Electornic Data Interchange
| version | section | schema |
|---|---|---|
| 04.2020 | 1.0.0 | X12 |
EDI File Structure
Contains a tree-like structure of the EDI file in terms of loops and segments Format ` {:
Open EDI Script
A Domain Specific Language to enable better mappings of EDI transactions and offer greater extensibility while adhereing to the specifications.
# if then, end
SegPos = if (Condition|CodeCondition) then Usage|LocalCode|Error end
# if-then, else-end
SegPos = if (Condition|CodeCondition) then Usage|LocalCode|Error else Usage|LocalCode|Error end
# if-then, elseif-then-end
SegPos = if (Condition|CodeCondition) then Usage|LocalCode|Error elseif (Condition) then Usage|LocalCode|Error end
Defintions
SegPos
The segment position we want to modify. Ordinal values are used. For example SegPos[1] is the ISA segment. SegPos[1:2] will be the second element of segment ISA. SegPos[1:2:1] would be ISA02 composite element 1
Condition
A condition that must evaluate to true before the statement in the then clause can execute. `+SegPos[27] = if (SegPos[26:2] == "18") then Usage[Optional] else Usage[NotUsed] end `
[Segment/Element Position]=(Condition):ActionType:(true USAGE):(default USAGE)
ActionType is either USAGE or LOCALCODE
27=26:2’EQ'18!USAGE!0!1 31=26:2’EQ'18!USAGE!2!0 40=26:2’EQ'18!USAGE!2!1 146=140:1’EQ’R,S!USAGE!2!0 207=26:2’NE'18!USAGE!2!1 321=315:1’EQ’R,S!USAGE!2!0
Example
{INTERCHANGE HEADER:1[ISA,M]{FUNCTIONAL GROUP:1[GS,M]{ST HEADER:>1[ST,M][BHT,M]{1000A:1[NM1*1,M][PER*2,M,2]}{1000B:1[NM1*2,M]}{2000A:>1[HL*1,M][PRV*1][CUR]{2010AA:1[NM1*4,M][N3,M][N4*2,M][REF,M][REF,O,2][PER*2,O,2]}{2010AB:1[NM1*11][N3,M][N4*2,M]}{2010AC:1[NM1*2][N3,M][N4*2,M][REF][REF]}{2000B:>1[HL*2,M][SBR*1,M][PAT*1,X]{2010BA:1[NM1*3,M][N3][N4*2,M][DMG*3][REF][REF][PER*3]}{2010BB:1[NM1*2,M][N3][N4*2,M][REF,O,3][REF,O,2]}{2300:100[CLM*1,X][DTP][DTP][DTP][DTP][DTP][DTP][DTP][DTP][DTP][DTP][DTP][DTP][DTP][DTP,O,2][DTP][DTP][PWK*1,O,10][CN1][AMT*1][REF][REF][REF][REF][REF][REF][REF][REF][REF][REF][REF][REF][REF][REF][K3,O,10][NTE*1][CR1*2][CR2*1][CRC*1,O,3][CRC*1,O,3][CRC*2][CRC*3][HI*1,M][HI*2][HI*1,O,2][HCP*1]{2310A:2[NM1*4][REF,O,3]}{2310B:1[NM1*4][PRV*1][REF,O,4]}{2310C:1[NM1*12][N3,M][N4*2,M][REF,O,3][PER*3]}{2310D:1[NM1*4][REF,O,4]}{2310E:1[NM1*11][N3,M][N4*2,M]}{2310F:1[NM1*13][N3,M][N4*2,M]}{2320:10[SBR*4][CAS*1,O,5][AMT*1][AMT*1][AMT*1][OI*1,M][MOA]{2330A:1[NM1*3,M][N3][N4*2,M][REF]}{2330B:1[NM1*2,M][N3][N4*2,M][DTP][REF,O,2][REF][REF][REF][REF]}{2330C:2[NM1*11][REF,M,3]}{2330D:1[NM1*11][REF,M,3]}{2330E:1[NM1*11][REF,M,3]}{2330F:1[NM1*11][REF,M,3]}{2330G:1[NM1*11][REF,M,2]}}{2400:50[LX*1,M][SV1*1,M][SV5*1][PWK*1,O,10][PWK*2][CR1*2][CR3*1][CRC*1,O,3][CRC*2][CRC*4][DTP,M][DTP][DTP][DTP][DTP][DTP][DTP,O,2][DTP][DTP][DTP][QTY][QTY][MEA,O,5][CN1*1][REF][REF][REF,O,5][REF][REF][REF][REF][REF][REF,O,5][AMT*1][AMT*1][K3,O,10][NTE*1][NTE][PS1*1][HCP*2]{2410:1[LIN*1][CTP*1][REF]}{2420A:1[NM1*4][PRV*1][REF,O,20]}{2420B:1[NM1*9][REF,O,20]}{2420C:1[NM1*12][N3,M][N4*2,M][REF,O,3]}{2420D:1[NM1*4][REF,O,20]}{2420E:1[NM1*4][N3][N4*2,M][REF,O,20][PER*2]}{2420F:2[NM1*4][REF,O,20]}{2420G:1[NM1*11][N3,M][N4*2,M]}{2420H:1[NM1*13][N3,M][N4*2,M]}{2430:15[SVD*1][CAS*1,O,5][DTP,M][AMT]}{2440:>1[LQ*1][FRM*1,O,99]}}}{2000C:>1[HL*2,X][PAT*2,M]{2010CA:1[NM1*5,M][N3,M][N4*2,M][DMG*3,M][REF][PER*3]}{2300:100[CLM*1,X][DTP][DTP][DTP][DTP][DTP][DTP][DTP][DTP][DTP][DTP][DTP][DTP][DTP][DTP,O,2][DTP][DTP][PWK*1,O,10][CN1][AMT*1][REF][REF][REF][REF][REF][REF][REF][REF][REF][REF][REF][REF][REF][REF][K3,O,10][NTE*1][CR1*2][CR2*1][CRC*1,O,3][CRC*1,O,3][CRC*2][CRC*3][HI*1,M][HI*2][HI*1,O,2][HCP*1]{2310A:2[NM1*4][REF,O,3]}{2310B:1[NM1*4][PRV*1][REF,O,4]}{2310C:1[NM1*12][N3,M][N4*2,M][REF,O,3][PER*3]}{2310D:1[NM1*4][REF,O,4]}{2310E:1[NM1*11][N3,M][N4*2,M]}{2310F:1[NM1*13][N3,M][N4*2,M]}{2320:10[SBR*4][CAS*1,O,5][AMT*1][AMT*1][AMT*1][OI*1,M][MOA]{2330A:1[NM1*3,M][N3][N4*2,M][REF]}{2330B:1[NM1*2,M][N3][N4*2,M][DTP][REF,O,2][REF][REF][REF][REF]}{2330C:2[NM1*11][REF,M,3]}{2330D:1[NM1*11][REF,M,3]}{2330E:1[NM1*11][REF,M,3]}{2330F:1[NM1*11][REF,M,3]}{2330G:1[NM1*11][REF,M,2]}}{2400:50[LX*1,M][SV1*1,M][SV5*1][PWK,O,10][PWK*2][CR1*2][CR3*1][CRC*1,O,3][CRC*2][CRC*4,O,2][DTP,M][DTP][DTP][DTP][DTP][DTP][DTP,O,2][DTP][DTP][DTP][QTY][QTY][MEA,O,5][CN1*1][REF][REF][REF,O,5][REF][REF][REF][REF][REF][REF,O,5][AMT*1][AMT*1][K3,O,10][NTE*1][NTE][PS1*1][HCP*2]{2410:1[LIN*1][CTP*1][REF]}{2420A:1[NM1*4][PRV*1][REF,O,20]}{2420B:1[NM1*9][REF,O,20]}{2420C:1[NM1*12][N3,M][N4*2,M][REF,O,3]}{2420D:1[NM1*4][REF,O,20]}{2420E:1[NM1*4][N3][N4*2,M][REF,O,20][PER*2]}{2420F:2[NM1*4][REF,O,20]}{2420G:1[NM1*11][N3,M][N4*2,M]}{2420H:1[NM1*13][N3,M][N4*2,M]}{2430:15[SVD*1][CAS*1,O,5][DTP,M][AMT]}{2440:>1[LQ*1][FRM*1,O,99]}}}}}}{END ST HEADER LOOP:1[+SE,M]}}{END GS LOOP:1[+GE,M]}}{END ISA LOOP:1[+IEA,M]}}
