1038 Name Prefix N
07 1039 Name Suffix N
08 66 Identification Code Qualifier N
09 67 Identification Code N
10 706 Entity Relationship Code N
11 98 fier Code N

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

NM1- Other Payer Service Facility Provider
01 98 Entity Identifier Code R
FA
02 1065 Entity Type Qualifier R
2
03 1035 Name Last or Organization Name N
04 1036 Name First N
05 1037 Name Middle N
06 1038 Name Prefix N
07 1039 Name Suffix N
08 66 ode Qualifier N
09 67 Identification Code N
10 706 Entity Relationship Code N
11 98 Entity Identifier Code N

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

LX- Service Line Number
01 554 Assigned Number R

SV2- Institutional Service Line
01 234 Service Line Revenue Code R
S C003 Service Line Procedure Code
01 235 Product or Service ID Qualifier R
HC IV N4 ZZ
02 234 Procedure Code R
03 1339 HCPCS Modifier 1 S
04 1339 HCPCS Modifier 2 S
05 1339 HCPCS Modifier 3 S
06 1339 HCPCS Modifier 4 S
07 352 Description N
03 782 Line Item Charge Amount R
04 355 Unit or Basis for Measurement Code R
DA F2 UN
05 380 Service Unit Count R
06 1371 Service Line Rate S
07 782 Line Item Denied Charge or Non-Covered Charge Amount S
08 1073 Yes/No Condition or Response Code N
09 1345 Status Code N
10 1337 Level of Care Code N

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

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

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

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

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

HCP- Line Pricing/Repricing Information R0113 P0910 P1112
01 1473 Pricing Methodology R
00 01 02 03 04 05 06 07 08 09 10 11 12 13 14
02 782 Repriced Allowed Amount R
03 782 Repriced Saving Amount S
04 127 Repriced Organizational Identifier S
05 118 Repricing Per Diem or Flat Rate Amount S
06 127 Repriced Approved Ambulatory Patient Group Code S
07 782 Repriced Approved Ambulatory Patient Group Amount S
08 234 Repriced Approved Revenue Code S
09 235 Product/ Service ID Qualifier S
HC
10 234 Procedure Code S
11 355 Unit or Basis for Measurement Code S
DA UN
12 380 Repricing 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 P0405 P0607 P0809 P1011 P1213 P1415 P1617 P1819 P2021 P2223 P2425 P2627 P2829 P3031
01 350 Assigned Identification N
02 235 Product/Service ID Qualifier R
N4
03 234 Product/Service ID 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 P0405 C0607 C0902 C1002 C1103
01 687 Class of Trade Code N
02 236 Price Identifier Code N
03 212 Unit Price R
04 380 Quantity R
R C001 Composite Unit of Measure
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 of Unit Price Code N
10 499 Condition Value N
11 289 Multiple Price Quantity N

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

NM1- Attending Physician Name
01 98 Entity Identifier Code R
71
02 1065 Entity Type Qualifier R
1 2
03 1035 Attending Physician Last Name R
04 1036 Attending Physician First Name S
05 1037 Attending Physician Middle Name S
06 1038 Name Prefix N
07 1039 Attending Physician Name Suffix S
08 66 Identification Code Qualifier R
24 34 XX
09 67 Attending Physician Primary Identifier R
10 706 Entity Relationship Code N
11 98 Entity Identifier Code N

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

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

NM1- Operating Physician Name
01 98 Entity Identifier Code R
72
02 1065 Entity Type Qualifier R
1
03 1035 Operating Physician Last Name R
04 1036 Operating Physician First Name R
05 1037 Operating Physician Middle Name S
06 1038 Name Prefix N
07 1039 Operating Physician Name Suffix S
08 66 Identification Code Qualifier R
24 34 XX
09 67 Operating Physician Primary Identifier R
10 706 Entity Relationship Code N
11 98 Entity Identifier Code N

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

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

NM1- Other Provider Name
01 98 Entity Identifier Code R
73
02 1065 Entity Type Qualifier R
1 2
03 1035 Other Physician Last Name R
04 1036 Other Physician First Name S
05 1037 Other Provider Middle Name S
06 1038 Name Prefix N
07 1039 Other Provider Name Suffix S
08 66 Identification Code Qualifier R
24 34 XX
09 67 Other Provider Identifier R
10 706 Entity Relationship Code N
11 98 Entity Identifier Code N

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

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

SVD- Service Line Adjudication Information
01 67 Payer Identifier R
02 782 Service Line Paid Amount R
S C003 Composite Medical Procedure Identifier
01 235 Product or Service ID Qualifier R
HC IV ZZ
02 234 Procedure Code R
03 1339 Procedure Modifier S
04 1339 Procedure Modifier S
05 1339 Procedure Modifier S
06 1339 Procedure Modifier S
07 352 Procedure Code Description S
04 234 Service Line Revenue Code R
05 380 Adjustment Quantity R
06 554 Bundled or Unbundled Line Number S

CAS- Service Line Adjustment
01 1033 Claim Adjustment Group Code R
CO CR OA PI PR
02 1034 Adjustment Reason Code R
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 A0 A1 A2 A3 A4 A5 A6 A7 A8 B1 B2 B3 B4 B5 B6 B7 B8 B9 B10 B11 B12 B13 B14 B15 B16 B17 B18 B19 B20 B21 B22 B23 D1 D2 D3 D4 D5 D6 D7 D8 D9 D10 D11 D12 D13 D14 D15 W1
03 782 Adjustment Amount R
04 380 Adjustment Quantity S
05 1034 Adjustment Reason Code S
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 A0 A1 A2 A3 A4 A5 A6 A7 A8 B1 B2 B3 B4 B5 B6 B7 B8 B9 B10 B11 B12 B13 B14 B15 B16 B17 B18 B19 B20 B21 B22 B23 D1 D2 D3 D4 D5 D6 D7 D8 D9 D10 D11 D12 D13 D14 D15 W1
06 782 Adjustment Amount S
07 380 Adjustment Quantity S
08 1034 Adjustment Reason Code S
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 A0 A1 A2 A3 A4 A5 A6 A7 A8 B1 B2 B3 B4 B5 B6 B7 B8 B9 B10 B11 B12 B13 B14 B15 B16 B17 B18 B19 B20 B21 B22 B23 D1 D2 D3 D4 D5 D6 D7 D8 D9 D10 D11 D12 D13 D14 D15 W1
09 782 Adjustment Amount S
10 380 Adjustment Quantity S
11 1034 Adjustment Reason Code S
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 A0 A1 A2 A3 A4 A5 A6 A7 A8 B1 B2 B3 B4 B5 B6 B7 B8 B9 B10 B11 B12 B13 B14 B15 B16 B17 B18 B19 B20 B21 B22 B23 D1 D2 D3 D4 D5 D6 D7 D8 D9 D10 D11 D12 D13 D14 D15 W1
12 782 Adjustment Amount S
13 380 Adjustment Quantity S
14 1034 Adjustment Reason Code S
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 A0 A1 A2 A3 A4 A5 A6 A7 A8 B1 B2 B3 B4 B5 B6 B7 B8 B9 B10 B11 B12 B13 B14 B15 B16 B17 B18 B19 B20 B21 B22 B23 D1 D2 D3 D4 D5 D6 D7 D8 D9 D10 D11 D12 D13 D14 D15 W1
15 782 Adjustment Amount S
16 380 Adjustment Quantity S
17 1034 Adjustment Reason Code S
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 A0 A1 A2 A3 A4 A5 A6 A7 A8 B1 B2 B3 B4 B5 B6 B7 B8 B9 B10 B11 B12 B13 B14 B15 B16 B17 B18 B19 B20 B21 B22 B23 D1 D2 D3 D4 D5 D6 D7 D8 D9 D10 D11 D12 D13 D14 D15 W1
18 782 Adjustment Amount S
19 380 Adjustment Quantity S

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

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
01 1069 Patients Relationship to Insured R
01 04 05 07 10 15 17 19 20 21 22 23 24 29 32 33 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 N
06 1251 Date Time Period N
07 355 Unit or Basis for Measurement Code N
08 81 Patient Weight N
09 1073 Pregnancy Indicator N

NM1- Patient Name
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 R
02 166 Patient Address Line S

N4- Patient City/State/ZIP Code
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 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 Number
01 128 Reference Identification Qualifier R
1W 23 IG SY
02 127 Patient Secondary Identifier R
03 352 Description N
N C040 Reference Identifier

