130 |
|
2300 - Claim Information |
|
100 |
130 |
CLM |
Claim Information |
R |
1 |
|
135 |
DTP |
Date - Order Date |
S |
1 |
|
135 |
DTP |
Date - Initial Treatment |
S |
1 |
|
135 |
DTP |
Date - Referral Date |
S |
1 |
|
135 |
DTP |
Date - Date Last Seen |
S |
1 |
|
135 |
DTP |
Date - Onset of Current Illness/Symptom |
S |
1 |
|
135 |
DTP |
Date - Acute Manifestation |
S |
5 |
|
135 |
DTP |
Date - Similar Illness/Symptom Onset |
S |
10 |
|
135 |
DTP |
Date - Accident |
S |
10 |
|
135 |
DTP |
Date - Last Menstrual Period |
S |
1 |
|
135 |
DTP |
Date - Last X-Ray |
S |
1 |
|
135 |
DTP |
Date - Estimated Date of Birth |
S |
1 |
|
135 |
DTP |
Date - Hearing and Vision Prescription Date |
S |
1 |
|
135 |
DTP |
Date - Disability Begin |
S |
5 |
|
135 |
DTP |
Date - Disability End |
S |
5 |
|
135 |
DTP |
Date - Last Worked |
S |
1 |
|
135 |
DTP |
Date - Authorized Return to Work |
S |
1 |
|
135 |
DTP |
Date - Admission |
S |
1 |
|
135 |
DTP |
Date - Discharge |
S |
1 |
|
135 |
DTP |
Date - Assumed and Relinquished Care Dates |
S |
2 |
|
155 |
PWK |
Claim Supplemental Information |
S |
10 |
|
160 |
CN1 |
Contract Information |
S |
1 |
|
175 |
AMT |
Credit/Debit Card Maximum Amount |
S |
1 |
|
175 |
AMT |
Patient Amount Paid |
S |
1 |
|
175 |
AMT |
Total Purchased Service Amount |
S |
1 |
|
180 |
REF |
Service Authorization Exception Code |
S |
1 |
|
180 |
REF |
Mandatory Medicare (Section 4081) Crossover Indicator |
S |
1 |
|
180 |
REF |
Mammography Certification Number |
S |
1 |
|
180 |
REF |
Prior Authorization or Referral Number |
S |
2 |
|
180 |
REF |
Original Reference Number (ICN/DCN) |
S |
1 |
|
180 |
REF |
Clinical Laboratory Improvement Amendment (CLIA) Number |
S |
3 |
|
180 |
REF |
Repriced Claim Number |
S |
1 |
|
180 |
REF |
Adjusted Repriced Claim Number |
S |
1 |
|
180 |
REF |
Investigational Device Exemption Number |
S |
1 |
|
180 |
REF |
Claim Identification Number for Clearing Houses and Other Transmission Intermediaries |
S |
1 |
|
180 |
REF |
Ambulatory Patient Group (APG) |
S |
4 |
|
180 |
REF |
Medical Record Number |
S |
1 |
|
180 |
REF |
Demonstration Project Identifier |
S |
1 |
|
185 |
K3 |
File Information |
S |
10 |
|
190 |
NTE |
Claim Note |
S |
1 |
|
195 |
CR1 |
Ambulance Transport Information |
S |
1 |
|
200 |
CR2 |
Spinal Manipulation Service Information |
S |
1 |
|
220 |
CRC |
Ambulance Certification |
S |
3 |
|
220 |
CRC |
Patient Condition Information: Vision |
S |
3 |
|
220 |
CRC |
Homebound Indicator |
S |
1 |
|
231 |
HI |
Health Care Diagnosis Code |
S |
1 |
|
241 |
HCP |
Claim Pricing/Repricing Information |
S |
1 |
|
242 |
|
2305 - Home Health Care Plan Information |
|
6 |
242 |
CR7 |
Home Health Care Plan Information |
S |
1 |
|
243 |
HSD |
Health Care Services Delivery |
S |
3 |
|
|
250 |
|
2310A - Referring Provider Name |
|
2 |
250 |
NM1 |
Referring Provider Name |
S |
1 |
|
255 |
PRV |
Referring Provider Specialty Information |
S |
1 |
|
260 |
N2 |
Additional Referring Provider Name Information |
S |
1 |
|
271 |
REF |