Each segment that appears in the structure has an implicit ordinal value beginning with 1. For example segment ISA has an ordinal value of 1, segment GS has an ordinal value of 2, ST has an ordinal value of 3 and BHT has an ordinal value of 4. This ordinal value is what uniquely identifies each segment in the structure.
FILE DATA
Version=004010 Description=837 Health Care Claims ELEMENT DEFINITIONS 19=AN,2,30,City Name 26=ID,2,3,Country Code 28=NO,1,9,Group Control Number 66=ID,1,2,Identification Code Qualifier 67=AN,2,80,Identification Code 81=R,1,10,Weight 93=AN,1,60,Name 96=NO,1,10,Number of Included Segments 97=NO,1,6,Number of Transaction Sets Included 98=ID,2,3,Entity Identifier Code 100=ID,3,3,Currency Code 101=ID,2,2,Authorization Information Qualifier 102=AN,10,10,Author Information 103=ID,2,2,Security Information Qualifier 104=AN,10,10,Security Information 105=ID,2,2,Interchange ID Qualifier 106=AN,15,15,Interchange Sender ID 107=AN,15,15,Interchange Receiver ID 108=DT,6,6,Interchange Date 109=TM,4,4,Interchange Time 110=ID,1,1 111=ID,5,5,Interchange Control Version Number 112=NO,9,9,Interchange Control Number 113=ID,1,1,Acknowledgment Requested 114=ID,1,1,Interchange Usage Indicator 115=ID,1,1,Component Element Separator 116=ID,3,15,Postal Code 118=NO,1,9,Rate 124=AN,2,15,Application Receiver Code 127=AN,1,50,Reference Identification 128=ID,2,3,Reference Identification Qualifier 142=AN,2,15,Application Sender Code 143=ID,3,3,Transaction Set Identifier Code 156=ID,2,2,State or Province Code 165=ID,1,1,Repetition Separator 166=AN,1,55,Address Information 212=R,1,17,Unit Price 234=AN,1,48,Product/Service ID 235=ID,2,2,Product/Service ID Qualifier 236=ID,3,3,Price Identifier Code 309=ID,1,2,Location Qualifier 310=AN,1,30,Location Identifier 329=AN,4,9,Transaction Set Control Number 332=R,1,6,Percent Decimal Format 337=TM,4,8,Time 338=R,1,6,Terms Discount Percent 350=AN,1,20,Assigned Identification 352=AN,1,80,Description 353=ID,2,2,Transaction Set Purpose Code 355=ID,2,2,Unit or Basis for Measurement Code 363=ID,3,3,Note Reference Code 364=AN,1,256,Communication Number 365=ID,2,2,Communication Number Qualifier 366=ID,2,2,Contact Function Code 373=DT,8,8,Date 374=ID,3,3,Date/Time Qualifier 380=R,1,15,Quantity 449=AN,1,80,Fixed Format Information 455=ID,1,2,Responsible Agency Code 478=ID,1,1,Credit/Debit Flag Code 479=ID,2,2,Functional Identifier Code 480=AN,1,12,Version / Release / Industry Identifier Code 522=ID,1,3,Amount Qualifier Code 554=NO,1,6,Assigned Number 584=ID,2,2,Employment Status Code 594=ID,1,1,Frequency Code 609=NO,1,9,Count 615=ID,1,2 616=NO,1,3 628=AN,1,12 640=ID,2,2,Transaction Type Code 659=ID,1,2 673=ID,2,2 678=ID,1,2 679=ID,1,1 687=ID,2,2,Class of Trade Code 706=ID,2,2,Entity Relationship Code 734=AN,1,12,Hierarchical Parent ID Number 735=ID,1,2,Hierarchical Level Code 736=ID,1,1,Hierarchical Child Code 737=ID,2,2,Measurement Reference ID Code 738=ID,1,3,Measurement Qualifier 739=R,1,20,Measurement Value 755=ID,2,2,Report Type Code 756=ID,1,2,Report Transmission Code 757=NO,1,2,Report Copies Needed 782=R,1,18,Monetary Amount 799=AN,1,30,Version Identifier 901=ID,2,2,Reject Reason Code 921=ID,2,2 923=ID,1,1,Prognosis Code 954=R,1,10,Percent 1005=ID,4,4,Hierarchical Structure Code 1028=AN,1,38,Claim Submitter Identifier 1029=ID,1,2,Claim Status Code 1032=ID,1,2,Claim Filing Indicator Code 1033=ID,1,2,Claim Adj Group Code 1034=ID,1,5,Claim Adj Reason Code 1035=AN,1,60,Name Last or Organization Name 1036=AN,1,35,Name First 1037=AN,1,25,Name Middle 1038=AN,1,10,Name Prefix 1039=AN,1,10,Name Suffix 1065=ID,1,1,Entity Type Qualifier 1066=ID,1,2,Citizenship Status Code 1067=ID,1,1,Marital Status Code 1068=ID,1,1,Gender Code 1069=ID,2,2,Individual Relationship Code 1073=ID,1,1,Yes/No Condition or Response Code 1109=ID,1,1 1136=ID,2,2,Code Category 1138=ID,1,1,Payer Responsibility Sequence Number Code 1143=ID,1,1,Coordination of Benefits Code 1166=ID,2,2,Contract Type Code 