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

CLM- Claim Information
01 1028 Patient Account Number R
02 782 Total Claim Charge Amount R
03 1032 Claim Filing Indicator Code N
04 1343 Non-Institutional Claim Type Code N
R C023 Type of Bill
01 1331 Facility Type Code R
02 1332 Facility Code Qualifier R
A
03 1325 Claim Frequency Code R
0 1 2 3 4 5 6 7 8 9 A B C D E F G H I J K L M N O X Y Z
06 1073 Provider or Supplier Signature Indicator R
N Y
07 1359 Medicare Assignment Code S
A C
08 1073 Benefits Assignment Certification Indicator R
N Y
09 1363 Release of Information Code R
A I M N O Y
10 1351 Patient Signature Source Code N
N C024 Property and Casualty Related Causes Codes
12 1366 Special Program Indicator N
01 02 03 05 07 08 09
13 1073 Yes/No Condition or Response Code N
14 1338 Level of Service Code N
15 1073 Yes/No Condition or Response Code N
16 1360 Provider Agreement Code N
17 1029 Claim Status Code N
18 1073 Explanation of Benefits Indicator R
N Y
19 1383 Claim Submission Reason Code N
20 1514 Delay Reason Code S
1 2 3 4 5 6 7 8 9 10 11

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

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

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

CL1- Institutional Claim Code
01 1315 Admission Type Code S
02 1314 Admission Source Code S
03 1352 Patient Status Code S
04 1345 Nursing Home Residential Status Code N

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

CN1- Contract Information
01 1166 Contract Type Code R
01 02 03 04 05 06 09
02 782 Contract Amount S
03 332 Contract Percentage S
04 127 Contract Code S
05 338 Terms Discount Percentage S
06 799 Contract Version Identifier S

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

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

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

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

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

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

REF- Claim Identification Number For Clearinghouses and Other Transmission Intermediaries
01 128 Reference Identification Qualifier R
D9
02 127 Value Added Network Trace Number R
03 352 Description N
N C040 Reference Identifier

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

REF- Original Reference Number (ICN/DCN)
01 128 Reference Identification Qualifier R
F8
02 127 Claim Original Reference Number R
03 352 Description N
N C040 Reference Identifier

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

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

REF- Peer Review Organization (PRO) Approval Number
01 128 Reference Identification Qualifier R
G4
02 127 Peer Review Authorization Number R
03 352 Description N
N C040 Reference Identifier

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

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

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

K3- File Information
01 449 Fixed Format Information R
02 1333 Record Format Code N
N C001 Composite Unit of Measure

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

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

CR6- Home Health Care Information
01 923 Prognosis Indicator R
1 2 3 4 5 6 7 8
02 373 Service From Date R
03 1250 Date Time Period Format Qualifier S
RD8
04 1251 Home Health Certification Period S
05 373 Diagnosis Date R
06 1073 Skilled Nursing Facility Indicator R
N U Y
07 1073 Medicare Coverage Indicator R
N Y
08 1322 Certification Type Indicator R
I R S
09 373 Surgery Date S
10 235 Product or Service ID Qualifier S
HC ID
11 1137 Surgical Procedure Code S
12 373 Physician Order Date S
13 373 Last Visit Date S
14 373 Physician Contact Date S
15 1250 Date Time Period Format Qualifier S
RD8
16 1251 Last Admission Period S
17 1384 Patient Discharge Facility Type Code R
A B C D E F G H L M O R S T
18 373 Diagnosis Date S
19 373 Diagnosis Date S
20 373 Diagnosis Date S
21 373 Diagnosis Date S

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

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

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

HI- Principal, Admitting, E-Code and Patient Reason for Visit Diagnosis Information
R C022 Health Care Code Information
01 1270 Code List Qualifier Code R
BK
02 1271 Industry Code R
03 1250 Date Time Period Format Qualifier N
04 1251 Date Time Period N
05 782 Monetary Amount N
06 380 Quantity N
07 799 Version Identifier N
S C022 Health Care Code Information
01 1270 Code List Qualifier Code R
BJ ZZ
02 1271 Industry Code R
03 1250 Date Time Period Format Qualifier N
04 1251 Date Time Period N
05 782 Monetary Amount N
06 380 Quantity N
07 799 Version Identifier N
S C022 Health Care Code Information
01 1270 Code List Qualifier Code R
BN
02 1271 Industry Code R
03 1250 Date Time Period Format Qualifier N
04 1251 Date Time Period N
05 782 Monetary Amount N
06 380 Quantity N
07 799 Version Identifier N
N C022 Health Care Code Information
N C022 Health Care Code Information
N C022 Health Care Code Information
N C022 Health Care Code Information
N C022 Health Care Code Information
N C022 Health Care Code Information
N C022 Health Care Code Information
N C022 Health Care Code Information
N C022 Health Care Code Information

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

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

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

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

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

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

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

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

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

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

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

CR7- Home Health Care Plan Information
01 921 Discipline Type Code R
AI MS OT PT SN ST
02 1470 Visits Prior to Recertification Date Count R
03 1470 Total Visits Projected This Certification Count R

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

NM1- Attending Physician Name
01 98 Entity Identifier Code R
71
02 1065 Entity Type Qualifier R
1 2
03 1035 Attending Physician Last Name R
04 1036 Attending Physician First Name S
05 1037 Attending Physician Middle Name S
06 1038 Name Prefix N
07 1039 Attending Physician Name Suffix S
08 66 Identification Code Qualifier R
24 34 XX
09 67 Attending Physician Primary Identifier R
10 706 Entity Relationship Code N
11 98 Entity Identifier Code N

PRV- Attending Physician Specialty Information
01 1221 Provider Code R
AT SU
02 128 Reference Identification Qualifier R
ZZ
03 127 Provider Taxonomy Code R
04 156 State or Province Code N
External Source: states
N C035 Provider Specialty Information
06 1223 Provider Organization Code N

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

NM1- Operating Physician Name
01 98 Entity Identifier Code R
72
02 1065 Entity Type Qualifier R
1
03 1035 Operating Physician Last Name R
04 1036 Operating Physician First Name R
05 1037 Operating Physician Middle Name S
06 1038 Name Prefix N
07 1039 Operating Physician Name Suffix S
08 66 Identification Code Qualifier R
24 34 XX
09 67 Operating Physician Primary Identifier R
10 706 Entity Relationship Code N
11 98 Entity Identifier Code N

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

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

NM1- Other Provider Name
01 98 Entity Identifier Code R
73
02 1065 Entity Type Qualifier R
1 2
03 1035 Other Physician Last Name R
04 1036 Other Physician First Name S
05 1037 Other Provider Middle Name S
06 1038 Name Prefix N
07 1039 Other Provider Name Suffix S
08 66 Identification Code Qualifier R
24 34 XX
09 67 Other Physician Identifier R
10 706 Entity Relationship Code N
11 98 Entity Identifier Code N

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

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

NM1- Service Facility Name
01 98 Entity Identifier Code R
FA
02 1065 Entity Type Qualifier R
2
03 1035 Laboratory or Facility Name R
04 1036 Name First N
05 1037 Name Middle N
06 1038 Name Prefix N
07 1039 Name Suffix N
08 66 Identification Code Qualifier S
24 34 XX
09 67 Laboratory or Facility Primary Identifier S
10 706 Entity Relationship Code N
11 98 Entity Identifier Code N

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

N3- Service Facility Address
01 166 Laboratory or Facility Address Line R
02 166 Laboratory or Facility Address Line S

N4- Service Facility City/State/Zip Code
01 19 Laboratory or Facility City Name R
02 156 Laboratory or Facility State or Province Code R
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 Secondary Identification
01 128 Reference Identification Qualifier R
0B 1A 1B 1C 1D 1G 1H 1J EI FH G2 G5 LU N5 X5
02 127 Laboratory or Facility Secondary Identifier R
03 352 Description N
N C040 Reference Identifier

