ISA- Interchange Control Header

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

GS- Functional Group Header

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

ST- Transaction Set Header

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

BHT- Beginning of Hierarchical Transaction

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

REF- Transaction Type Identification

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

NM1- Submitter Name

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

PER- Submitter EDI Contact Information

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

NM1- Receiver Name

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

HL- Billing/Pay-To Provider Hierarchical Level

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

PRV- Billing/Pay-To Provider Specialty Information

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

CUR- Foreign Currency Information

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

NM1- Billing Provider Name

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

N3- Billing Provider Address

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

N4- Billing Provider City/State/ZIP Code

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

REF- Billing Provider Secondary Identification

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

REF- Credit/Debit Card Billing Information

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

PER- Billing Provider Contact Information

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

NM1- Pay-To Provider Name

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

N3- Pay-To Provider Address

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

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

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

REF- Pay-To Provider Secondary Identification

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

HL- Subscriber Hierarchical Level

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

SBR- Subscriber Information

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

PAT- Patient Information

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

NM1- Subscriber Name

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

N3- Subscriber Address

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

N4- Subscriber City/State/ZIP Code

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

DMG- Subscriber Demographic Information

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

REF- Subscriber Secondary Identification

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

REF- Property and Casualty Claim Number

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

NM1- Credit/Debit Card Account Holder Name

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

REF- Credit/Debit Card Information

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

NM1- Payer Name

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

N3- Payer Address

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

N4- Payer City/State/ZIP Code

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

REF- Payer Secondary Identification

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

NM1- Responsible Party Name

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

N3- Responsible Party Address

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

N4- Responsible Party City/State/ZIP Code

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

CLM- Claim Information

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

DTP- Discharge Hour

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

DTP- Statement Dates

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

DTP- Admission Date/Hour

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

CL1- Institutional Claim Code

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

PWK- Claim Supplemental Information

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

CN1- Contract Information

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

AMT- Payer Estimated Amount Due

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

AMT- Patient Estimated Amount Due

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

AMT- Patient Paid Amount

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

AMT- Credit/Debit Card Maximum Amount

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

REF- Adjusted Repriced Claim Number

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

REF- Repriced Claim Number

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

REF- Claim Identification Number For Clearinghouses and Other Transmission Intermediaries

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

REF- Document Identification Code

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

REF- Original Reference Number (ICN/DCN)