1167=R,1,6 1220=ID,1,1,Student Status Code 1221=AN,1,3,Provider Code 1250=ID,2,3,DateTime Period Format Qualifier 1251=AN,1,35,Date Time Period 1270=ID,1,3,Code List Qual Code 1271=AN,1,30,Industry Code 1316=ID,1,1,Ambulance Trans Code 1317=ID,1,1,Ambulance Reason Code 1321=ID,2,2,CertificateCond Code 1325=ID,1,1,Claim Frequency Type Code 1327=ID,1,1,Copay Status Code 1328=NO,1,2,Diagnosis Code Pointer 1331=AN,1,2,Facility Code Value 1332=ID,1,2,Facility Code Qualifier 1334=ID,1,1,Health Care Professional Shortage Area Code 1335=ID,1,1,Insulin Dependent Code 1336=ID,1,3,Insurance Type Code 1337=ID,1,1,Level of Care Code 1338=ID,1,3,Level of Service Code 1339=AN,2,2,Procedure Modifier 1340=ID,1,2,Multiple Procedure Code 1341=AN,1,2,National or Local Assigned Review Value 1342=ID,1,1,Nature of Cond Code 1343=ID,1,2,Non-Institutional Claim Type Code 1348=ID,1,1 1349=ID,1,1 1350=ID,1,1 1351=ID,1,1,Patient Signature Source Code 1359=ID,1,1,Provider Accept Assignment Code 1360=ID,1,1,Provider Agreement Code 1362=ID,2,3,Related Causes Code 1363=ID,1,1,Release of Information Code 1364=ID,1,2,Review Code 1365=ID,1,2,Service Type Code 1366=ID,2,3,Special Program Code 1367=ID,2,3,Subluxation Level Code 1382=ID,1,1 1383=ID,2,2,Claim Submission Reason Code 1384=ID,1,1,Patient Location Code 1470=NO,1,9 1473=ID,2,2,Pricing Methodology 1514=ID,1,2,Delay Reason Code 1525=ID,1,2,Request Category Code 1526=ID,1,2,Policy Compliance Code 1527=ID,1,2,Exception Code 1705=AN,1,35,Implementation Convention Reference 1715=ID,1,3,Country Subdivision Code 11111112=NO,1,9 11111116=NO,1,5 COMPOSITE ELEMENT DEFINITIONS C001=[355,O],@ C003=[235,O][234,O][1339,O][1339,O][1339,O][1339,O][352,O],@@.....,@@#####,@@.....
C004=[1328,O][1328,O][1328,O][1328,O],@...
C022=[1270,O][1271,O][1250,O][1251,O][782,O][380,O][799,O],@@#####,####### C023=[1331,O][1332,O][1325,O],@#@,@@@ C024=[1362,O][1362,O][1362,O][156,O][26,O],@....,@.#..
C056=[1109,O][1270,O][1271,O],...
SEGMENT DEFINITIONS AMT=[522][782][478],@@# BHT=[1005,M][353,M][127,M][373,M][337,M][640,M] CAS=[1033][1034][782][380][1034][782][380][1034][782][380][1034][782][380][1034][782][380][1034][782][380]+C0605C0705C0908C1008C1211C1311C1514C1614C1817C1917L050607L080910L111213L141516L171819,@@@................
CLM=[1028][782][1032][1343][C023][1073][1359][1073][1363][1351][C024][1366][1073][1338][1073][1360][1029][1073][1383][1514],@@##@__2@@@@..__2.#######.
CN1=[1166,M][782][332][127][338][799],@.....
CR1=[355][81][1316][1317][355][380][166][166][352][352]+P0102P0506,..@@@@##..,..#@@@##..
CR2=[609][380][1367][1367][355][380][380][1342][1073][352][352][1073]+P0102P0506C0403,#######@#..# CR3=[1332][355][380][1335][352],@@@## CR5=[1332][380][1348][1348][352][380][380][380][352][380][380][1349][1350][1350][1350][380][1382][1348]+R1011,@@#######..@...### CR7=[921][1470][1470],@@@ CRC=[1136][1073][1321][1321][1321][1321][1321],@@@....,@@@####,@@@..##,@@@.### CTP=[687][236][212][380][C001],###@@__1 CUR=[98,M][100,M] DMG=[1250][1251][1068][1067][C056][1066][26][659][380][1270][1271]+P0102P1011C1105,@@@..__1.###..,.....__1.###..,@@@##__1###### DTP=[374,M][1250,M][1251,M] FRM=[350][1073][127][373][332]+R02030405,@....
GE=[97,M][28,M] GS=[479,M][142,M][124,M][373,M][337,M][28,M][455,M][480,M] HCP=[1473][782][782][127][118][127][782][234][235][234][355][380][901][1526][1527]+P0910P1112R0113,@@.....#####...,@@.....#.......
HI=[C022][C022][C022][C022][C022][C022][C022][C022][C022][C022][C022][C022],@__1.__1.__1.__1.__1.__1.__1.__1.__1.__1.__1.__1,@__1.__1#__1#__1#__1#__1#__1#__1#__1#__1#__1#__1 HL=[628][734][735][736],@#@@,@@@@ HSD=[673][380][355][1167][615][616][678][679]+P0102C0605,........
IEA=[11111116,M][11111112,M] ISA=[101,M][102,M][103,M][104,M][105,M][106,M][105,M][107,M][108,M][109,M][165,M][111,M][112,M][113,M][114,M][115,M] K3=[449,M] LIN,1=[350][235][234],#@@ LQ=[1270][1271]+C0102,@@ LX=[554],@ MEA=[737,M][738,M][739,M] MOA=[954][782][127][127][127][127][127][782][782] N3=[166,M][166] N4=[19,M][156][116][26][309][310][1715]+C0605C0704E0207,@......,@...##.
NM1=[98,M][1065,M][1035][1036][1037][1038][1039][66][67]+P0809,@@@..##@@,@@@####@@,@@@..#.@@,@@@..#...,@@@..#.##,@@@..##..,@@.####..,@@@@.#...,@@#####..,@@#####@@,@@#######,@@@####..,@@.###### NTE=[363][352],@@ OI=[1032][1383][1073][1351][1360][1363],##@.#@ PAT=[1069][1384][584][1220][1250][1251][355][81][1073]+P0506P0708,####.....,@###.....