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

CAS- Claim Level Adjustment
01 1033 Claim Adjustment Group Code R
CO CR OA PI PR
02 1034 Adjustment Reason Code R
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 A0 A1 A2 A3 A4 A5 A6 A7 A8 B1 B2 B3 B4 B5 B6 B7 B8 B9 B10 B11 B12 B13 B14 B15 B16 B17 B18 B19 B20 B21 B22 B23 D1 D2 D3 D4 D5 D6 D7 D8 D9 D10 D11 D12 D13 D14 D15 W1
03 782 Adjustment Amount R
04 380 Adjustment Quantity S
05 1034 Adjustment Reason Code S
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 A0 A1 A2 A3 A4 A5 A6 A7 A8 B1 B2 B3 B4 B5 B6 B7 B8 B9 B10 B11 B12 B13 B14 B15 B16 B17 B18 B19 B20 B21 B22 B23 D1 D2 D3 D4 D5 D6 D7 D8 D9 D10 D11 D12 D13 D14 D15 W1
06 782 Adjustment Amount S
07 380 Adjustment Quantity S
08 1034 Adjustment Reason Code S
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 A0 A1 A2 A3 A4 A5 A6 A7 A8 B1 B2 B3 B4 B5 B6 B7 B8 B9 B10 B11 B12 B13 B14 B15 B16 B17 B18 B19 B20 B21 B22 B23 D1 D2 D3 D4 D5 D6 D7 D8 D9 D10 D11 D12 D13 D14 D15 W1
09 782 Adjustment Amount S
10 380 Adjustment Quantity S
11 1034 Adjustment Reason Code S
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 A0 A1 A2 A3 A4 A5 A6 A7 A8 B1 B2 B3 B4 B5 B6 B7 B8 B9 B10 B11 B12 B13 B14 B15 B16 B17 B18 B19 B20 B21 B22 B23 D1 D2 D3 D4 D5 D6 D7 D8 D9 D10 D11 D12 D13 D14 D15 W1
12 782 Adjustment Amount S
13 380 Adjustment Quantity S
14 1034 Adjustment Reason Code S
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 A0 A1 A2 A3 A4 A5 A6 A7 A8 B1 B2 B3 B4 B5 B6 B7 B8 B9 B10 B11 B12 B13 B14 B15 B16 B17 B18 B19 B20 B21 B22 B23 D1 D2 D3 D4 D5 D6 D7 D8 D9 D10 D11 D12 D13 D14 D15 W1
15 782 Adjustment Amount S
16 380 Adjustment Quantity S
17 1034 Adjustment Reason Code S
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 A0 A1 A2 A3 A4 A5 A6 A7 A8 B1 B2 B3 B4 B5 B6 B7 B8 B9 B10 B11 B12 B13 B14 B15 B16 B17 B18 B19 B20 B21 B22 B23 D1 D2 D3 D4 D5 D6 D7 D8 D9 D10 D11 D12 D13 D14 D15 W1
18 782 Adjustment Amount S
19 380 Adjustment Quantity S

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

AMT- Coordination of Benefits (COB) Total Allowed Amount
01 522 Amount Qualifier Code R
B6
02 782 Allowed Amount R
03 478 Credit/Debit Flag Code N

AMT- Coordination of Benefits (COB) Total Submitted Charges
01 522 Amount Qualifier Code R
T3
02 782 Coordination of Benefits Total Submitted Charge Amount R
03 478 Credit/Debit Flag Code N

AMT- Diagnostic Related Group (DRG) Outlier Amount
01 522 Amount Qualifier Code R
ZZ
02 782 Claim DRG Outlier Amount R
03 478 Credit/Debit Flag Code N

AMT- Coordination of Benefits (COB) Total Medicare Paid Amount
01 522 Amount Qualifier Code R
N1
02 782 Total Medicare Paid Amount R
03 478 Credit/Debit Flag Code N

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

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

AMT- Coordination of Benefits (COB) Medicare A Trust Fund Paid Amount
01 522 Amount Qualifier Code R
AA
02 782 Paid From Part A Medicare Trust Fund Amount R
03 478 Credit/Debit Flag Code N

AMT- Coordination of Benefits (COB) Medicare B Trust Fund Paid Amount
01 522 Amount Qualifier Code R
B1
02 782 Paid From Part B Medicare Trust Fund Amount R
03 478 Credit/Debit Flag Code N

AMT- Coordination of Benefits (COB) Total Non-Covered Amount
01 522 Amount Qualifier Code R
A8
02 782 Non-Covered Charge Amount R
03 478 Credit/Debit Flag Code N

AMT- Coordination of Benefits (COB) Total Denied Amount
01 522 Amount Qualifier Code R
YT
02 782 Claim Total Denied Charge Amount R
03 478 Credit/Debit Flag Code N