Referring Provider Secondary Identification |
S |
5 |
|
|
250 |
|
2310B - Rendering Provider Name |
|
1 |
250 |
NM1 |
Rendering Provider Name |
S |
1 |
|
255 |
PRV |
Rendering Provider Specialty Information |
R |
1 |
|
260 |
N2 |
Additional Rendering Provider Name Information |
S |
1 |
|
271 |
REF |
Rendering Provider Secondary Identification |
S |
5 |
|
|
250 |
|
2310C - Purchased Service Provider Name |
|
1 |
250 |
NM1 |
Purchased Service Provider Name |
S |
1 |
|
271 |
REF |
Purchased Service Provider Secondary Identification |
S |
5 |
|
|
250 |
|
2310D - Service Facility Location |
|
1 |
250 |
NM1 |
Service Facility Location |
S |
1 |
|
260 |
N2 |
Additional Service Facility Location Name Information |
S |
1 |
|
265 |
N3 |
Service Facility Location Address |
R |
1 |
|
270 |
N4 |
Service Facility Location City/State/ZIP |
R |
1 |
|
271 |
REF |
Service Facility Location Secondary Identification |
S |
5 |
|
|
250 |
|
2310E - Supervising Provider Name |
|
1 |
250 |
NM1 |
Supervising Provider Name |
S |
1 |
|
260 |
N2 |
Additional Supervising Provider Name Information |
S |
1 |
|
271 |
REF |
Supervising Provider Secondary Identification |
S |
5 |
|
|
290 |
|
2320 - Other Subscriber Information |
|
10 |
290 |
SBR |
Other Subscriber Information |
S |
1 |
|
295 |
CAS |
Claim Level Adjustments |
S |
5 |
|
300 |
AMT |
Coordination of Benefits (COB) Payer Paid Amount |
S |
1 |
|
300 |
AMT |
Coordination of Benefits (COB) Approved Amount |
S |
1 |
|
300 |
AMT |
Coordination of Benefits (COB) Allowed Amount |
S |
1 |
|
300 |
AMT |
Coordination of Benefits (COB) Patient Responsibility Amount |
S |
1 |
|
300 |
AMT |
Coordination of Benefits (COB) Covered Amount |
S |
1 |
|
300 |
AMT |
Coordination of Benefits (COB) Discount Amount |
S |
1 |
|
300 |
AMT |
Coordination of Benefits (COB) Per Day Limit Amount |
S |
1 |
|
300 |
AMT |
Coordination of Benefits (COB) Patient Paid Amount |
S |
1 |
|
300 |
AMT |
Coordination of Benefits (COB) Tax Amount |
S |
1 |
|
300 |
AMT |
Coordination of Benefits (COB) Total Claim Before Taxes Amount |
S |
1 |
|
305 |
DMG |
Subscriber Demographic Information |
S |
1 |
|
310 |
OI |
Other Insurance Coverage Information |
R |
1 |
|
320 |
MOA |
Medicare Outpatient Adjudication Information |
S |
1 |
|
325 |
|
2330A - Other Subscriber Name |
|
1 |
325 |
NM1 |
Other Subscriber Name |
R |
1 |
|
330 |
N2 |
Additional Other Subscriber Name Information |
S |
1 |
|
332 |
N3 |
Other Subscriber Address |
S |
1 |
|
340 |
N4 |
Other Subscriber City/State/ZIP Code |
S |
1 |
|
355 |
REF |
Other Subscriber Secondary Identification |
S |
3 |
|
|
325 |
|
2330B - Other Payer Name |
|
1 |
325 |
NM1 |
Other Payer Name |
R |
1 |
|
330 |
N2 |
Additional Other Payer Name Information |
S |
1 |
|
345 |
PER |
Other Payer Contact Information |
S |
2 |
|
345 |
DTP |
Claim Adjudication Date |
S |
1 |
|
355 |
REF |
Other Payer Secondary Identifier |
S |
2 |
|
355 |
REF |
Other Payer Prior Authorization or Referral Number |
S |
2 |
|
355 |
REF |
Other Payer Claim Adjustment Indicator |
S |
2 |
|
|
325 |
|