PER=[366][93][365][364][365][364][365][364]+P0304P0506P0708,@@@@....,@.@@....,@.@@..## PRV=[1221][128][127],@@@ PS1=[127][782][156],@@# PWK=[755,M][756][757][98][66][67]+P0506,@@##..,@@#### QTY=[673,M][380,M] REF=[128,M][127,M] SBR=[1138,M][1069][127][93][1336][1143][1073][584][1032],@....###.,@@..@###.,@@@...###,@@...###.
SE=[96,M][329,M] ST=[143,M][329,M][1705,M] SV1=[C003][782][355][380][1331][1365][C004][782][1073][1340][1073][1073][1364][1341][1327][1334][127][116][782][1337][1360]+P0304,@__1@@@.#@__1#.#..##.###### SV5=[C003][355][380][782][782][594][923],@__2@@@@@# SVD=[67][782][C003][234][380][554],@@@__3#@.
SEGMENT SELF RULES NM1~2~[EQ]1~4~0 NM1~2~[EQ]2~2~4,5 PWK~2~[EQ]BM,EL,EM,FX,FT~5,6~0 COMPOSITE ELEMENT SELF RULES C024~1~[EQ]AA~4~0 C024~2~[EQ]AA~4~0 CODELISTS States=[States.txt__,] POSCodes=[POSCodes.txt__,] ZipCodes=[ZipCodes.txt__,] ClaimAdjustmentReasonCode=[ClaimAdjustmentReasonCode.txt__~] FORMATS EIN={caret}\d\{9}$ EIN2={caret}\d\{2}-\d\{7}$ SOCIALSECURITY1={caret}\d\{9}$ SOCIALSECURITY2={caret}\d\{3}-\d\{2}-\d\{4}$ ZipCode={caret}\d\{5}([-]\d\{4})?$ MilitaryTimeFormat={caret}([0-1][0-9]|[2][0-3])([0-5][0-9])$ DateYYMMDD={caret}((\d\{2}((0[13578]|1[02])(0[1-9]|[12]\d|3[01])|(0[13456789]|1[012])(0[1-9]|[12]\d|30)|02(0[1-9]|1\d|2[0-8])))|([02468][048]|[13579][26])0229)$ DateCCYYMMDD={caret}(((\d\{4}((0[13578]|1[02])(0[1-9]|[12]\d|3[01])|(0[13456789]|1[012])(0[1-9]|[12]\d|30)|02(0[1-9]|1\d|2[0-8])))|((\d\{2}[02468][048]|\d\{2}[13579][26]))0229)){0,8}$ EDI FILE STRUCTURE {INTERCHANGE HEADER:1[ISA,M]{FUNCTIONAL GROUP:>1[GS,M]{ST 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374=41:1,431__42:1,454__43:1,304__44:1,453__45:1,439__46:1,484__47:1,455__48:1,471__49:1,314,360,361__50:1,297__51:1,296__52:1,435__53:1,096__54:1,090,091__55:1,444__56:1,050__118:1,573__144:1,472__145:1,471__146:1,607__147:1,463__148:1,461__149:1,304__150:1,738,739__151:1,011__152:1,455__153:1,454__203:1,573__217:1,431__218:1,454__219:1,304__220:1,453__221:1,439__222:1,484__223:1,455__224:1,471__225:1,314,360,361__226:1,297__227:1,296__228:1,435__229:1,096__230:1,090,091__231:1,444__232:1,050__294:1,573__320:1,472__321:1,471__322:1,607__323:1,463__324:1,461__325:1,304__326:1,738,739__327:1,011__328:1,455__329:1,454__379:1,573 755=57:1,03,04,05,06,07,08,09,10,11,13,15,21,A3,A4,AM,AS,B2,B3,B4,BR,BS,BT,CB,CK,CT,D2,DA,DB,DG,DJ,DS,EB,HC,HR,I5,R,LA,M1,MT,NN,OB,OC,OD,OE,OX,OZ,P4,P5,PE,PN,PO,PQ,PY,PZ,RB,RR,RT,RX,SG,V5,XP__137:1,03,04,05,06,07,08,09,10,11,13,15,21,A3,A4,AM,AS,B2,B3,B4,BR,BS,BT,CB,CK,CT,D2,DA,DB,DG,DJ,DS,EB,HC,HR,I5,IR,LA,M1,MT,NN,OB,OC,OD,OE,OX,OZ,P4,P5,PE,PN,PO,PQ,PY,PZ,RB,RR,RT,RX,SG,V5,XP__138:1,CT__233:1,03,04,05,06,07,08,09,10,11,13,15,21,A3,A4,AM,AS,B2,B3,B4,BR,BS,BT,CB,CK,CT,D2,DA,DB,DG,DJ,DS,EB,HC,HR,I5,R,LA,M1,MT,NN,OB,OC,OD,OE,OX,OZ,P4,P5,PE,PN,PO,PQ,PY,PZ,RB,RR,RT,RX,SG,V5,XP__313:1,03,04,05,06,07,08,09,10,11,13,15,21,A3,A4,AM,AS,B2,B3,B4,BR,BS,BT,CB,CK,CT,D2,DA,DB,DG,DJ,DS,EB,HC,HR,I5,IR,LA,M1,MT,NN,OB,OC,OD,OE,OX,OZ,P4,P5,PE,PN,PO,PQ,PY,PZ,RB,RR,RT,RX,SG,V5,XP__314:1,CT 756=57:2,AA,BM,EL,EM,FT,FX__137:2,AA,BM,EL,FT__138:2,AB,AD,AF,AG,NS__233:2,AA,BM,EL,EM,FT,FX__314:2,AB,AD,AF,AG,NS 1166=58:1,01,02,03,04,05,06,09__157:1,01,02,03,04,05,06,09__234:1,01,02,03,04,05,06,09__333:1,01,02,03,04,05,06,09 522=59:1,F5__106:1,D__107:1,A8__108:1,EAF__167:1,T__168:1,F4__204:1,EAF__235:1,F5__282:1,D__283:1,A8__284:1,EAF__343:1,T__344:1,F4__380:1,EAF 127=60:2,1,2,3,4,5,6,7__61:2,Y,N__122:2,Y__236:2,1,2,3,4,5,6,7__237:2,Y,N__298:2,Y 363=75:1,ADD,CER,DCP,DGN,TPO__170:1,ADD,DCP__171:1,TPO__251:1,ADD,CER,DCP,DGN,TPO__346:1,ADD,DCP__347:1,TPO 1317=76:4,A,B,C,D,E__139:4,A,B,C,D,E__252:4,A,B,C,D,E__315:4,A,B,C,D,E 1342=77:8,A,C,D,E,F,G,M__253:8,A,C,D,E,F,G,M 1136=78:1,07__79:1,E1,E2,E3__80:1,75__81:1,ZZ__141:1,07__142:1,70__143:1,09__254:1,07__255:1,E1,E2,E3__256:1,75__257:1,ZZ__317:1,07__318:1,70__319:1,09 1321=78:3,01,04,05,06,07,08,09,12__78:4,01,04,05,06,07,08,09,12__78:5,01,04,05,06,07,08,09,12__78:6,01,04,05,06,07,08,09,12__78:7,01,04,05,06,07,08,09,12__79:3,L1,L2,L3,L4,L5__79:4,L1,L2,L3,L4,L5__79:5,L1,L2,L3,L4,L5__79:6,L1,L2,L3,L4,L5__79:7,L1,L2,L3,L4,L5__80:3,IH__81:3,AV,NU,S2,ST__81:4,AV,NU,S2,ST__81:5,AV,NU,S2,ST__141:3,01,04,05,06,07,08,09,12__141:4,01,04,05,06,07,08,09,12__141:5,01,04,05,06,07,08,09,12__141:6,01,04,05,06,07,08,09,12__141:7,01,04,05,06,07,08,09,12__142:3,65__143:3,38,ZV__143:4,38,ZV__254:3,01,04,05,06,07,08,09,12__254:4,01,04,05,06,07,08,09,12__254:5,01,04,05,06,07,08,09,12__254:6,01,04,05,06,07,08,09,12__254:7,01,04,05,06,07,08,09,12__255:3,L1,L2,L3,L4,L5__255:4,L1,L2,L3,L4,L5__255:5,L1,L2,L3,L4,L5__255:6,L1,L2,L3,L4,L5__255:7,L1,L2,L3,L4,L5__256:3,IH__257:3,AV,NU,S2,ST__257:4,AV,NU,S2,ST__257:5,AV,NU,S2,ST__317:3,01,04,05,06,07,08,09,60__317:4,01,04,05,06,07,08,09,60__317:5,01,04,05,06,07,08,09,60__317:6,01,04,05,06,07,08,09,60__317:7,01,04,05,06,07,08,09,60__318:3,65__319:3,ZV__319:4,ZV 