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

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

MIA- Medicare Inpatient Adjudication Information
01 380 Covered Days or Visits Count R
02 380 Lifetime Reserve Days Count S
03 380 Lifetime Psychiatric Days Count S
04 782 Claim DRG Amount S
05 127 Remark Code S
M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 M13 M14 M15 M16 M17 M18 M19 M20 M21 M22 M23 M24 M25 M26 M27 M28 M29 M30 M31 M32 M33 M34 M35 M36 M37 M38 M39 M40 M41 M42 M43 M44 M45 M46 M47 M48 M49 M50 M51 M52 M53 M54 M55 M56 M57 M58 M59 M60 M61 M62 M63 M64 M65 M66 M67 M68 M69 M70 M71 M72 M73 M74 M75 M76 M77 M78 M79 M80 M81 M82 M83 M84 M85 M86 M87 M88 M89 M90 M91 M92 M93 M94 M95 M96 M97 M98 M99 M100 M101 M102 M103 M104 M105 M106 M107 M108 M109 M110 M111 M112 M113 M114 M115 M116 M117 M118 M119 M120 M121 M122 M123 M124 M125 M126 M127 M128 M129 M130 M131 M132 M133 M134 M135 M136 M137 M138 M139 M140 M141 M142 M143 M144 MA01 MA02 MA03 MA04 MA05 MA06 MA07 MA08 MA09 MA10 MA11 MA12 MA13 MA14 MA15 MA16 MA17 MA18 MA19 MA20 MA21 MA22 MA23 MA24 MA25 MA26 MA27 MA28 MA29 MA30 MA31 MA32 MA33 MA34 MA35 MA36 MA37 MA38 MA39 MA40 MA41 MA42 MA43 MA44 MA45 MA46 MA47 MA48 MA49 MA50 MA51 MA52 MA53 MA54 MA55 MA56 MA57 MA58 MA59 MA60 MA61 MA62 MA63 MA64 MA65 MA66 MA67 MA68 MA69 MA70 MA71 MA72 MA73 MA74 MA75 MA76 MA77 MA78 MA79 MA80 MA81 MA82 MA83 MA84 MA85 MA86 MA87 MA88 MA89 MA90 MA91 MA92 MA93 MA94 MA95 MA96 MA97 MA98 MA99 MA100 MA101 MA102 MA103 MA104 MA105 MA106 MA107 MA108 MA109 MA110 MA111 MA112 MA113 MA114 MA115 MA116 MA117 MA118 MA119 MA120 MA121 MA122 MA123 MA124 MA125 MA126 MA127 MA128 MA129 MA130 MA131 MA132 MA133 MA134 N1 N2 N3 N4 N5 N6 N7 N8 N9 N10 N11 N12 N13 N14 N15 N16 N17 N18 N19 N20 N21 N22 N23 N24 N25 N26 N27 N28 N29 N30 N31 N32 N33 N34 N35 N36 N37 N38 N39 N40 N41 N42 N43 N44 N45 N46 N47 N48 N49 N50 N51 N52 N53 N54 N55 N56 N57 N58 N59 N60 N61 N62 N63 N64 N65 N66 N67 N68 N69 N70 N71 N72 N73 N74 N75 N76 N77 N78 N79 N80 N81 N82 N83 N84 N85 N86 N87 N88 N89 N90 N91 N92 N93 N94 N95 N96 N97 N98 N99 N100 N101 N102 N103 N104 N105 N106 N107 N108 N109 N110 N111 N112 N113 N114 N115 N116 N117 N118 N119 N120 N121 N122 N123 N124 N125 N126 N127 N128 N129 N130 N131 N132 N133 N134 N135 N136 N137 N138 N139 N140 N141 N142 N143 N144 N145 N146 N147 N148 N149 N150 N151 N152 N153 N154 N155 N156
06 782 Claim Disproportionate Share Amount S
07 782 Claim MSP Pass-through Amount S
08 782 Claim PPS Capital Amount S
09 782 PPS-Capital FSP DRG Amount S
10 782 PPS-Capital HSP DRG Amount S
11 782 PPS-Capital DSH DRG Amount S
12 782 Old Capital Amount S
13 782 PPS-Capital IME Amount S
14 782 PPS-Operating Hospital Specific DRG Amount S
15 380 Cost Report Day Count S
16 782 PPS-Operating Federal Specific DRG Amount S
17 782 Claim PPS Capital Outlier Amount S
18 782 Claim Indirect Teaching Amount S
19 782 Nonpayable Professional Component Amount S
20 127 Remark Code S
M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 M13 M14 M15 M16 M17 M18 M19 M20 M21 M22 M23 M24 M25 M26 M27 M28 M29 M30 M31 M32 M33 M34 M35 M36 M37 M38 M39 M40 M41 M42 M43 M44 M45 M46 M47 M48 M49 M50 M51 M52 M53 M54 M55 M56 M57 M58 M59 M60 M61 M62 M63 M64 M65 M66 M67 M68 M69 M70 M71 M72 M73 M74 M75 M76 M77 M78 M79 M80 M81 M82 M83 M84 M85 M86 M87 M88 M89 M90 M91 M92 M93 M94 M95 M96 M97 M98 M99 M100 M101 M102 M103 M104 M105 M106 M107 M108 M109 M110 M111 M112 M113 M114 M115 M116 M117 M118 M119 M120 M121 M122 M123 M124 M125 M126 M127 M128 M129 M130 M131 M132 M133 M134 M135 M136 M137 M138 M139 M140 M141 M142 M143 M144 MA01 MA02 MA03 MA04 MA05 MA06 MA07 MA08 MA09 MA10 MA11 MA12 MA13 MA14 MA15 MA16 MA17 MA18 MA19 MA20 MA21 MA22 MA23 MA24 MA25 MA26 MA27 MA28 MA29 MA30 MA31 MA32 MA33 MA34 MA35 MA36 MA37 MA38 MA39 MA40 MA41 MA42 MA43 MA44 MA45 MA46 MA47 MA48 MA49 MA50 MA51 MA52 MA53 MA54 MA55 MA56 MA57 MA58 MA59 MA60 MA61 MA62 MA63 MA64 MA65 MA66 MA67 MA68 MA69 MA70 MA71 MA72 MA73 MA74 MA75 MA76 MA77 MA78 MA79 MA80 MA81 MA82 MA83 MA84 MA85 MA86 MA87 MA88 MA89 MA90 MA91 MA92 MA93 MA94 MA95 MA96 MA97 MA98 MA99 MA100 MA101 MA102 MA103 MA104 MA105 MA106 MA107 MA108 MA109 MA110 MA111 MA112 MA113 MA114 MA115 MA116 MA117 MA118 MA119 MA120 MA121 MA122 MA123 MA124 MA125 MA126 MA127 MA128 MA129 MA130 MA131 MA132 MA133 MA134 N1 N2 N3 N4 N5 N6 N7 N8 N9 N10 N11 N12 N13 N14 N15 N16 N17 N18 N19 N20 N21 N22 N23 N24 N25 N26 N27 N28 N29 N30 N31 N32 N33 N34 N35 N36 N37 N38 N39 N40 N41 N42 N43 N44 N45 N46 N47 N48 N49 N50 N51 N52 N53 N54 N55 N56 N57 N58 N59 N60 N61 N62 N63 N64 N65 N66 N67 N68 N69 N70 N71 N72 N73 N74 N75 N76 N77 N78 N79 N80 N81 N82 N83 N84 N85 N86 N87 N88 N89 N90 N91 N92 N93 N94 N95 N96 N97 N98 N99 N100 N101 N102 N103 N104 N105 N106 N107 N108 N109 N110 N111 N112 N113 N114 N115 N116 N117 N118 N119 N120 N121 N122 N123 N124 N125 N126 N127 N128 N129 N130 N131 N132 N133 N134 N135 N136 N137 N138 N139 N140 N141 N142 N143 N144 N145 N146 N147 N148 N149 N150 N151 N152 N153 N154 N155 N156
21 127 Remark Code S