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

REF- Investigational Device Exemption Number

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

REF- Service Authorization Exception Code

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

REF- Peer Review Organization (PRO) Approval Number

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

REF- Prior Authorization or Referral Number

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

REF- Medical Record Number

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

REF- Demonstration Project Identifier

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

K3- File Information

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

NTE- Claim Note

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

NTE- Billing Note

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

CR6- Home Health Care Information

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

CRC- Home Health Functional Limitations

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

CRC- Home Health Activities Permitted

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

CRC- Home Health Mental Status

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

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

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

HI- Diagnosis Related Group (DRG) Information

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

HI- Other Diagnosis Information

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

HI- Principal Procedure Information

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

HI- Other Procedure Information

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

HI- Occurrence Span Information

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

HI- Occurrence Information

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

HI- Value Information

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

HI- Condition Information

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

HI- Treatment Code Information

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

QTY- Claim Quantity

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

HCP- Claim Pricing/Repricing Information

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

CR7- Home Health Care Plan Information

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

HSD- Health Care Services Delivery

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

NM1- Attending Physician Name

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

PRV- Attending Physician Specialty Information

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

REF- Attending Physician Secondary Identification

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

NM1- Operating Physician Name

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

PRV- Operating Physician Specialty Information

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

REF- Operating Physician Secondary Identification

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

NM1- Other Provider Name

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

PRV- Other Provider Specialty Information

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

REF- Other Provider Secondary Identification

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

NM1- Referring Provider Name

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

PRV- Referring Provider Specialty Information

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

REF- Referring Provider Secondary Identification

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

NM1- Service Facility Name

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

PRV- Service Facility Specialty Information

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

N3- Service Facility Address

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

N4- Service Facility City/State/Zip Code

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

REF- Service Facility Secondary Identification

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

SBR- Other Subscriber Information

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

CAS- Claim Level Adjustment

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

AMT- Payer Prior Payment

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

AMT- Coordination of Benefits (COB) Total Allowed Amount

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

AMT- Coordination of Benefits (COB) Total Submitted Charges

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

AMT- Diagnostic Related Group (DRG) Outlier Amount

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

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

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

AMT- dicare Paid Amount - 100%

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

AMT- Medicare Paid Amount - 80%

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

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

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

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

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

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

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

AMT- Coordination of Benefits (COB) Total Denied Amount

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

DMG- Other Subscriber Demographic Information

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

OI- Other Insurance Coverage Information

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

MIA- Medicare Inpatient Adjudication Information

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

MOA- Medicare Outpatient Adjudication Information

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

NM1- Other Subscriber Name

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

N3- Other Subscriber Address

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

N4- Other Subscriber City/State/ZIP Code

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

REF- Other Subscriber Secondary Identification

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

NM1- Other Payer Name

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

N3- Other Payer Address

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

N4- Other Payer City/State/ZIP Code

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

DTP- Claim Adjudication Date

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

REF- Other Payer Secondary Identification and Reference Number

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

REF- Other Payer Prior Authorization or Referral Number

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

NM1- Other Payer Patient Information

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

REF- Other Payer identification Number

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

NM1- Other Payer Attending Provider

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

REF- Other Payer Attending Provider Identification

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

NM1- Other Payer Operating Provider

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

REF- Other Payer Operating Provider Identification

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

NM1- Other Payer Other Provider

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

REF- Other Payer Other Provider Identification

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

NM1- Other Payer Referring Provider

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

REF- Other Payer Referring Provider Identification

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

NM1- Other Payer Service Facility Provider

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

REF- Other Payer Service Facility Provider Identification

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

LX- Service Line Number

554

Assigned Number

SV2- Institutional Service Line

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

SV4- Prescription Number

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

PWK- Line Supplemental Information

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

DTP- Service Line Date

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

DTP- Assessment Date

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

AMT- Service Tax Amount

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

AMT- Facility Tax Amount

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

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 IH 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

NM1- Referring Provider Name

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

PRV- Referring Provider Specialty Information

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

REF- Referring Provider Secondary Identification

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

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/Service ID Qualifier	R
	HC IV N1 N2 N3 N4 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
	External Source: adjustment_reason
03	782	Adjustment Amount	R
04	380	Adjustment Quantity	S
05	1034	Adjustment Reason Code	S
	External Source: adjustment_reason
06	782	Adjustment Amount	S
07	380	Adjustment Quantity	S
08	1034	Adjustment Reason Code	S
	External Source: adjustment_reason
09	782	Adjustment Amount	S
10	380	Adjustment Quantity	S
11	1034	Adjustment Reason Code	S
	External Source: adjustment_reason
12	782	Adjustment Amount	S
13	380	Adjustment Quantity	S
14	1034	Adjustment Reason Code	S
	External Source: adjustment_reason
15	782	Adjustment Amount	S
16	380	Adjustment Quantity	S
17	1034	Adjustment Reason Code	S
	External Source: adjustment_reason
18	782	Adjustment Amount	S
19	380	Adjustment Quantity	S

DTP- 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	S
	GR
08	81	Patient Weight	S
09	1073	Pregnancy Indicator	S
	Y