1270=82:1:1,ABK,BK__82:2:1,ABF,BF__82:3:1,ABF,BF__82:4:1,ABF,BF__82:5:1,ABF,BF__82:6:1,ABF,BF__82:7:1,ABF,BF__82:8:1,ABF,BF__82:9:1,ABF,BF__82:10:1,ABF,BF__82:11:1,ABF,BF__82:12:1,ABF,BF__83:1:1,BP__83:2:1,BO__84:1:1,BG__84:2:1,BG__84:3:1,BG__84:4:1,BG__84:5:1,BG__84:6:1,BG__84:7:1,BG__84:8:1,BG__84:9:1,BG__84:10:1,BG__84:11:1,BG__84:12:1,BG__205:1,AS,UT__258:1:1,ABK,BK__258:2:1,ABF,BF__258:3:1,ABF,BF__258:4:1,ABF,BF__258:5:1,ABF,BF__258:6:1,ABF,BF__258:7:1,ABF,BF__258:8:1,ABF,BF__258:9:1,ABF,BF__258:10:1,ABF,BF__258:11:1,ABF,BF__258:12:1,ABF,BF__259:1:1,BP__259:2:1,BO__260:1:1,BG__260:2:1,BG__260:3:1,BG__260:4:1,BG__260:5:1,BG__260:6:1,BG__260:7:1,BG__260:8:1,BG__260:9:1,BG__260:10:1,BG__260:11:1,BG__260:12:1,BG__381:1,AS,UT 1473=85:1,00,01,02,03,04,05,07,08,09,10,11,12,13,14__173:1,00,01,02,03,04,05,06,07,08,09,10,11,12,13,14__261:1,00,01,02,03,04,05,07,08,09,10,11,12,13,14__349:1,00,01,02,03,04,05,06,07,08,09,10,11,12,13,14 901=85:13,T1,T2,T3,T4,T5,T6__173:13,T1,T2,T3,T4,T5,T6__261:13,T1,T2,T3,T4,T5,T6__349:13,T1,T2,T3,T4,T5,T6 1526=85:14,1,2,3,4,5__173:14,1,2,3,4,5__261:14,1,2,3,4,5__349:14,1,2,3,4,5 1527=85:15,1,2,3,4,5,6__173:15,1,2,3,4,5,6__261:15,1,2,3,4,5,6__349:15,1,2,3,4,5,6 1033=105:1,CO,CR,OA,PI,PR__202:1,CO,CR,OA,PI,PR__281:1,CO,CR,OA,PI,PR__378:1,CO,CR,OA,PI,PR 235=135:1:1,ER,HC,IV,WK__136:1:1,HC__173:9,ER,HC,IV,WK__174:2,N4,EN,EO,HI,ON,UK,UP__201:3:1,ER,HC,IV,WK__311:1:1,ER,HC,IV,WK__312:1:1,HC__349:9,ER,HC,IV,WK__350:2,N4,EN,EO,HI,ON,UK,UP__377:3:1,ER,HC,IV,WK 1327=135:15,0__311:15,0 594=136:6,1,4,6__312:6,1,4,6 673=154:1,PT__155:1,FL__330:1,PT__331:1,FL 737=156:1,OG,TR__332:1,OG,TR 738=156:2,HT,R1,R2,R3,R4__332:2,HT,R1,R2,R3,R4 ELEMENT FORMATS 108=1:9,0,0,DateYYMMDD 373=2:4,0,0,DateCCYYMMDD 1251=31:2,0,,DateCCYYMMDD__41:3,0,,DateCCYYMMDD__42:3,0,,DateCCYYMMDD__43:3,0,,DateCCYYMMDD__44:3,0,,DateCCYYMMDD__45:3,0,,DateCCYYMMDD__46:3,0,,DateCCYYMMDD__47:3,0,,DateCCYYMMDD__48:3,0,,DateCCYYMMDD__49:3,0,,DateCCYYMMDD__50:3,0,,DateCCYYMMDD__51:3,0,,DateCCYYMMDD__52:3,0,,DateCCYYMMDD__53:3,0,,DateCCYYMMDD__54:3,0,,DateCCYYMMDD__55:3,0,,DateCCYYMMDD__56:3,0,,DateCCYYMMDD__217:3,0,,DateCCYYMMDD__218:3,0,,DateCCYYMMDD__219:3,0,,DateCCYYMMDD__220:3,0,,DateCCYYMMDD__221:3,0,,DateCCYYMMDD__222:3,0,,DateCCYYMMDD__223:3,0,,DateCCYYMMDD__224:3,0,,DateCCYYMMDD__225:3,0,,DateCCYYMMDD__226:3,0,,DateCCYYMMDD__227:3,0,,DateCCYYMMDD__228:3,0,,DateCCYYMMDD__229:3,0,,DateCCYYMMDD__230:3,0,,DateCCYYMMDD__231:3,0,,DateCCYYMMDD*232:3,0,,DateCCYYMMDD SUMMARY 40:2=135:2 220:2=319:2 ELEMENT EQUALITY 1:13=385:2 2:6=384:2 3:2=383:2 RULES 27=26:2'EQ'18!USAGE!0!1 31=26:2'EQ'18!USAGE!2!0 40=26:2'EQ'18!USAGE!2!1 104=26:1'EQ'S!USAGE!2!0 146=140:1'EQ'R,S!USAGE!2!0 207=26:2'NE'18!USAGE!2!1 321=315:1'EQ'R,S!USAGE!2!0 +SegPos[135:5] = if (SegPos[135:5] == SegPos[40:5:1]) then Error[ElementHasWrongValue,"SV105 must be different from 2300 CLM05-01"] end ELEMENT COUNTERS 554=134:1 554=309:1 ELEMENT CODE DESCRIPTION LOOP DESCRIPTIONS INTERCHANGE HEADER=Beginning of the EDI Interchange FUNCTIONAL GROUP=Beginning of Functional Group ST HEADER=Header Loop 1000A=SUBMITTER NAME 1000B=RECEIVER NAME 2000A=BILLING/PAY-TO PROVIDER HIERARCHICAL LEVEL 2010AA=BILLING PROVIDER NAME 2010AB=PAY-TO ADDRESS NAME 2010AC=PAY-TO PLAN NAME 2000B=SUBSCRIBER HIERARCHICAL LEVEL 2010BA=SUBSCRIBER NAME 2010BB=PAYER NAME 2300=CLAIM INFORMATION 2310A=REFERRING PROVIDER NAME 2310B=RENDERING PROVIDER NAME 2310C=SERVICE FACILITY LOCATION 2310D=SUPERVISING PROVIDER NAME 2310E=AMBULANCE PICK-UP LOCATION 2310F=AMBULANCE DROP-OFF LOCATION 2320=OTHER SUBSCRIBER INFORMATION 2330A=OTHER SUBSCRIBER NAME 2330B=OTHER PAYER NAME 2330C=OTHER PAYER REFERRING PROVIDER 2330D=OTHER PAYER RENDERING PROVIDER 2330E=OTHER PAYER SERVICE FACILITY LOCATION 2330F=OTHER PAYER SUPERVISING PROVIDER 2330G=OTHER PAYER BILLING PROVIDER 2400=SERVICE LINE 2410=DRUG IDENTIFICATION 2420A=RENDERING PROVIDER NAME 2420B=PURCHASED SERVICE PROVIDER NAME 2420C=SERVICE FACILITY LOCATION 2420D=SUPERVISING PROVIDER NAME 2420E=ORDERING PROVIDER NAME 2420F=REFERRING PROVIDER NAME 2420G=AMBULANCE PICK-UP LOCATION 2420H=AMBULANCE DROP-OFF LOCATION 2430=LINE ADJUDICATION INFORMATION 2440=FORM IDENTIFICATION CODE 2000C=PATIENT HIERARCHICAL LEVEL 2010CA=PATIENT NAME 2300=CLAIM INFORMATION 2310A=REFERRING PROVIDER NAME 2310B=RENDERING PROVIDER NAME 2310C=SERVICE FACILITY LOCATION 2310D=SUPERVISING PROVIDER NAME 2310E=AMBULANCE PICK-UP LOCATION 2310F=AMBULANCE DROP-OFF LOCATION 2320=OTHER SUBSCRIBER INFORMATION 2330A=OTHER SUBSCRIBER NAME 2330B=OTHER PAYER NAME 2330C=OTHER PAYER REFERRING PROVIDER 2330D=OTHER PAYER RENDERING PROVIDER 2330E=OTHER PAYER SERVICE FACILITY LOCATION 2330F=OTHER PAYER SUPERVISING PROVIDER 2330G=OTHER PAYER BILLING PROVIDER 2400=SERVICE LINE 2410=DRUG IDENTIFICATION 2420A=RENDERING PROVIDER NAME 2420B=PURCHASED SERVICE PROVIDER NAME 2420C=SERVICE FACILITY LOCATION 2420D=SUPERVISING PROVIDER NAME 2420E=ORDERING PROVIDER NAME 2420F=REFERRING PROVIDER NAME 2420G=AMBULANCE PICK-UP