M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 M13 M14 M15 M16 M17 M18 M19 M20 M21 M22 M23 M24 M25 M26 M27 M28 M29 M30 M31 M32 M33 M34 M35 M36 M37 M38 M39 M40 M41 M42 M43 M44 M45 M46 M47 M48 M49 M50 M51 M52 M53 M54 M55 M56 M57 M58 M59 M60 M61 M62 M63 M64 M65 M66 M67 M68 M69 M70 M71 M72 M73 M74 M75 M76 M77 M78 M79 M80 M81 M82 M83 M84 M85 M86 M87 M88 M89 M90 M91 M92 M93 M94 M95 M96 M97 M98 M99 M100 M101 M102 M103 M104 M105 M106 M107 M108 M109 M110 M111 M112 M113 M114 M115 M116 M117 M118 M119 M120 M121 M122 M123 M124 M125 M126 M127 M128 M129 M130 M131 M132 M133 M134 M135 M136 M137 M138 M139 M140 M141 M142 M143 M144 MA01 MA02 MA03 MA04 MA05 MA06 MA07 MA08 MA09 MA10 MA11 MA12 MA13 MA14 MA15 MA16 MA17 MA18 MA19 MA20 MA21 MA22 MA23 MA24 MA25 MA26 MA27 MA28 MA29 MA30 MA31 MA32 MA33 MA34 MA35 MA36 MA37 MA38 MA39 MA40 MA41 MA42 MA43 MA44 MA45 MA46 MA47 MA48 MA49 MA50 MA51 MA52 MA53 MA54 MA55 MA56 MA57 MA58 MA59 MA60 MA61 MA62 MA63 MA64 MA65 MA66 MA67 MA68 MA69 MA70 MA71 MA72 MA73 MA74 MA75 MA76 MA77 MA78 MA79 MA80 MA81 MA82 MA83 MA84 MA85 MA86 MA87 MA88 MA89 MA90 MA91 MA92 MA93 MA94 MA95 MA96 MA97 MA98 MA99 MA100 MA101 MA102 MA103 MA104 MA105 MA106 MA107 MA108 MA109 MA110 MA111 MA112 MA113 MA114 MA115 MA116 MA117 MA118 MA119 MA120 MA121 MA122 MA123 MA124 MA125 MA126 MA127 MA128 MA129 MA130 MA131 MA132 MA133 MA134 N1 N2 N3 N4 N5 N6 N7 N8 N9 N10 N11 N12 N13 N14 N15 N16 N17 N18 N19 N20 N21 N22 N23 N24 N25 N26 N27 N28 N29 N30 N31 N32 N33 N34 N35 N36 N37 N38 N39 N40 N41 N42 N43 N44 N45 N46 N47 N48 N49 N50 N51 N52 N53 N54 N55 N56 N57 N58 N59 N60 N61 N62 N63 N64 N65 N66 N67 N68 N69 N70 N71 N72 N73 N74 N75 N76 N77 N78 N79 N80 N81 N82 N83 N84 N85 N86 N87 N88 N89 N90 N91 N92 N93 N94 N95 N96 N97 N98 N99 N100 N101 N102 N103 N104 N105 N106 N107 N108 N109 N110 N111 N112 N113 N114 N115 N116 N117 N118 N119 N120 N121 N122 N123 N124 N125 N126 N127 N128 N129 N130 N131 N132 N133 N134 N135 N136 N137 N138 N139 N140 N141 N142 N143 N144 N145 N146 N147 N148 N149 N150 N151 N152 N153 N154 N155 N156
22 127 Remark Code S
M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 M13 M14 M15 M16 M17 M18 M19 M20 M21 M22 M23 M24 M25 M26 M27 M28 M29 M30 M31 M32 M33 M34 M35 M36 M37 M38 M39 M40 M41 M42 M43 M44 M45 M46 M47 M48 M49 M50 M51 M52 M53 M54 M55 M56 M57 M58 M59 M60 M61 M62 M63 M64 M65 M66 M67 M68 M69 M70 M71 M72 M73 M74 M75 M76 M77 M78 M79 M80 M81 M82 M83 M84 M85 M86 M87 M88 M89 M90 M91 M92 M93 M94 M95 M96 M97 M98 M99 M100 M101 M102 M103 M104 M105 M106 M107 M108 M109 M110 M111 M112 M113 M114 M115 M116 M117 M118 M119 M120 M121 M122 M123 M124 M125 M126 M127 M128 M129 M130 M131 M132 M133 M134 M135 M136 M137 M138 M139 M140 M141 M142 M143 M144 MA01 MA02 MA03 MA04 MA05 MA06 MA07 MA08 MA09 MA10 MA11 MA12 MA13 MA14 MA15 MA16 MA17 MA18 MA19 MA20 MA21 MA22 MA23 MA24 MA25 MA26 MA27 MA28 MA29 MA30 MA31 MA32 MA33 MA34 MA35 MA36 MA37 MA38 MA39 MA40 MA41 MA42 MA43 MA44 MA45 MA46 MA47 MA48 MA49 MA50 MA51 MA52 MA53 MA54 MA55 MA56 MA57 MA58 MA59 MA60 MA61 MA62 MA63 MA64 MA65 MA66 MA67 MA68 MA69 MA70 MA71 MA72 MA73 MA74 MA75 MA76 MA77 MA78 MA79 MA80 MA81 MA82 MA83 MA84 MA85 MA86 MA87 MA88 MA89 MA90 MA91 MA92 MA93 MA94 MA95 MA96 MA97 MA98 MA99 MA100 MA101 MA102 MA103 MA104 MA105 MA106 MA107 MA108 MA109 MA110 MA111 MA112 MA113 MA114 MA115 MA116 MA117 MA118 MA119 MA120 MA121 MA122 MA123 MA124 MA125 MA126 MA127 MA128 MA129 MA130 MA131 MA132 MA133 MA134 N1 N2 N3 N4 N5 N6 N7 N8 N9 N10 N11 N12 N13 N14 N15 N16 N17 N18 N19 N20 N21 N22 N23 N24 N25 N26 N27 N28 N29 N30 N31 N32 N33 N34 N35 N36 N37 N38 N39 N40 N41 N42 N43 N44 N45 N46 N47 N48 N49 N50 N51 N52 N53 N54 N55 N56 N57 N58 N59 N60 N61 N62 N63 N64 N65 N66 N67 N68 N69 N70 N71 N72 N73 N74 N75 N76 N77 N78 N79 N80 N81 N82 N83 N84 N85 N86 N87 N88 N89 N90 N91 N92 N93 N94 N95 N96 N97 N98 N99 N100 N101 N102 N103 N104 N105 N106 N107 N108 N109 N110 N111 N112 N113 N114 N115 N116 N117 N118 N119 N120 N121 N122 N123 N124 N125 N126 N127 N128 N129 N130 N131 N132 N133 N134 N135 N136 N137 N138 N139 N140 N141 N142 N143 N144 N145 N146 N147 N148 N149 N150 N151 N152 N153 N154 N155 N156
23 127 Remark Code S
M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 M13 M14 M15 M16 M17 M18 M19 M20 M21 M22 M23 M24 M25 M26 M27 M28 M29 M30 M31 M32 M33 M34 M35 M36 M37 M38 M39 M40 M41 M42 M43 M44 M45 M46 M47 M48 M49 M50 M51 M52 M53 M54 M55 M56 M57 M58 M59 M60 M61 M62 M63 M64 M65 M66 M67 M68 M69 M70 M71 M72 M73 M74 M75 M76 M77 M78 M79 M80 M81 M82 M83 M84 M85 M86 M87 M88 M89 M90 M91 M92 M93 M94 M95 M96 M97 M98 M99 M100 M101 M102 M103 M104 M105 M106 M107 M108 M109 M110 M111 M112 M113 M114 M115 M116 M117 M118 M119 M120 M121 M122 M123 M124 M125 M126 M127 M128 M129 M130 M131 M132 M133 M134 M135 M136 M137 M138 M139 M140 M141 M142 M143 M144 MA01 MA02 MA03 MA04 MA05 MA06 MA07 MA08 MA09 MA10 MA11 MA12 MA13 MA14 MA15 MA16 MA17 MA18 MA19 MA20 MA21 MA22 MA23 MA24 MA25 MA26 MA27 MA28 MA29 MA30 MA31 MA32 MA33 MA34 MA35 MA36 MA37 MA38 MA39 MA40 MA41 MA42 MA43 MA44 MA45 MA46 MA47 MA48 MA49 MA50 MA51 MA52 MA53 MA54 MA55 MA56 MA57 MA58 MA59 MA60 MA61 MA62 MA63 MA64 MA65 MA66 MA67 MA68 MA69 MA70 MA71 MA72 MA73 MA74 MA75 MA76 MA77 MA78 MA79 MA80 MA81 MA82 MA83 MA84 MA85 MA86 MA87 MA88 MA89 MA90 MA91 MA92 MA93 MA94 MA95 MA96 MA97 MA98 MA99 MA100 MA101 MA102 MA103 MA104 MA105 MA106 MA107 MA108 MA109 MA110 MA111 MA112 MA113 MA114 MA115 MA116 MA117 MA118 MA119 MA120 MA121 MA122 MA123 MA124 MA125 MA126 MA127 MA128 MA129 MA130 MA131 MA132 MA133 MA134 N1 N2 N3 N4 N5 N6 N7 N8 N9 N10 N11 N12 N13 N14 N15 N16 N17 N18 N19 N20 N21 N22 N23 N24 N25 N26 N27 N28 N29 N30 N31 N32 N33 N34 N35 N36 N37 N38 N39 N40 N41 N42 N43 N44 N45 N46 N47 N48 N49 N50 N51 N52 N53 N54 N55 N56 N57 N58 N59 N60 N61 N62 N63 N64 N65 N66 N67 N68 N69 N70 N71 N72 N73 N74 N75 N76 N77 N78 N79 N80 N81 N82 N83 N84 N85 N86 N87 N88 N89 N90 N91 N92 N93 N94 N95 N96 N97 N98 N99 N100 N101 N102 N103 N104 N105 N106 N107 N108 N109 N110 N111 N112 N113 N114 N115 N116 N117 N118 N119 N120 N121 N122 N123 N124 N125 N126 N127 N128 N129 N130 N131 N132 N133 N134 N135 N136 N137 N138 N139 N140 N141 N142 N143 N144 N145 N146 N147 N148 N149 N150 N151 N152 N153 N154 N155 N156
24 782 PPS-Capital Exception Amount S