2330C - Other Payer Patient Information |
|
1 |
325 |
NM1 |
Other Payer Patient Information |
S |
1 |
|
355 |
REF |
Other Payer Patient Identification |
S |
3 |
|
|
325 |
|
2330D - Other Payer Referring Provider |
|
2 |
325 |
NM1 |
Other Payer Referring Provider |
S |
1 |
|
355 |
REF |
Other Payer Referring Provider Identification |
R |
3 |
|
|
325 |
|
2330E - Other Payer Rendering Provider |
|
1 |
325 |
NM1 |
Other Payer Rendering Provider |
S |
1 |
|
355 |
REF |
Other Payer Rendering Provider Secondary Identification |
R |
3 |
|
|
325 |
|
2330F - Other Payer Purchased Service Provider |
|
1 |
325 |
NM1 |
Other Payer Purchased Service Provider |
S |
1 |
|
355 |
REF |
Other Payer Purchased Service Provider Identification |
R |
3 |
|
|
325 |
|
2330G - Other Payer Service Facility Location |
|
1 |
325 |
NM1 |
Other Payer Service Facility Location |
S |
1 |
|
355 |
REF |
Other Payer Service Facility Location Identification |
R |
3 |
|
|
325 |
|
2330H - Other Payer Supervising Provider |
|
1 |
325 |
NM1 |
Other Payer Supervising Provider |
S |
1 |
|
355 |
REF |
Other Payer Supervising Provider Identification |
R |
3 |
|
|
|
365 |
|
2400 - Service Line |
|
50 |
365 |
LX |
Service Line |
R |
1 |
|
370 |
SV1 |
Professional Service |
R |
1 |
|
385 |
SV4 |
Prescription Number |
S |
1 |
|
420 |
PWK |
DMERC CMN Indicator |
S |
1 |
|
425 |
CR1 |
Ambulance Transport Information |
S |
1 |
|
430 |
CR2 |
Spinal Manipulation Service Information |
S |
5 |
|
435 |
CR3 |
Durable Medical Equipment Certification |
S |
1 |
|
445 |
CR5 |
Home Oxygen Therapy Information |
S |
1 |
|
450 |
CRC |
Ambulance Certification |
S |
3 |
|
450 |
CRC |
Hospice Employee Indicator |
S |
1 |
|
450 |
CRC |
DMERC Condition Indicator |
S |
2 |
|
455 |
DTP |
Date - Service Date |
R |
1 |
|
455 |
DTP |
Date - Certification Revision Date |
S |
1 |
|
455 |
DTP |
Date - Referral Date |
S |
1 |
|
455 |
DTP |
Date - Begin Therapy Date |
S |
1 |
|
455 |
DTP |
Date - Last Certification Date |
S |
1 |
|
455 |
DTP |
Date - Order Date |
S |
1 |
|
455 |
DTP |
Date - Date Last Seen |
S |
1 |
|
455 |
DTP |
Date - Test |
S |
2 |
|
455 |
DTP |
Date - Oxygen Saturation/Arterial Blood Gas Test |
S |
3 |
|
455 |
DTP |
Date - Shipped |
S |
1 |
|
455 |
DTP |
Date - Onset of Current Symptom/Illness |
S |
1 |
|
455 |
DTP |
Date - Last X-ray |
S |
1 |
|
455 |
DTP |
Date - Acute Manifestation |
S |
1 |
|
455 |
DTP |
Date - Initial Treatment |
S |
1 |
|
455 |
DTP |
Date - Similar Illness/Symptom Onset |
S |
1 |
|
460 |
QTY |
Anesthesia Modifying Units |
S |
5 |
|
462 |
MEA |
Test Result |
S |
20 |
|
465 |
CN1 |
Contract Information |
S |
1 |
|
470 |
REF |
Repriced Line Item Reference Number |
S |
1 |
|
470 |
REF |
Adjusted Repriced Line Item Reference Number |
S |
1 |
|
470 |
REF |
Prior Authorization or Referral Number |
S |
2 |
|
470 |
REF |
Line Item Control Number |
S |
1 |
|
470 |
REF |
Mammography Certification Number |
S |
1 |
|
470 |
REF |
Clinical Laboratory Improvement Amendment (CLIA) Identification |
S |
1 |
|
470 |
REF |
Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification |
S |
1 |
|
470 |
REF |
Immunization Batch Number |
S |
1 |
|
470 |
REF |
Ambulatory Patient Group (APG) |
S |
4 |
|
470 |
REF |
Oxygen Flow Rate |
S |
1 |
|
470 |
REF |
Universal Product Number (UPN) |
S |
1 |
|
475 |
AMT |
Sales Tax Amount |
S |
1 |
|
475 |
AMT |
Approved Amount |
S |
1 |
|
475 |
AMT |
Postage Claimed Amount |
S |
1 |
|
480 |
K3 |
File Information |
S |
10 |
|
485 |
NTE |
Line Note |
S |
1 |
|
488 |
PS1 |
Purchased Service Information |
S |
1 |
|
491 |
HSD |
Health Care Services Delivery |
S |
1 |
|
492 |
HCP |
Line Pricing/Repricing Information |
S |
1 |
|
500 |
|
2420A - Rendering Provider Name |
|
1 |
500 |
NM1 |
Rendering Provider Name |
S |
1 |
|
505 |
PRV |
Rendering Provider Specialty Information |
R |
1 |
|
510 |
N2 |
Additional Rendering Provider Name Information |
S |
1 |
|
525 |
REF |
Rendering Provider Secondary Identification |
S |
5 |
|
|
500 |
|
2420B - Purchased Service Provider Name |
|
1 |
500 |
NM1 |
Purchased Service Provider Name |
S |
1 |
|
525 |
REF |
Purchased Service Provider Secondary Identification |
S |
5 |
|
|
500 |
|
2420C - Service Facility Location |
|
1 |
500 |
NM1 |
Service Facility Location |
S |
1 |
|
510 |
N2 |
Additional Service Facility Location Name Information |
S |
1 |
|
514 |
N3 |
Service Facility Location Address |
R |
1 |
|
520 |
N4 |
Service Facility Location City/State/ZIP |
R |
1 |
|
525 |
REF |
Service Facility Location Secondary Identification |
S |
5 |
|
|
500 |
|
2420D - Supervising Provider Name |
|
1 |
500 |
NM1 |
Supervising Provider Name |
S |
1 |
|
510 |
N2 |
Additional Supervising Provider Name Information |
S |
1 |
|
525 |
REF |
Supervising Provider Secondary Identification |
S |
5 |
|
|
500 |
|
2420E - Ordering Provider Name |
|
1 |
500 |
NM1 |
Ordering Provider Name |
S |
1 |
|
510 |
N2 |
Additional Ordering Provider Name Information |
S |
1 |
|
514 |
N3 |
Ordering Provider Address |
S |
1 |
|
520 |
N4 |
Ordering Provider City/State/ZIP Code |
S |
1 |
|
525 |
REF |
Ordering Provider Secondary Identification |
S |
5 |
|
530 |
PER |
Ordering Provider Contact Information |
S |
1 |
|
|
500 |
|
2420F - Referring Provider Name |
|
2 |
500 |
NM1 |
Referring Provider Name |
S |
1 |
|
505 |
PRV |
Referring Provider Specialty Information |
S |
1 |
|
510 |
N2 |
Additional Referring Provider Name Information |
S |
1 |
|
525 |
REF |
Referring Provider Secondary Identification |
S |
5 |
|
|
500 |
|
2420G - Other Payer Prior Authorization or Referral Number |
|
4 |
500 |
NM1 |
Other Payer Prior Authorization or Referral Number |
S |
1 |
|
525 |
REF |
Other Payer Prior Authorization or Referral Number |
R |
2 |
|
|
540 |
|
2430 - Line Adjudication Information |
|
25 |
540 |
SVD |
Line Adjudication Information |
S |
1 |
|
545 |
CAS |
Line Adjustment |
S |
99 |
|
550 |
DTP |
Line Adjudication Date |
R |
1 |
|
|
551 |
|
2440 - Form Identification Code |
|
5 |
551 |
LQ |
Form Identification Code |
S |
1 |
|
552 |
FRM |
Supporting Documentation |
R |
99 |
|
|
|