LOCATION 2420H=AMBULANCE DROP-OFF LOCATION 2430=LINE ADJUDICATION INFORMATION 2440=FORM IDENTIFICATION CODE END ST HEADER LOOP=END OF THE ST HEADER END GS LOOP=END OF FUNCTIONAL GROUP END ISA LOOP=END OF TRANSACTION SEGMENT DESCRIPTIONS ISA=1,Interchange Control Header GS=2,Functional Group Header ST=3,Transaction Set Header BHT=4,Beginning of Hierarchical Transaction NM1=5,Submitter Name PER=6,Submitter EDI Contact Information NM1=7,Receiver Name HL=8,Billing/Pay-to Provider Hierarchical Level PRV=9,Billing/Pay-to Provider Specialty Information CUR=10,Foreign Currency Information NM1=11,Billing Provider Name N3=12,Billing Provider Address N4=13,Billing Provider City/State/ZIP Code REF=14,Billing Provider Tax Identification REF=15,Billing Provider UPIN/License Information PER=16,Billing Provider Contact Information NM1=17,Pay-to Provider Name N3=18,Pay-to Provider Address N4=19,Pay-to Provider City/State/ZIP Code NM1=20,Pay-To Plan Name N3=21,Pay-to Plan Address N4=22,Pay-To Plan City REF=23,Pay-to Plan Secondary Identification REF=24,Pay-To Plan Tax Identification Number HL=25,Subscriber Hierarchical Level SBR=26,Subscriber Information PAT=27,Patient Information NM1=28,Subscriber Name N3=29,Subscriber Address N4=30,Subscriber City/State/ZIP Code DMG=31,Subscriber Demographic Information REF=32,Subscriber Secondary Identification REF=33,Property and Casualty Claim Number PER=34,Property and Casualty Subscriber Contact Information NM1=35,Payer Name N3=36,Payer Address N4=37,Payer City/State/ZIP Code REF=38,Payer Secondary Identification REF=39,Billing Provider Secondary Identification CLM=40,Claim Information DTP=41,Onset of Current Illness or Symptom DTP=42,Initial Treatment DTP=43,Date Last Seen DTP=44,Acute Manifestation DTP=45,Accident Date DTP=46,Last Menstrual Period DTP=47,Last X-ray DTP=48,Hearing and Vision Prescription Date DTP=49,Disability Dates DTP=50,Last Worked DTP=51,Authorized Return to Work DTP=52,Admission DTP=53,Discharge DTP=54,Assumed and Relinquished Care Dates DTP=55,Property and Casualty Date of First Contact DTP=56,Repricer Received Date PWK=57,Claim Supplemental Information CN1=58,Contract Information AMT=59,Patient Amount Paid REF=60,Service Authorization Exception Code REF=61,Mandatory Medicare (Section 4081) Crossover Indicator REF=62,Mammography Certification Number REF=63, Referral Number REF=64,Prior Authorization REF=65,Payer Claim Control Number REF=66,Clinical Laboratory Improvement Amendment (CLIA) Number REF=67,Repriced Claim Number REF=68,Adjusted Repriced Claim Number REF=69,Investigational Device Exemption Number REF=70,Claim Identification Number for Clearing Houses and Other Transmission Intermediaries REF=71,Medical Record Number REF=72,Demonstration Project Identifier REF=73,Care Plan Oversight K3=74,File Information NTE=75,Claim Note CR1=76,Ambulance Transport Information CR2=77,Spinal Manipulation Service Information CRC=78,Ambulance Certification CRC=79,Patient Condition Information: Vision CRC=80,Homebound Indicator CRC=81,EPSDT Referral HI=82,Health Care Diagnosis Code HI=83,Anesthesia Related Procedure HI=84,Condition Information HCP=85,Claim Pricing/Repricing Information NM1=86,Referring Provider Name REF=87,Referring Provider Secondary Identification NM1=88,Rendering Provider Name PRV=89,Rendering Provider Specialty Information REF=90,Rendering Provider Secondary Identification NM1=91,Service Facility Location Name N3=92,Service Facility Location Address N4=93,Service Facility Location City/State/ZIP REF=94,Service Facility Location Secondary Identification PER=95,Service Facility Contact Information NM1=96,Supervising Provider Name REF=97,Supervising Provider Secondary Identification NM1=98,AMBULANCE PICK-UP LOCATION N3=99,Ambulance Pick-up Location Address N4=100,Ambulance Pick-up Location City NM1=101,AMBULANCE DROP-OFF LOCATION N3=102,Ambulance Drop-off Location Address N4=103,Ambulance Drop-off Location City SBR=104,Other Subscriber Information CAS=105,Claim Level Adjustments AMT=106,Coordination of Benefits (COB) Payer Paid Amount AMT=107,Coordination of Benefits (COB) Total Non-Covered AMT=108,Remaining Patient Liability OI=109,Other Insurance Coverage Information MOA=110,Medicare Outpatient Adjudication Information NM1=111,Other Subscriber Name N3=112,Other Subscriber Address N4=113,Other Subscriber City/State/ZIP Code REF=114,Other Subscriber Secondary Identification NM1=115,Other Payer Name N3=116,Other Payer Address N4=117,Other Payer City DTP=118,Claim Check or Remittance Date REF=119,Other Payer Secondary Identifier REF=120,Other Payer Prior Authorization REF=121,Other Payer Referral Number REF=122,Other Payer Claim Adjustment Indicator REF=123,Other Payer Claim Control Number NM1=124,Other Payer Referring Provider REF=125,Other Payer Referring Provider Identification NM1=126,Other Payer Rendering Provider REF=127,Other Payer Rendering Provider Secondary Identification NM1=128,Other