MOA- Medicare Outpatient Adjudication Information
01 954 Reimbursement Rate S
02 782 Claim HCPCS Payable Amount S
03 127 Remark Code S
M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 M13 M14 M15 M16 M17 M18 M19 M20 M21 M22 M23 M24 M25 M26 M27 M28 M29 M30 M31 M32 M33 M34 M35 M36 M37 M38 M39 M40 M41 M42 M43 M44 M45 M46 M47 M48 M49 M50 M51 M52 M53 M54 M55 M56 M57 M58 M59 M60 M61 M62 M63 M64 M65 M66 M67 M68 M69 M70 M71 M72 M73 M74 M75 M76 M77 M78 M79 M80 M81 M82 M83 M84 M85 M86 M87 M88 M89 M90 M91 M92 M93 M94 M95 M96 M97 M98 M99 M100 M101 M102 M103 M104 M105 M106 M107 M108 M109 M110 M111 M112 M113 M114 M115 M116 M117 M118 M119 M120 M121 M122 M123 M124 M125 M126 M127 M128 M129 M130 M131 M132 M133 M134 M135 M136 M137 M138 M139 M140 M141 M142 M143 M144 MA01 MA02 MA03 MA04 MA05 MA06 MA07 MA08 MA09 MA10 MA11 MA12 MA13 MA14 MA15 MA16 MA17 MA18 MA19 MA20 MA21 MA22 MA23 MA24 MA25 MA26 MA27 MA28 MA29 MA30 MA31 MA32 MA33 MA34 MA35 MA36 MA37 MA38 MA39 MA40 MA41 MA42 MA43 MA44 MA45 MA46 MA47 MA48 MA49 MA50 MA51 MA52 MA53 MA54 MA55 MA56 MA57 MA58 MA59 MA60 MA61 MA62 MA63 MA64 MA65 MA66 MA67 MA68 MA69 MA70 MA71 MA72 MA73 MA74 MA75 MA76 MA77 MA78 MA79 MA80 MA81 MA82 MA83 MA84 MA85 MA86 MA87 MA88 MA89 MA90 MA91 MA92 MA93 MA94 MA95 MA96 MA97 MA98 MA99 MA100 MA101 MA102 MA103 MA104 MA105 MA106 MA107 MA108 MA109 MA110 MA111 MA112 MA113 MA114 MA115 MA116 MA117 MA118 MA119 MA120 MA121 MA122 MA123 MA124 MA125 MA126 MA127 MA128 MA129 MA130 MA131 MA132 MA133 MA134 N1 N2 N3 N4 N5 N6 N7 N8 N9 N10 N11 N12 N13 N14 N15 N16 N17 N18 N19 N20 N21 N22 N23 N24 N25 N26 N27 N28 N29 N30 N31 N32 N33 N34 N35 N36 N37 N38 N39 N40 N41 N42 N43 N44 N45 N46 N47 N48 N49 N50 N51 N52 N53 N54 N55 N56 N57 N58 N59 N60 N61 N62 N63 N64 N65 N66 N67 N68 N69 N70 N71 N72 N73 N74 N75 N76 N77 N78 N79 N80 N81 N82 N83 N84 N85 N86 N87 N88 N89 N90 N91 N92 N93 N94 N95 N96 N97 N98 N99 N100 N101 N102 N103 N104 N105 N106 N107 N108 N109 N110 N111 N112 N113 N114 N115 N116 N117 N118 N119 N120 N121 N122 N123 N124 N125 N126 N127 N128 N129 N130 N131 N132 N133 N134 N135 N136 N137 N138 N139 N140 N141 N142 N143 N144 N145 N146 N147 N148 N149 N150 N151 N152 N153 N154 N155 N156
04 127 Remark Code S
M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 M13 M14 M15 M16 M17 M18 M19 M20 M21 M22 M23 M24 M25 M26 M27 M28 M29 M30 M31 M32 M33 M34 M35 M36 M37 M38 M39 M40 M41 M42 M43 M44 M45 M46 M47 M48 M49 M50 M51 M52 M53 M54 M55 M56 M57 M58 M59 M60 M61 M62 M63 M64 M65 M66 M67 M68 M69 M70 M71 M72 M73 M74 M75 M76 M77 M78 M79 M80 M81 M82 M83 M84 M85 M86 M87 M88 M89 M90 M91 M92 M93 M94 M95 M96 M97 M98 M99 M100 M101 M102 M103 M104 M105 M106 M107 M108 M109 M110 M111 M112 M113 M114 M115 M116 M117 M118 M119 M120 M121 M122 M123 M124 M125 M126 M127 M128 M129 M130 M131 M132 M133 M134 M135 M136 M137 M138 M139 M140 M141 M142 M143 M144 MA01 MA02 MA03 MA04 MA05 MA06 MA07 MA08 MA09 MA10 MA11 MA12 MA13 MA14 MA15 MA16 MA17 MA18 MA19 MA20 MA21 MA22 MA23 MA24 MA25 MA26 MA27 MA28 MA29 MA30 MA31 MA32 MA33 MA34 MA35 MA36 MA37 MA38 MA39 MA40 MA41 MA42 MA43 MA44 MA45 MA46 MA47 MA48 MA49 MA50 MA51 MA52 MA53 MA54 MA55 MA56 MA57 MA58 MA59 MA60 MA61 MA62 MA63 MA64 MA65 MA66 MA67 MA68 MA69 MA70 MA71 MA72 MA73 MA74 MA75 MA76 MA77 MA78 MA79 MA80 MA81 MA82 MA83 MA84 MA85 MA86 MA87 MA88 MA89 MA90 MA91 MA92 MA93 MA94 MA95 MA96 MA97 MA98 MA99 MA100 MA101 MA102 MA103 MA104 MA105 MA106 MA107 MA108 MA109 MA110 MA111 MA112 MA113 MA114 MA115 MA116 MA117 MA118 MA119 MA120 MA121 MA122 MA123 MA124 MA125 MA126 MA127 MA128 MA129 MA130 MA131 MA132 MA133 MA134 N1 N2 N3 N4 N5 N6 N7 N8 N9 N10 N11 N12 N13 N14 N15 N16 N17 N18 N19 N20 N21 N22 N23 N24 N25 N26 N27 N28 N29 N30 N31 N32 N33 N34 N35 N36 N37 N38 N39 N40 N41 N42 N43 N44 N45 N46 N47 N48 N49 N50 N51 N52 N53 N54 N55 N56 N57 N58 N59 N60 N61 N62 N63 N64 N65 N66 N67 N68 N69 N70 N71 N72 N73 N74 N75 N76 N77 N78 N79 N80 N81 N82 N83 N84 N85 N86 N87 N88 N89 N90 N91 N92 N93 N94 N95 N96 N97 N98 N99 N100 N101 N102 N103 N104 N105 N106 N107 N108 N109 N110 N111 N112 N113 N114 N115 N116 N117 N118 N119 N120 N121 N122 N123 N124 N125 N126 N127 N128 N129 N130 N131 N132 N133 N134 N135 N136 N137 N138 N139 N140 N141 N142 N143 N144 N145 N146 N147 N148 N149 N150 N151 N152 N153 N154 N155 N156
05 127 Remark Code S
M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 M13 M14 M15 M16 M17 M18 M19 M20 M21 M22 M23 M24 M25 M26 M27 M28 M29 M30 M31 M32 M33 M34 M35 M36 M37 M38 M39 M40 M41 M42 M43 M44 M45 M46 M47 M48 M49 M50 M51 M52 M53 M54 M55 M56 M57 M58 M59 M60 M61 M62 M63 M64 M65 M66 M67 M68 M69 M70 M71 M72 M73 M74 M75 M76 M77 M78 M79 M80 M81 M82 M83 M84 M85 M86 M87 M88 M89 M90 M91 M92 M93 M94 M95 M96 M97 M98 M99 M100 M101 M102 M103 M104 M105 M106 M107 M108 M109 M110 M111 M112 M113 M114 M115 M116 M117 M118 M119 M120 M121 M122 M123 M124 M125 M126 M127 M128 M129 M130 M131 M132 M133 M134 M135 M136 M137 M138 M139 M140 M141 M142 M143 M144 MA01 MA02 MA03 MA04 MA05 MA06 MA07 MA08 MA09 MA10 MA11 MA12 MA13 MA14 MA15 MA16 MA17 MA18 MA19 MA20 MA21 MA22 MA23 MA24 MA25 MA26 MA27 MA28 MA29 MA30 MA31 MA32 MA33 MA34 MA35 MA36 MA37 MA38 MA39 MA40 MA41 MA42 MA43 MA44 MA45 MA46 MA47 MA48 MA49 MA50 MA51 MA52 MA53 MA54 MA55 MA56 MA57 MA58 MA59 MA60 MA61 MA62 MA63 MA64 MA65 MA66 MA67 MA68 MA69 MA70 MA71 MA72 MA73 MA74 MA75 MA76 MA77 MA78 MA79 MA80 MA81 MA82 MA83 MA84 MA85 MA86 MA87 MA88 MA89 MA90 MA91 MA92 MA93 MA94 MA95 MA96 MA97 MA98 MA99 MA100 MA101 MA102 MA103 MA104 MA105 MA106 MA107 MA108 MA109 MA110 MA111 MA112 MA113 MA114 MA115 MA116 MA117 MA118 MA119 MA120 MA121 MA122 MA123 MA124 MA125 MA126 MA127 MA128 MA129 MA130 MA131 MA132 MA133 MA134 N1 N2 N3 N4 N5 N6 N7 N8 N9 N10 N11 N12 N13 N14 N15 N16 N17 N18 N19 N20 N21 N22 N23 N24 N25 N26 N27 N28 N29 N30 N31 N32 N33 N34 N35 N36 N37 N38 N39 N40 N41 N42 N43 N44 N45 N46 N47 N48 N49 N50 N51 N52 N53 N54 N55 N56 N57 N58 N59 N60 N61 N62 N63 N64 N65 N66 N67 N68 N69 N70 N71 N72 N73 N74 N75 N76 N77 N78 N79 N80 N81 N82 N83 N84 N85 N86 N87 N88 N89 N90 N91 N92 N93 N94 N95 N96 N97 N98 N99 N100 N101 N102 N103 N104 N105 N106 N107 N108 N109 N110 N111 N112 N113 N114 N115 N116 N117 N118 N119 N120 N121 N122 N123 N124 N125 N126 N127 N128 N129 N130 N131 N132 N133 N134 N135 N136 N137 N138 N139 N140 N141 N142 N143 N144 N145 N146 N147 N148 N149 N150 N151 N152 N153 N154 N155 N156
06 127 Remark Code S
M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 M13 M14 M15 M16 M17 M18 M19 M20 M21 M22 M23 M24 M25 M26 M27 M28 M29 M30 M31 M32 M33 M34 M35 M36 M37 M38 M39 M40 M41 M42 M43 M44 M45 M46 M47 M48 M49 M50 M51 M52 M53 M54 M55 M56 M57 M58 M59 M60 M61 M62 M63 M64 M65 M66 M67 M68 M69 M70 M71 M72 M73 M74 M75 M76 M77 M78 M79 M80 M81 M82 M83 M84 M85 M86 M87 M88 M89 M90 M91 M92 M93 M94 M95 M96 M97 M98 M99 M100 M101 M102 M103 M104 M105 M106 M107 M108 M109 M110 M111 M112 M113 M114 M115 M116 M117 M118 M119 M120 M121 M122 M123 M124 M125 M126 M127 M128 M129 M130 M131 M132 M133 M134 M135 M136 M137 M138 M139 M140 M141 M142 M143 M144 MA01 MA02 MA03 MA04 MA05 MA06 MA07 MA08 MA09 MA10 MA11 MA12 MA13 MA14 MA15 MA16 MA17 MA18 MA19 MA20 MA21 MA22 MA23 MA24 MA25 MA26 MA27 MA28 MA29 MA30 MA31 MA32 MA33 MA34 MA35 MA36 MA37 MA38 MA39 MA40 MA41 MA42 MA43 MA44 MA45 MA46 MA47 MA48 MA49 MA50 MA51 MA52 MA53 MA54 MA55 MA56 MA57 MA58 MA59 MA60 MA61 MA62 MA63 MA64 MA65 MA66 MA67 MA68 MA69 MA70 MA71 MA72 MA73 MA74 MA75 MA76 MA77 MA78 MA79 MA80 MA81 MA82 MA83 MA84 MA85 MA86 MA87 MA88 MA89 MA90 MA91 MA92 MA93 MA94 MA95 MA96 MA97 MA98 MA99 MA100 MA101 MA102 MA103 MA104 MA105 MA106 MA107 MA108 MA109 MA110 MA111 MA112 MA113 MA114 MA115 MA116 MA117 MA118 MA119 MA120 MA121 MA122 MA123 MA124 MA125 MA126 MA127 MA128 MA129 MA130 MA131 MA132 MA133 MA134 N1 N2 N3 N4 N5 N6 N7 N8 N9 N10 N11 N12 N13 N14 N15 N16 N17 N18 N19 N20 N21 N22 N23 N24 N25 N26 N27 N28 N29 N30 N31 N32 N33 N34 N35 N36 N37 N38 N39 N40 N41 N42 N43 N44 N45 N46 N47 N48 N49 N50 N51 N52 N53 N54 N55 N56 N57 N58 N59 N60 N61 N62 N63 N64 N65 N66 N67 N68 N69 N70 N71 N72 N73 N74 N75 N76 N77 N78 N79 N80 N81 N82 N83 N84 N85 N86 N87 N88 N89 N90 N91 N92 N93 N94 N95 N96 N97 N98 N99 N100 N101 N102 N103 N104 N105 N106 N107 N108 N109 N110 N111 N112 N113 N114 N115 N116 N117 N118 N119 N120 N121 N122 N123 N124 N125 N126 N127 N128 N129 N130 N131 N132 N133 N134 N135 N136 N137 N138 N139 N140 N141 N142 N143 N144 N145 N146 N147 N148 N149 N150 N151 N152 N153 N154 N155 N156
07 127 Remark Code S
M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 M13 M14 M15 M16 M17 M18 M19 M20 M21 M22 M23 M24 M25 M26 M27 M28 M29 M30 M31 M32 M33 M34 M35 M36 M37 M38 M39 M40 M41 M42 M43 M44 M45 M46 M47 M48 M49 M50 M51 M52 M53 M54 M55 M56 M57 M58 M59 M60 M61 M62 M63 M64 M65 M66 M67 M68 M69 M70 M71 M72 M73 M74 M75 M76 M77 M78 M79 M80 M81 M82 M83 M84 M85 M86 M87 M88 M89 M90 M91 M92 M93 M94 M95 M96 M97 M98 M99 M100 M101 M102 M103 M104 M105 M106 M107 M108 M109 M110 M111 M112 M113 M114 M115 M116 M117 M118 M119 M120 M121 M122 M123 M124 M125 M126 M127 M128 M129 M130 M131 M132 M133 M134 M135 M136 M137 M138 M139 M140 M141 M142 M143 M144 MA01 MA02 MA03 MA04 MA05 MA06 MA07 MA08 MA09 MA10 MA11 MA12 MA13 MA14 MA15 MA16 MA17 MA18 MA19 MA20 MA21 MA22 MA23 MA24 MA25 MA26 MA27 MA28 MA29 MA30 MA31 MA32 MA33 MA34 MA35 MA36 MA37 MA38 MA39 MA40 MA41 MA42 MA43 MA44 MA45 MA46 MA47 MA48 MA49 MA50 MA51 MA52 MA53 MA54 MA55 MA56 MA57 MA58 MA59 MA60 MA61 MA62 MA63 MA64 MA65 MA66 MA67 MA68 MA69 MA70 MA71 MA72 MA73 MA74 MA75 MA76 MA77 MA78 MA79 MA80 MA81 MA82 MA83 MA84 MA85 MA86 MA87 MA88 MA89 MA90 MA91 MA92 MA93 MA94 MA95 MA96 MA97 MA98 MA99 MA100 MA101 MA102 MA103 MA104 MA105 MA106 MA107 MA108 MA109 MA110 MA111 MA112 MA113 MA114 MA115 MA116 MA117 MA118 MA119 MA120 MA121 MA122 MA123 MA124 MA125 MA126 MA127 MA128 MA129 MA130 MA131 MA132 MA133 MA134 N1 N2 N3 N4 N5 N6 N7 N8 N9 N10 N11 N12 N13 N14 N15 N16 N17 N18 N19 N20 N21 N22 N23 N24 N25 N26 N27 N28 N29 N30 N31 N32 N33 N34 N35 N36 N37 N38 N39 N40 N41 N42 N43 N44 N45 N46 N47 N48 N49 N50 N51 N52 N53 N54 N55 N56 N57 N58 N59 N60 N61 N62 N63 N64 N65 N66 N67 N68 N69 N70 N71 N72 N73 N74 N75 N76 N77 N78 N79 N80 N81 N82 N83 N84 N85 N86 N87 N88 N89 N90 N91 N92 N93 N94 N95 N96 N97 N98 N99 N100 N101 N102 N103 N104 N105 N106 N107 N108 N109 N110 N111 N112 N113 N114 N115 N116 N117 N118 N119 N120 N121 N122 N123 N124 N125 N126 N127 N128 N129 N130 N131 N132 N133 N134 N135 N136 N137 N138 N139 N140 N141 N142 N143 N144 N145 N146 N147 N148 N149 N150 N151 N152 N153 N154 N155 N156
08 782 Claim ESRD Payment Amount S
09 782 Nonpayable Professional Component Amount S