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
	AA AB AE AK AL AP AR AS AZ BC CA CO CT DC DE FL FM GA GU HI IA ID IL IN KS KY LA MA MB MD ME MH MI MN MO MP MS MT NB NC ND NE NF NH NJ NM NS NT NV NY OH OK ON OR PA PE PQ PR RI SC SD SK TN TX UT VA VI VT WA WI WV WY YT
03	116	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
06	1073	Provider or Supplier Signature Indicator	R
	N Y
07	1359	Medicare Assignment Code	S
	A C
08	1073	Benefits Assignment Certification Indicator	R
	N Y
09	1363	Release of Information Code	R
	A I M N O Y
10	1351	Patient Signature Source Code	N
S		C024	Property and Casualty Related Causes Codes
01	1362	Related Causes Code	R
	AA AB AP EM OA
02	1362	Related Causes Code	S
	AA AB AP EM OA
03	1362	Related Causes Code	S
	AA AB AP EM OA
04	156	Auto Accident State or Province Code	S
	AA AB AE AK AL AP AR AS AZ BC CA CO CT DC DE FL FM GA GU HI IA ID IL IN KS KY LA MA MB MD ME MH MI MN MO MP MS MT NB NC ND NE NF NH NJ NM NS NT NV NY OH OK ON OR PA PE PQ PR RI SC SD SK TN TX UT VA VI VT WA WI WV WY YT
05	26	Country Code	S
	External Source: country
12	1366	Special Program Indicator	S
	01 02 03 05 07 08 09
13	1073	Yes/No Condition or Response Code	N
14	1338	Level of Service Code	N
15	1073	Yes/No Condition or Response Code	N
16	1360	Provider Agreement Code	N
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
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		022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BH
02	1271	Occurrence Code	R
03	1250	Date Time Period Format Qualifier	R
	D8
04	1251	Occurrence or Occurrence Span Code Associated Date	R
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BH
02	1271	Occurrence Code	R
03	1250	Date Time Period Format Qualifier	R
	D8
04	1251	Occurrence or Occurrence Span Code Associated Date	R
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BH
02	1271	Occurrence Code	R
03	1250	Date Time Period Format Qualifier	R
	D8
04	1251	Occurrence or Occurrence Span Code Associated Date	R
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BH
02	1271	Occurrence Code	R
03	1250	Date Time Period Format Qualifier	R
	D8
04	1251	Occurrence or Occurrence Span Code Associated Date	R
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BH
02	1271	Occurrence Code	R
03	1250	Date Time Period Format Qualifier	R
	D8
04	1251	Occurrence or Occurrence Span Code Associated Date	R
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BH
02	1271	Occurrence Code	R
03	1250	Date Time Period Format Qualifier	R
	D8
04	1251	Occurrence or Occurrence Span Code Associated Date	R
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BH
02	1271	Occurrence Code	R
03	1250	Date Time Period Format Qualifier	R
	D8
04	1251	Occurrence or Occurrence Span Code Associated Date	R
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BH
02	1271	Occurrence Code	R
03	1250	Date Time Period Format Qualifier	R
	D8
04	1251	Occurrence or Occurrence Span Code Associated Date	R
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BH
02	1271	Occurrence Code	R
03	1250	Date Time Period Format Qualifier	R
	D8
04	1251	Occurrence or Occurrence Span Code Associated Date	R
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BH
02	1271	Occurrence Code	R
03	1250	Date Time Period Format Qualifier	R
	D8
04	1251	Occurrence or Occurrence Span Code Associated Date	R
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BH
02	1271	Occurrence Code	R
03	1250	Date Time Period Format Qualifier	R
	D8
04	1251	Occurrence or Occurrence Span Code Associated Date	R
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Health Care Code Information
01	1270	Code List Qualifier Code	R
	BH
02	1271	Occurrence Code	R
03	1250	Date Time Period Format Qualifier	R
	D8
04	1251	Occurrence or Occurrence Span Code Associated Date	R
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N