Payer Service Facility Location REF=129,Other Payer Service Facility Location Identification NM1=130,Other Payer Supervising Provider REF=131,Other Payer Supervising Provider Identification NM1=132,Other Payer Billing Provider REF=133,Other Payer Billing Provider Secondary Identification LX=134,Service Line SV1=135,Professional Service SV5=136,Durable Medical Equipment Service PWK=137,Line Supplemental Information PWK=138,DMERC CMN Indicator CR1=139,Ambulance Transport Information CR3=140,Durable Medical Equipment Certification CRC=141,Ambulance Certification CRC=142,Hospice Employee Indicator CRC=143,Condition Indicator/Durable Medical Equipment DTP=144,Date - Service Date DTP=145,Prescription Date DTP=146,Certification Revision/Recertification Date DTP=147,Date - Begin Therapy Date DTP=148,Date - Last Certification Date DTP=149,Date - Date Last Seen DTP=150,Date - Test DTP=151,Date - Shipped DTP=152,Date - Last X-ray DTP=153,Date - Initial Treatment QTY=154,Ambulance Patient Count QTY=155,Obstetric Anesthesia Additional Units MEA=156,Test Result CN1=157,Contract Information REF=158,Repriced Line Item Reference Number REF=159,Adjusted Repriced Line Item Reference Number REF=160,Prior Authorization REF=161,Line Item Control Number REF=162,Mammography Certification Number REF=163,Clinical Laboratory Improvement Amendment (CLIA) Identification REF=164,Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification REF=165,Immunization Batch Number REF=166,Referral Number AMT=167,Sales Tax Amount AMT=168,Postage Claimed Amount K3=169,File Information NTE=170,Line Note NTE=171,Third Party Organization Notes PS1=172,Purchased Service Information HCP=173,Line Pricing/Repricing Information LIN=174,Drug Identification CTP=175,Drug Pricing REF=176,Prescription Number NM1=177,Rendering Provider Name PRV=178,Rendering Provider Specialty Information REF=179,Rendering Provider Secondary Identification NM1=180,Purchased Service Provider Name REF=181,Purchased Service Provider Secondary Identification NM1=182,Service Facility Location N3=183,Service Facility Location Address N4=184,Service Facility Location City/State/ZIP REF=185,Service Facility Location Secondary Identification NM1=186,Supervising Provider Name REF=187,Supervising Provider Secondary Identification NM1=188,Ordering Provider Name N3=189,Ordering Provider Address N4=190,Ordering Provider City/State/ZIP Code REF=191,Ordering Provider Secondary Identification PER=192,Ordering Provider Contact Information NM1=193,Referring Provider Name REF=194,Other Payer Prior Authorization or Referral Number NM1=195,Ambulance Pick-up Location N3=196,Ambulance Pick-up Location Address N4=197,Ambulance Pick-up Location City NM1=198,Ambulance Pick-up Location N3=199,Ambulance Pick-up Location Address N4=200,Ambulance Pick-up Location City SVD=201,Line Adjudication Information CAS=202,Line Adjustment DTP=203,Line Check or Remittance Date AMT=204,Remaining Patient Liability LQ=205,Form Identification Code FRM=206,Supporting Documentation HL=207,Patient Hierarchical Level PAT=208,Patient Information NM1=209,Patient Name N3=210,Patient Address N4=211,Patient City/State/ZIP Code DMG=212,Patient Demographic Information REF=213,Property and Casualty Claim Number REF=214,Property and Casualty Patient Identifier PER=215,Property and Casualty Patient Contact Information CLM=216,Claim Information DTP=217,Onset of Current Illness or Symptom DTP=218,Initial Treatment DTP=219,Date Last Seen DTP=220,Acute Manifestation DTP=221,Accident Date DTP=222,Last Menstrual Period DTP=223,Last X-ray DTP=224,Hearing and Vision Prescription Date DTP=225,Disability Dates DTP=226,Last Worked DTP=227,Authorized Return to Work DTP=228,Admission DTP=229,Discharge DTP=230,Assumed and Relinquished Care Dates DTP=231,Property and Casualty Date of First Contact DTP=232,Repricer Received Date PWK=233,Claim Supplemental Information CN1=234,Contract Information AMT=235,Patient Amount Paid REF=236,Service Authorization Exception Code REF=237,Mandatory Medicare (Section 4081) Crossover Indicator REF=238,Mammography Certification Number REF=239, Referral Number REF=240,Prior Authorization REF=241,Payer Claim Control Number REF=242,Clinical Laboratory Improvement Amendment (CLIA) Number REF=243,Repriced Claim Number REF=244,Adjusted Repriced Claim Number REF=245,Investigational Device Exemption Number REF=246,Claim Identification Number for Clearing Houses and Other Transmission Intermediaries REF=247,Medical Record Number REF=248,Demonstration Project Identifier REF=249,Care Plan Oversight K3=250,File Information NTE=251,Claim Note CR1=252,Ambulance Transport Information CR2=253,Spinal Manipulation Service Information CRC=254,Ambulance Certification CRC=255,Patient Condition Information: Vision CRC=256,Homebound Indicator CRC=257,EPSDT Referral HI=258,Health Care Diagnosis Code HI=259,Anesthesia Related Procedure HI=260,Condition Information HCP=261,Claim