NM1- Other Subscriber Name
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 fix N
07 1039 Other Insured Name Suffix S
08 66 Identification Code Qualifier R
MI ZZ
09 67 Other Insured Identifier R
10 706 Entity Relationship Code N
11 98 Entity Identifier Code N

N3- Other Subscriber Address
01 166 Other Insured Address Line R
02 166 Other Insured Address Line S

N4- Other Subscriber City/State/ZIP Code
01 19 Other Insured City Name R
02 156 Other Insured State Code R
External Source: states
03 116 Other Insured Postal Zone or Zip Code R
04 26 Subscriber Country Code S
External Source: country
05 309 Location Qualifier N
06 310 Location Identifier N

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

NM1- Other Payer Name
01 98 Entity Identifier Code R
PR
02 1065 Entity Type Qualifier R
2
03 1035 Other Payer Last or Organization Name R
04 1036 Name First N
05 1037 Name Middle N
06 1038 Name Prefix N
07 1039 Name Suffix N
08 66 Identification Code Qualifier R
PI XV
09 67 Other Payer Primary Identifier R
10 706 Entity Relationship Code N
11 98 Entity Identifier Code N

N3- Other Payer Address
01 166 Other Payer Address Line R
02 166 Other Payer Address Line S

N4- Other Payer City/State/ZIP Code
01 19 Other Payer City Name R
02 156 Other Payer State Code R
External Source: states
03 116 Other Payer Postal Zone or Zip Code R
04 26 Payer Country Code S
External Source: country
05 309 Location Qualifier N
06 310 Location Identifier N

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

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

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

NM1- Other Payer Patient Information
01 98 Entity Identifier Code R
QC
02 1065 Entity Type Qualifier R
1
03 1035 Name Last or Organization Name N
04 1036 Name First N
05 1037 Name Middle N
06 1038 Name Prefix N
07 1039 Name Suffix N
08 66 Identification Code Qualifier R
EI MI
09 67 Other Payer Patient Primary Identifier R
10 706 Entity Relationship Code N
11 98 Entity Identifier Code N

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

NM1- Other Payer Attending Provider
01 98 Entity Identifier Code R
71
02 1065 Entity Type Qualifier R
1 2
03 1035 Name Last or Organization Name N
04 1036 Name First N
05 1037 Name Middle N
06 1038 Name Prefix N
07 1039 Name Suffix N
08 66 Identification Code Qualifier N
09 67 Identification Code N
10 706 Entity Relationship Code N
11 98 Entity Identifier Code N