HI- Value Information

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

HI- Condition Information

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

HI- Treatment Code Information

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

QTY- Claim Quantity

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

HCP- Claim Pricing/Repricing Information

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

CR7- Home Health Care Plan Information

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

HSD- Health Care Services Delivery

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

NM1- Attending Physician Name

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

PRV- Attending Physician Specialty Information

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

REF- Attending Physician Secondary Identification

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

NM1- Operating Physician Name

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

PRV- Operating Physician Specialty Information

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

REF- Operating Physician Secondary Identification

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

NM1- Other Provider Name

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

PRV- Other Provider Specialty Information

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

REF- Other Provider Secondary Identification

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

NM1- Referring Provider Name

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

PRV- Referring Provider Specialty Information

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

REF- Referring Provider Secondary Identification

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

NM1- Service Facility Name

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

PRV- Service Facility Specialty Information

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

N3- Service Facility Address

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

N4- Service Facility City/State/Zip Code

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

REF- Service Facility Secondary Identification

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

SBR- Other Subscriber Information

01	1138	Payer Responsibility Sequence Number Code	R
	P S T
02	1069	Individual Relationship Code	R
	01 04 05 07 10 15 17 18 19 20 21 22 23 24 29 32 33 36 39 40 41 43 53 G8
03	127	Insured Group or Policy Number	S
04	93	Other Insured Group Name	S
05	1336	Insurance Type Code	N
06	1143	Coordination of Benefits Code	N
07	1073	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

CAS- Claim Level Adjustment

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

AMT- Payer Prior Payment

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

AMT- Coordination of Benefits (COB) Total Allowed Amount

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

AMT- Coordination of Benefits (COB) Total Submitted Charges

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

AMT- Diagnostic Related Group (DRG) Outlier Amount

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

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

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

AMT- 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	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

OI- Other Insurance Coverage Information

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

MIA- Medicare Inpatient Adjudication Information

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

MOA- Medicare Outpatient Adjudication Information

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

NM1- Other Subscriber Name

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

N3- Other Subscriber Address

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

N4- Other Subscriber City/State/ZIP Code

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

REF- Other Subscriber Secondary Identification

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

NM1- Other Payer Name

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

N3- Other Payer Address

01	166	Other Payer 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
	AA AB AE AK AL AP AR AS AZ BC CA CO CT DC DE FL FM GA GU HI IA ID IL IN KS KY LA MA MB MD ME MH MI MN MO MP MS MT NB NC ND NE NF NH NJ NM NS NT NV NY OH OK ON OR PA PE PQ PR RI SC SD SK TN TX UT VA VI VT WA WI WV WY YT
03	116	Other Payer Postal Zone or Zip Code	R
04	26	Payer Country Code	S
	External Source: country
05	309	Location Qualifier	N
06	310	Location Identifier	N

DTP- Claim Adjudication Date

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

REF- Other Payer Secondary Identification and Reference Number

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

REF- Other Payer Prior Authorization or Referral Number

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

NM1- Other Payer Patient Information

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

REF- Other Payer Patient 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	Entity Identifier 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	Description	N
N		C040	Reference Identifier

NM1- Other Payer Referring Provider

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

REF- Other Payer Referring Provider Identification

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

NM1- Other Payer Service Facility Provider

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

REF- Other Payer Service Facility Provider Identification

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

LX- Service Line Number

554

Assigned Number

SV2- Institutional Service Line

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

SV4- Prescription Number

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

PWK- Line Supplemental Information

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

DTP- Service Line Date

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

DTP- Assessment Date

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

AMT- Service Tax Amount

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

AMT- Facility Tax Amount

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

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 IH 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

NM1- Referring Provider Name

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

PRV- Referring Provider Specialty Information

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

REF- Referring Provider Secondary Identification

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

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/Service ID Qualifier	R
	HC IV N1 N2 N3 N4 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
	External Source: adjustment_reason
03	782	Adjustment Amount	R
04	380	Adjustment Quantity	S
05	1034	Adjustment Reason Code	S
	External Source: adjustment_reason
06	782	Adjustment Amount	S
07	380	Adjustment Quantity	S
08	1034	Adjustment Reason Code	S
	External Source: adjustment_reason
09	782	Adjustment Amount	S
10	380	Adjustment Quantity	S
11	1034	Adjustment Reason Code	S
	External Source: adjustment_reason
12	782	Adjustment Amount	S
13	380	Adjustment Quantity	S
14	1034	Adjustment Reason Code	S
	External Source: adjustment_reason
15	782	Adjustment Amount	S
16	380	Adjustment Quantity	S
17	1034	Adjustment Reason Code	S
	External Source: adjustment_reason
18	782	Adjustment Amount	S
19	380	Adjustment Quantity	S

DTP- 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