Pricing/Repricing Information NM1=262,Referring Provider Name REF=263,Referring Provider Secondary Identification NM1=264,Rendering Provider Name PRV=265,Rendering Provider Specialty Information REF=266,Rendering Provider Secondary Identification NM1=267,Service Facility Location Name N3=268,Service Facility Location Address N4=269,Service Facility Location City/State/ZIP REF=270,Service Facility Location Secondary Identification PER=271,Service Facility Contact Information NM1=272,Supervising Provider Name REF=273,Supervising Provider Secondary Identification NM1=274,AMBULANCE PICK-UP LOCATION N3=275,Ambulance Pick-up Location Address N4=276,Ambulance Pick-up Location City NM1=277,AMBULANCE DROP-OFF LOCATION N3=278,Ambulance Drop-off Location Address N4=279,Ambulance Drop-off Location City SBR=280,Other Subscriber Information CAS=281,Claim Level Adjustments AMT=282,Coordination of Benefits (COB) Payer Paid Amount AMT=283,Coordination of Benefits (COB) Total Non-Covered AMT=284,Remaining Patient Liability OI=285,Other Insurance Coverage Information MOA=286,Medicare Outpatient Adjudication Information NM1=287,Other Subscriber Name N3=288,Other Subscriber Address N4=289,Other Subscriber City/State/ZIP Code REF=290,Other Subscriber Secondary Identification NM1=291,Other Payer Name N3=292,Other Payer Address N4=293,Other Payer City DTP=294,Claim Check or Remittance Date REF=295,Other Payer Secondary Identifier REF=296,Other Payer Prior Authorization REF=297,Other Payer Referral Number REF=298,Other Payer Claim Adjustment Indicator REF=299,Other Payer Claim Control Number NM1=300,Other Payer Referring Provider REF=301,Other Payer Referring Provider Identification NM1=302,Other Payer Rendering Provider REF=303,Other Payer Rendering Provider Secondary Identification NM1=304,Other Payer Service Facility Location REF=305,Other Payer Service Facility Location Identification NM1=306,Other Payer Supervising Provider REF=307,Other Payer Supervising Provider Identification NM1=308,Other Payer Billing Provider REF=309,Other Payer Billing Provider Secondary Identification LX=310,Service Line SV1=311,Professional Service SV5=312,Durable Medical Equipment Service PWK=313,Line Supplemental Information PWK=314,DMERC CMN Indicator CR1=315,Ambulance Transport Information CR3=316,Durable Medical Equipment Certification CRC=317,Ambulance Certification CRC=318,Hospice Employee Indicator CRC=319,Condition Indicator/Durable Medical Equipment DTP=320,Date - Service Date DTP=321,Prescription Date DTP=322,Certification Revision/Recertification Date DTP=323,Date - Begin Therapy Date DTP=324,Date - Last Certification Date DTP=325,Date - Date Last Seen DTP=326,Date - Test DTP=327,Date - Shipped DTP=328,Date - Last X-ray DTP=329,Date - Initial Treatment QTY=330,Ambulance Patient Count QTY=331,Obstetric Anesthesia Additional Units MEA=332,Test Result CN1=333,Contract Information REF=334,Repriced Line Item Reference Number REF=335,Adjusted Repriced Line Item Reference Number REF=336,Prior Authorization REF=337,Line Item Control Number REF=338,Mammography Certification Number REF=339,Clinical Laboratory Improvement Amendment (CLIA) Identification REF=340,Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification REF=341,Immunization Batch Number REF=342,Referral Number AMT=343,Sales Tax Amount AMT=344,Postage Claimed Amount K3=345,File Information NTE=346,Line Note NTE=347,Third Party Organization Notes PS1=348,Purchased Service Information HCP=349,Line Pricing/Repricing Information LIN=350,Drug Identification CTP=351,Drug Pricing REF=352,Prescription Number NM1=353,Rendering Provider Name PRV=354,Rendering Provider Specialty Information REF=355,Rendering Provider Secondary Identification NM1=356,Purchased Service Provider Name REF=357,Purchased Service Provider Secondary Identification NM1=358,Service Facility Location N3=359,Service Facility Location Address N4=360,Service Facility Location City/State/ZIP REF=361,Service Facility Location Secondary Identification NM1=362,Supervising Provider Name REF=363,Supervising Provider Secondary Identification NM1=364,Ordering Provider Name N3=365,Ordering Provider Address N4=366,Ordering Provider City/State/ZIP Code REF=367,Ordering Provider Secondary Identification PER=368,Ordering Provider Contact Information NM1=369,Referring Provider Name REF=370,Other Payer Prior Authorization or Referral Number NM1=371,Ambulance Pick-up Location N3=372,Ambulance Pick-up Location Address N4=373,Ambulance Pick-up Location City NM1=374,Ambulance Pick-up Location N3=375,Ambulance Pick-up Location Address N4=376,Ambulance Pick-up Location City SVD=377,Line Adjudication Information CAS=378,Line Adjustment DTP=379,Line Check or Remittance Date AMT=380,Remaining Patient Liability LQ=381,Form Identification Code FRM=382,Supporting Documentation SE=383,Transaction Set Trailer GE=384,Functional Group Trailer IEA=385,Interchange Control Trailer
Last update: June 27, 2020