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

NM1- Other Payer Operating Provider
01 98 Entity Identifier Code R
72
02 1065 Entity Type Qualifier R
1
03 1035 Name Last or Organization Name N
04 1036 Name First N
05 1037 Name Middle N
06 1038 Name Prefix N
07 1039 Name Suffix N
08 66 Identification Code Qualifier N
09 67 Identification Code N
10 706 Entity Relationship Code N
11 98 Entity Identifier Code N

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

NM1- Other Payer Other Provider
01 98 Entity Identifier Code R
73
02 1065 Entity Type Qualifier R
1 2
03 1035 Name Last or Organization Name N
04 1036 Name First N
05 1037 Name Middle N
06 1038 Name Prefix N
07 1039 Name Suffix N
08 66 Identification Code Qualifier N
09 67 Identification Code N
10 706 Entity Relationship Code N
11 98 fier Code N

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

NM1- Other Payer Service Facility Provider
01 98 Entity Identifier Code R
FA
02 1065 Entity Type Qualifier R
2
03 1035 Name Last or Organization Name N
04 1036 Name First N
05 1037 Name Middle N
06 1038 Name Prefix N
07 1039 Name Suffix N
08 66 ode Qualifier N
09 67 Identification Code N
10 706 Entity Relationship Code N
11 98 Entity Identifier Code N

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

LX- Service Line Number
01 554 Assigned Number R

SV2- Institutional Service Line
01 234 Service Line Revenue Code R
S C003 Service Line Procedure Code
01 235 Product or Service ID Qualifier R
HC IV N4 ZZ
02 234 Procedure Code R
03 1339 HCPCS Modifier 1 S
04 1339 HCPCS Modifier 2 S
05 1339 HCPCS Modifier 3 S
06 1339 HCPCS Modifier 4 S
07 352 Description N
03 782 Line Item Charge Amount R
04 355 Unit or Basis for Measurement Code R
DA F2 UN
05 380 Service Unit Count R
06 1371 Service Line Rate S
07 782 Line Item Denied Charge or Non-Covered Charge Amount S
08 1073 Yes/No Condition or Response Code N
09 1345 Status Code N
10 1337 Level of Care Code N

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

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

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

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

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

HCP- Line Pricing/Repricing Information R0113 P0910 P1112
01 1473 Pricing Methodology R
00 01 02 03 04 05 06 07 08 09 10 11 12 13 14
02 782 Repriced Allowed Amount R
03 782 Repriced Saving Amount S
04 127 Repriced Organizational Identifier S
05 118 Repricing Per Diem or Flat Rate Amount S
06 127 Repriced Approved Ambulatory Patient Group Code S
07 782 Repriced Approved Ambulatory Patient Group Amount S
08 234 Repriced Approved Revenue Code S
09 235 Product/ Service ID Qualifier S
HC
10 234 Procedure Code S
11 355 Unit or Basis for Measurement Code S
DA UN
12 380 Repricing 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 P0405 P0607 P0809 P1011 P1213 P1415 P1617 P1819 P2021 P2223 P2425 P2627 P2829 P3031
01 350 Assigned Identification N
02 235 Product/Service ID Qualifier R
N4
03 234 Product/Service ID 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 P0405 C0607 C0902 C1002 C1103
01 687 Class of Trade Code N
02 236 Price Identifier Code N
03 212 Unit Price R
04 380 Quantity R
R C001 Composite Unit of Measure
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 of Unit Price Code N
10 499 Condition Value N
11 289 Multiple Price Quantity N

NM1- Attending Physician Name
01 98 Entity Identifier Code R
71
02 1065 Entity Type Qualifier R
1 2
03 1035 Attending Physician Last Name R
04 1036 Attending Physician First Name S
05 1037 Attending Physician Middle Name S
06 1038 Name Prefix N
07 1039 Attending Physician Name Suffix S
08 66 Identification Code Qualifier R
24 34 XX
09 67 Attending Physician Primary Identifier R
10 706 Entity Relationship Code N
11 98 Entity Identifier Code N

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

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

NM1- Operating Physician Name
01 98 Entity Identifier Code R
72
02 1065 Entity Type Qualifier R
1
03 1035 Operating Physician Last Name R
04 1036 Operating Physician First Name R
05 1037 Operating Physician Middle Name S
06 1038 Name Prefix N
07 1039 Operating Physician Name Suffix S
08 66 Identification Code Qualifier R
24 34 XX
09 67 Operating Physician Primary Identifier R
10 706 Entity Relationship Code N
11 98 Entity Identifier Code N

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

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

NM1- Other Provider Name
01 98 Entity Identifier Code R
73
02 1065 Entity Type Qualifier R
1 2
03 1035 Other Physician Last Name R
04 1036 Other Physician First Name S
05 1037 Other Provider Middle Name S
06 1038 Name Prefix N
07 1039 Other Provider Name Suffix S
08 66 Identification Code Qualifier R
24 34 XX
09 67 Other Provider Identifier R
10 706 Entity Relationship Code N
11 98 Entity Identifier Code N

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

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

SVD- Service Line Adjudication Information
01 67 Payer Identifier R
02 782 Service Line Paid Amount R
S C003 Composite Medical Procedure Identifier
01 235 Product or Service ID Qualifier R
HC IV ZZ
02 234 Procedure Code R
03 1339 Procedure Modifier S
04 1339 Procedure Modifier S
05 1339 Procedure Modifier S
06 1339 Procedure Modifier S
07 352 Procedure Code Description S
04 234 Service Line Revenue Code R
05 380 Adjustment Quantity R
06 554 Bundled or Unbundled Line Number S

CAS- Service Line Adjustment
01 1033 Claim Adjustment Group Code R
CO CR OA PI PR
02 1034 Adjustment Reason Code R
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 A0 A1 A2 A3 A4 A5 A6 A7 A8 B1 B2 B3 B4 B5 B6 B7 B8 B9 B10 B11 B12 B13 B14 B15 B16 B17 B18 B19 B20 B21 B22 B23 D1 D2 D3 D4 D5 D6 D7 D8 D9 D10 D11 D12 D13 D14 D15 W1
03 782 Adjustment Amount R
04 380 Adjustment Quantity S
05 1034 Adjustment Reason Code S
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 A0 A1 A2 A3 A4 A5 A6 A7 A8 B1 B2 B3 B4 B5 B6 B7 B8 B9 B10 B11 B12 B13 B14 B15 B16 B17 B18 B19 B20 B21 B22 B23 D1 D2 D3 D4 D5 D6 D7 D8 D9 D10 D11 D12 D13 D14 D15 W1
06 782 Adjustment Amount S
07 380 Adjustment Quantity S
08 1034 Adjustment Reason Code S
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 A0 A1 A2 A3 A4 A5 A6 A7 A8 B1 B2 B3 B4 B5 B6 B7 B8 B9 B10 B11 B12 B13 B14 B15 B16 B17 B18 B19 B20 B21 B22 B23 D1 D2 D3 D4 D5 D6 D7 D8 D9 D10 D11 D12 D13 D14 D15 W1
09 782 Adjustment Amount S
10 380 Adjustment Quantity S
11 1034 Adjustment Reason Code S
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 A0 A1 A2 A3 A4 A5 A6 A7 A8 B1 B2 B3 B4 B5 B6 B7 B8 B9 B10 B11 B12 B13 B14 B15 B16 B17 B18 B19 B20 B21 B22 B23 D1 D2 D3 D4 D5 D6 D7 D8 D9 D10 D11 D12 D13 D14 D15 W1
12 782 Adjustment Amount S
13 380 Adjustment Quantity S
14 1034 Adjustment Reason Code S
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 A0 A1 A2 A3 A4 A5 A6 A7 A8 B1 B2 B3 B4 B5 B6 B7 B8 B9 B10 B11 B12 B13 B14 B15 B16 B17 B18 B19 B20 B21 B22 B23 D1 D2 D3 D4 D5 D6 D7 D8 D9 D10 D11 D12 D13 D14 D15 W1
15 782 Adjustment Amount S
16 380 Adjustment Quantity S
17 1034 Adjustment Reason Code S
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 A0 A1 A2 A3 A4 A5 A6 A7 A8 B1 B2 B3 B4 B5 B6 B7 B8 B9 B10 B11 B12 B13 B14 B15 B16 B17 B18 B19 B20 B21 B22 B23 D1 D2 D3 D4 D5 D6 D7 D8 D9 D10 D11 D12 D13 D14 D15 W1
18 782 Adjustment Amount S
19 380 Adjustment Quantity S

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

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
2 I12 Interchange Control Number R